Advanced illness management and support for advance care planning is an essential element of VNSNY Care360° Solutions, and integrated into all programs.
Using a proprietary algorithm, the Advanced Illness Management (AIM) team analyzes members’ medical history and current state of health to proactively identify individuals with a high risk of mortality but who are not yet on hospice care.
For those high-risk members, a specially-trained Clinical Liaison RN is engaged to clarify goals of care, provide education on advance care planning, and discuss care options. If appropriate, the Clinical Liaison can help facilitate the transition to a hospice program of the member’s choosing.
By engaging members proactively in advanced illness conversations, the AIM team helps ensure members get the right level of care so they can remain safely at home and out of the hospital.
Target Population
Members with increased risk for condition deterioration and/or end-of-life prognosis; often those experiencing frequent health crises and declining quality of life.
Benefits
- Effective management of high-risk members, reducing unnecessary inpatient and emergency care
- Improved quality of life for members and families by facilitating a seamless transition to hospice when appropriate, helping them get the care and support needed
- Enhanced communication and coordination across care team, including member’s physician and health plan care manager
Unique Program Elements
Proprietary algorithm: Proprietary alogrithm used to proactively identify at-risk members
Clinical assessment: A nurse reviews each case to confirm appropriateness of risk prediction and perform a clinical assessment
Member engagement: Early engagement of members in advance care planning conversations helps to normalize end-of-life care planning discussions and improve overall experience
Enhanced coordination: AIM team helps with setting care goals, navigating care options, and facilitating communications between members, their families, and medical providers
Support for hospice transition: For hospice-eligible members, assistance is provided with the transition to a hospice organization of their choice
Award-Winning Care Approach
The Advanced Illness Management team’s model of care was recognized by the Centers for Medicare and Medicaid Services (CMS) in 2019 with a Quality Improvement and Innovation Group Challenge Coin, an award given to exceptionally innovative health care programs. Read more.
The AIM team works with people at an especially vulnerable time in their lives…the positive comments we’re hearing reflect the high level of empathy and effective support that AIM participants and their family members are experiencing.
Rose Madden-Baer, SVP, VNSNY Population Health
Demonstrated Impact
- Facilitates seamless transitions of care
- Reduces avoidable inpatient or emergency care
- Increases quality of life for members and their families by:
- Preventing symptom exacerbation
- Avoiding stressful cycle of hospitalizations
- Remaining at home with loved ones
