Patients Freed to Live Life Through Program Targeting Advanced Illness Management

By Betsy Gornet

Enes Cerini loves spending time with her husband of 63 years and their children, grandchildren and great-grandchildren. The 91-year-old South San Francisco resident is also an ovarian cancer survivor, managing health complications associated with chemotherapy, deep vein thrombosis and heart disease. Cerini says Sutter Health’s Advanced Illness Management (AIM) program allows her to continue doing what she enjoys most in life.

While everyone aspires to age gracefully, when people develop complex medical needs they require comprehensive care and coordinated support. AIM is a philosophy of care that partners an AIM team with one’s primary and specialty physicians, working to understand the patient’s health issues, lifestyle and personal preferences. Then all parties work together to tailor a care plan for the patient.

When someone first enters the AIM program, they are provided support services in the home. The AIM team assesses the home environment and caregiver arrangements. It communicates with the patient and their family to determine personal goals such as how they want to live, care choices, what type of symptoms typically cause health problems, a crisis plan to manage those problems, and at what point their doctor or the AIM team should be called to help mitigate progressing symptoms.

Cerini’s nurse, Remy Dris, R.N., visits regularly. “Every visit, I find something we need to address regarding her health, and we take care of it right away,” she said. Cereni and Dris have formed a partnership built on trust and a strong nurse-patient relationship.

“When it’s time for Remy to leave I ask her, ‘When are you coming back?’… If I’m worried about anything, I’d call her first before I’d call the emergency room,” said Cerini.

The right support can help patients with advanced chronic illnesses live the kind of life they want. Sutter Health research shows that AIM patients spend less time in the hospital and manage their pain and symptoms better through the innovative care provided.

The Centers for Medicare & Medicaid Services (CMS) recently awarded Sutter Health a three-year, $13 million Health Care Innovation Award to support AIM expansion throughout Northern California.

Betsy Gornet serves as the Chief Advanced Illness Management Executive for Sutter Health, a not-for-profit health system serving patients in more than 100 communities across Northern California. Ms. Gornet has more than 25 years experience in managing and leading health care organizations across the continuum of care, including acute and specialty hospitals, long-term care, physician practices, home health and hospice.

This article was brought to you by the editorial committee of ASA’s Healthcare and Aging Network (HAN).

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