Establishing an Advanced Illness Management (AIM) Model in a Community-based Setting: Innovation at the Visiting Nurse Service of New York

Grantee Name

Visiting Nurse Service of New York

Funding Area

Special Projects Fund

Publication Date

August 2011

Grant Amount

$864,837

Grant Date:

February 2007 – June 2009

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This project aimed to improve quality of care and reduce costs for patients with advanced illness by piloting the Advanced Illness Management (AIM) model and evaluating its impact on quality of care provided, hospice admissions, and hospitalization and emergency department use.

Although the model improved the quality of care patients received and created additional training opportunities for home care nurses, it did not result in an increase of hospice admission or a reduction in emergency department use and re-hospitalizations.

Outcomes and Lessons Learned

Used an algorithm based on the federally mandated Outcomes and Assessment Information Set (OASIS) assessment to identify 1,118 AIM-eligible patients.
Developed the AIM Clinical Resource Nurse training curriculum and produced other clinical resource materials and evaluation research tools.
Prepared 13 AIM Clinical Resource Nurses, who supported approximately 130 field nurses, providing care to nearly 500 AIM-eligible patients.
Evaluated the impact of AIM by examining patient data, such as demographic characteristics, clinical characteristics at the start of care, hospice referral and admission, hospital and emergency department utilization, and home care utilization.
Administered a survey to assess nurses’ perceptions and program experience.
Presented the project at several professional meetings and conferences.

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