Special Projects Fund

Project Title

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

Grant Amount


Priority Area

Special Projects Fund

Date Awarded

November 16, 2006







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.

Though most Americans indicate a strong preference for dying at home, more than 80% of New York residents die in the hospital. This grant to the Visiting Nurse Service of New York aims to reduce hospitalizations and improve quality by increasing use of cost-effective, home-based and hospice care for severely ill homecare patients.

The project will introduce the Advanced Illness Model into the Visiting Nurse Service’s home care services. The goals of the Advanced Illness Model are to increase discharge to hospice among hospice-eligible patients in home health agencies and improve palliative care (care given to address the symptoms of a disease without attempting to cure it) for those patients who, for reasons of choice or eligibility, remain in home health agencies.

Major activities of this grant include (1) implementation, evaluation, and development of a business case for an Advanced Illness Model that can be replicated by Medicare/Medicaid certified home health agencies; (2) movement of palliative care into the mainstream of chronic disease management by integrating Advanced Illness Management into care delivery; and (3) training and certification of members of the Visiting Nurse Service care teams to become Advanced Illness Management consultants, which is also a career growth opportunity for generalist RNs.

For more than 100 years, the Visiting Nurse Service of New York has provided home health services to the residents of the New York metropolitan area. The Visiting Nurse Service of New York is the largest nonprofit home health provider in the United States.