Advanced Illness Management is a collaboration between a patient’s primary care physician and a VNA physician. Dr. Mary Fox, VNA’s Advanced Illness Management Director, explains how AIM works as a consulting service to a primary care physician for a patient with a chronic illness.
VNA often will receive a call from a referring physician, a home health network or a patient asking for a consultation with VNA to help a patient dealing with a chronic illness. Fox explains that a common occurrence is that a patient will become too sick to visit their doctor to refill a medication, which inevitably causes the patient’s chronic illness to get out of control.
VNA sets up a meeting with the patient, which Fox said can take between a few days and two weeks in most cases. Fox will then visit the patient with a nurse practitioner to assess the patient’s illness. The patient’s caregiver, often the power of attorney, is present for the consultation. If the patient decides to begin the AIM program, the nurse practitioner will usually visit every month based on the patient’s need and Fox will visit every few months.
“The primary caregiver and referring physicians gets every progress note from our initial consultation, and they are kept in the loop following each visit,” Fox explains.
Fox said that VNA wants to work with physicians who do not have time to go into a patient’s home to provide extra assistance with the hope of keeping a patient out of the hospital. “We hope to help the physician keep that from happening. AIM is just helping that physician get more information and manage the patient better.”
While VNA does work one-on-one in the home with patients through the AIM program, Fox said they are not trying to take over the patient’s medical treatment. It’s a collaborative effort between VNA and the primary care doctor.
“We have good relationships with physicians because they know that when a patient is more stable they can go back to the physician’s office,” said Fox.
VNA’s AIM program serves four counties in the St. Louis area including St. Louis City, St. Louis County, Jefferson County and St. Charles County. They currently have patients in each county.
“It really is a wonderful service that will help people dealing with these chronic illnesses at home,” said Fox about the AIM program. “It will help the St. Louis community and will strengthen us as our population begins to age and develop chronic illnesses.”
The AIM program deals with the top five percent of the sickest people in the community, and when you provide them with help they are extremely grateful. Fox shared about one of her patient who was admitted to the hospital once every month for the first six months of the year, and after starting the AIM program has not been hospitalized since June 2016.
“Reducing hospital visits for this patient had a tremendous impact on her,” said Fox.
For more information about VNA’s Advanced Illness Management/ Palliative Care program, contact Deborah Jeffery, NP-C at 314.918.7171, ext. 1244 or djeffery@vnastl.com.
