Care Continuum Innovation through AIM (Advanced Illness Management)

The Advanced Illness Management (AIM) program is an innovative pilot that provides nurse-led care management, palliative care consultation and advance care planning for patients with late-stage chronic illness who are at risk of dying within the next twelve months. The AIM program bridges the gap between the hospital setting and the community physician’s office for the frailest, sickest patients. A single nurse-led interdisciplinary team provides specialized care management for patients in the hospital, at home, during home care episodes and in the physician’s office.