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Weekly Tips & Insights

Dr. Mary Fox shares insight into AIM program

Advanced Illness Management helps primary care physicians manage chronic illness from a patient’s home. Dr. Mary Fox, VNA’s Chief Medical Officer, shares more about the AIM program.

How can the AIM program help patients dealing with serious chronic illness reduce hospital visits?

Many patients that have severe, ongoing chronic illness, such as advanced heart disease or lung disease, cancer or dementia—the patient and their caregiver often have trouble getting into the physician’s offices. Transportation becomes an issue because it’s burdensome, they often may have a lot of equipment. They may feel poorly and not able to get into their physician’s offices. When that happens, they are often unable to get their medications refilled because they haven’t been into the physician’s office. That in turn can cause a worsening of their symptoms, so they often have to go back to the hospital.

Our goal, with respect to the AIM program, is to get to these people and act as a mediator— the team that mediates between the patient and their caregiver and the office-based physicians. So we can keep that patient at home having a good quality of life, without having to return to the hospital or the emergency room.

What kind of patients would benefit from the VNA home-based AIM program?

Anyone with advanced chronic illnesses. Sometimes we have people with several illnesses that combined together, make the patient feel pretty limited with respect to getting out of the home. They may not have severally advanced lung or heart disease, but because they have heart disease and perhaps kidney disease and diabetes, they have a lot of symptoms associated with those things that sometimes make it hard to get into the physician’s office. We work directly with the primary care or referring physician to help manage the patient and help them manage their own illness better.

How does Advanced Illness Management help families trying to care for a family member with a chronic illness?

It adds an extra layer of care. Most of the family and caregivers that we see taking care of patients are really on their last straw. They’re trying as best they can to care of someone who’s very ill. They don’t have a medical background. Many of them have to work and you can’t just go back and forth to take care of someone who’s at home or you’ll lose your job. They really are in a difficult spot.

When our team comes in it consists of a physician and a nurse practitioner and then we have a social worker and a spiritual counselor that can also come in and act as extra layers. We try to help patients where their need is the greatest and help the caregiver where the need is the greatest.

Can you talk about VNA’s Advanced Illness Management program in St. Louis and how it compares to other similar programs around the country?

The model really began in California, through hospital care that turned into a home-based palliative care program. They had the same goals—to help people burdened with severe, chronic illnesses be able to deal with it and manage it better. Their results were phenomenal. They started in 2008 and were able to reduced hospital visits by about 65 percent in the first 90 days. They saved a boatload of money over that period of time. Patients had much better care, much better quality of life.

It is a huge gap that exists in the St. Louis area and in the Midwest. The model that we’re doing is not a hospital-based program, but a community-based program as the VNA has been for a long time. So far it’s been very successful. Based on results from the summer, we’ve been able to reduce hospital visits by about 60 percent, so we’ve pretty much on target compared to the other programs throughout the country.

How does the AIM program fit into VNA’s broader mission that provides a coordinated continuum of care, throughout a patient’s life span?

AIM expands our ability to provide a continuum of care throughout the lifespan of the person, so it fills another gap within health care. That’s always been what the VNA has done—it’s has always jumped into the middle where a need exists and provided care in that gap. The AIM program is another way of filling in that mission for the greater St. Louis area.


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