Program helps at-risk patients stay healthy
Team contacts patients at least once a week
In the first eight months of the Advanced Illness Management (AIM) program at Carolinas HealthCare System, the 61 patients who received frequent and intense interventions from the AIM team experienced a 70% reduction in hospital admissions based on their readmissions for a similar time period before the program began.
Executive Summary
At Carolinas HealthCare System, an Advanced Illness Management (AIM) team targets patients with multiple health issues and frequent hospitalizations and emergency department visits.
- The program is staffed by five LPNs, two social workers, one RN, and one nurse practitioner who work with patients in many hospitals in the system.
- Members of the AIM team visit eligible patients in the hospital, explain the program, and ask if they would like to participate. After discharge, the LPN, RN, and social worker conduct an assessment in the home.
- Patients stay in the AIM program until they transfer to another point of care, such as a skilled nursing facility, or they no longer need the services.
The AIM program is staffed by five LPNs, two social workers, an RN, and a nurse practitioner. Each team includes an LPN, one of the social workers, the RN, and the nurse practitioner. The LPN is the primary contact for patients. The other clinicians join the teams as needed.
The program, which began in December 2013, targets patients who have multiple health issues that put them in the top 5% of healthcare utilizers, says Deana Williams, MBA/MHA, director of advanced illness management in the continuing care division for the healthcare system, which includes more than 900 care locations throughout North Carolina, South Carolina, and Georgia, including academic medical centers, hospitals, physician practices, post-acute facilities, home health agencies, and hospice services. With a total of 7,460 acute care and post-acute beds, Carolinas HealthCare System is the second largest public healthcare system in the country.
Before beginning the initiative, hospitals across the system looked at the continuum of care to develop strategies for coordinating care to ensure a smooth hand-off as patients move between levels of care, says Kathleen Kaney, DrPH, MBA, FACHE, senior vice president of system care coordination for Carolinas HealthCare System.
"We determined that we need to focus on a patient-by-patient level and work with at-risk patients where they really are. Educating patients on their medication regimen, helping them navigate the healthcare system, and connecting them with the correct physicians has been a big focus, and it ties in with our overall goal of providing and coordinating quality care efficiently and effectively as patients move across the continuum," she says.
The health system analyzes its medical records to identify patients at all participating hospitals who have been hospitalized twice in a six-month period or who have been to the emergency department three times in six months and who take multiple medications for chronic conditions. The AIM team reviews the records of referred patients and determines who could benefit most from the program.
"They work with patients with multiple needs and who require complex care coordination," Kaney says.
Typical patients in the program have a condition that puts them at risk, multiple comorbidities and are taking multiple medications, usually eight or more and sometimes as many as 30, Kaney says.
When a patient is identified for the program, members of the AIM team visit them in the hospital, explain the program, and ask if they would like to participate. The LPN and social worker check on the patients during the hospital stay and collaborate with the case manager on the floor to make sure the patient’s discharge needs are met. After discharge, the LPN, RN, and social worker make a home visit for an assessment that may last as long as an hour and a half, Williams says.
They go over the discharge plan with the patients and educate them on managing their illness and following the treatment plan. They make sure the patients have gotten their prescriptions filled and understand how to take their medication. They review the patients’ medication and conduct medication reconciliation. The team also makes a thorough home assessment to identify safety issues and determine if the patients need any community resources and, if so, help them apply for the services, Williams says.
After the initial visit, the LPN contacts the patient at least once a week and reminds them when they have a physician appointment and helps them arrange transportation if needed. If the patient prefers, a team member will go with them to see their physician. "The LPN is the main point of contact. If patients need something or have a concern, they call the LPN, who may refer them to other team members for assistance," Williams says.
The program is patient-centered, and the interventions and education vary based on what patients need and what patients want, Kaney says.
"Relationship-building is a big key to the success of the program. The LPNs get to know the patients, their conditions, medications, their understanding of the treatment plan, and their needs. They learn about the patients’ family dynamics, their past fears, and their hopes," she adds.
Over time, the LPNs build trust with the patients and their family members and often are able to get information that the patients ordinarily might not share.
"When people are this sick, it’s not just the patients who need assistance. The family who help care for them often are concerned about how to manage the medication and other needs. The LPNs help the families learn whatever needs to be done. As the relationship develops, the patients realize we care about them and their families," Williams says.
Patients stay in the AIM program until they transfer to another point of care, such as a skilled nursing facility, or they no longer need the services. When patients move to a different level of care, the AIM team works with clinicians at the receiving facility to get them up to speed on the patient’s conditions and issues and to ensure a smooth transition.
"The whole goal is not to ever lose a patient, to stay connected to them and ensure a smooth transition if they go to another level of care," Kaney says.
