When a person’s health and ability to function begin to decline due to an illness and treatments start to have less and less impact, Serious Illness Management (SIM), also known as Advanced Illness Management (AIM) is a program that strives to preserve the best possible quality of life for the person suffering from a chronic illness.
When the pain and discomfort of a life-threatening illness result in fatigue, shortness of breath, nausea, loss of appetite and other distressing symptoms related to serious illness, it may be time for a SIM plan.
How is the SIM Process Started?
To start the process, a referral is sent to the SIM team by the patient’s physician or Care Management associated with the physician’s office.
Focused on providing relief from the symptoms, pain and stress of a serious illness, the Advanced Illness Management team provides:
- Chronic Disease Management education.
- 24/7 emergency phone access to our nurses and physicians to help manage medical issues that may arise during off-hours at night, on weekends and holidays.
- Emotional support to help patients and families cope with the stress and emotional burden of illness. The team can also place patients and family members in touch with community services.
- Next Steps Planning Guidance for patients and family members on options regarding care.
Goals and Expectations of SIM
SIM strives to provide comfort and relief of the pain and other symptoms that result from a serious illness.
An Advanced Illness Management team may consist of the following individuals depending on the patient’s needs, situation and doctor’s instructions.
- Case managers – may be an RN, but is the person who has primary responsibility for the team involved in a patient’s home health care.
- Medical social workers – work with patients and their families to educate them on what services are needed and help remove any barriers to the patient receiving home health care. Medical social workers can help coordinate medical equipment rental and arrange transportation for follow-up visits.
- Community care workers – assist with obtaining community resources and completing activities of daily living.