this case, the AIM Case Manager can provide resources community caregiver agencies, or they can keep a watchful eye out for a time when the patient may qualify for home health or hospice services, and be able to receive these services entirely covered by Medicare or Medicaid. Proper and thorough documentation at every visit will ensure that careful consideration of this will be performed at each visit.
C157 Task 1 Page 13 The primary mission behind the AIM program is for educational purposes. The patient has 24 hours a day access to telephone nurse support, and regular telephone visits with a Nurse Case Manager. As proper teaching takes place, the Nurse will be armed with the information necessary to fully manage the disease process. The program also has teaching tools called Stoplight Tools. There is a specific tool for each of the leading diagnoses associated with the AIM program. The improvement or worsening of symptoms is set up in a stoplight tool fashion. For example, if a patient can easily manage their disease (i.e., no shortness of breath), they fall in the green light category. If they are experiencing some minor difficulties (i.e., mild to moderate shortness of breath), they classify under the yellow light category. If they are experiencing extreme symptoms (i.e., severe shortness of breath), they classify under the red-light category. The Stoplight tool method helps the patients relate these new and sometimes frightening symptoms to something straightforward to understand. The tool also provides pharmacologic and non-pharmacologic management techniques that assist in disease management (B. Lawrence, Personal Communication, June 10, 2019). A primary focus of the AIM program is to ensure that the proper education and assessment is taking place while using these stoplight tools. It is also essential to request regular teach back to ensure compliance with this tool. Compliance will result in better management of chronic disease. When the disease is managed effectively, patient success and financial reimbursement are more likely to occur. Goal setting is a useful engagement tool associated with the AIM program. When the Case Manager understands what the patient wants out of the program and out of their life, it is easier for them to formulate the best and most personalized plan of care for the patient. Proper documentation of the goal ensures that it fits in with the overall guidelines of the program. It also
C157 Task 1 Page 14 serves as a resource for the Case Manager to refer to in measuring progress for the patient. Proper documentation will also allow the patient’s other care team members to be aware of this goal and help where they can fit in as well. It is also imperative that the goal is documented in the utilization of SMART tool measures. As stated before, this will mean that the goal is specific, measurable, attainable, relevant, and time-based. So, instead of the Case Manager and patient coming up with the goal “to be able to walk,” the Case Manager will work to help make it a SMART format. In this case, the rewritten goal would state “the patient will be able to walk 10
- Spring '17
- SUTTER HEALTH