When April Feld, Director of Population Health Management at VNSNY, made a presentation on VNSNY’s Advanced Illness Management (AIM) program at the Home Care Association of New York State’s annual conference last spring, she wasn’t expecting the VNSNY Population Health team to receive an award from the Centers for Medicare and Medicaid Services (CMS). Yet that’s exactly what happened.
“Following the panel, I was approached by Dennis Wagner, Director of CMS’s Quality Improvement and Innovation Group, who had delivered the keynote address for our session,” recalls Feld. After congratulating VNSNY on its AIM initiative, Wagner handed Feld a Quality Improvement and Innovation Group Challenge Coin, an award given by CMS to exceptionally innovative health care programs.
“The award is clearly an honor,” says Rose Madden-Baer, who heads VNSNY’s Population Health division. “But more importantly, it’s additional confirmation that our AIM model works.” Too often, adds Madden-Baer, individuals who are approaching the end of life but haven’t yet entered hospice care find themselves experiencing one medical crisis after another. “This results in frequent hospitalizations that negatively impact their quality of life while doing little to improve their overall health status,” she explains.
To better address the needs of this population, VNSNY’s newly launched Care Management arm is collaborating with VNSNY CHOICE Health Plans and VNSNY Home Care to implement the AIM program. Using specialized algorithms, the AIM team regularly reviews VNSNY’s medical records to identify those patients and plan members with the highest mortality risk. The team then uses evidence-based care management interventions to manage the symptoms and challenges for these individuals more proactively and, where appropriate, will initiate conversations with the patients, their families and their medical providers about shifting to end-of-life hospice care.
“The goals of AIM are to ensure that these very ill patients and plan members receive the right level of care, while also ‘normalizing’ discussions around end-of-life planning,” says Madden-Baer. Although AIM works with people at an especially vulnerable time in their lives, she adds, “The positive comments we’re hearing reflect the high level of empathy and effective support that AIM participants and their family members are experiencing.”
At the same time, she notes, “From a quality and cost perspective, this innovative model is helping our partnering providers and insurers successfully implement their value-based care models and achieve their performance goals. In other words, this approach not only supports our very ill patients and members, but is also beneficial for our customers and partners involved in their care.”