New Initiative Decreases Hospital Readmissions

A new program at Forest Hills Hospital aims to improve the quality of life of elderly, chronically ill lung and heart disease patients.

The Advanced Illness Management (AIM) initiative debuted in fall 2014 at Forest Hills and is now being introduced throughout the North Shore-LIJ
Health System.

“Each hospital is doing something a little different,” explained Hallie Bleau, an acute care nurse practitioner and senior administrative director at Forest Hills. “But they all have aspects of a goals-of-care conversation, just with different patient populations.”

The target population at Forest Hills comprises patients 65 and older with chronic obstructive pulmonary disease (COPD) or chronic heart failure (CHF) who have been admitted to the hospital three or more times in the last 12 months.

When elderly COPD or CHF patients are admitted into the hospital, a review of their electronic medical records flags them as a risk for readmission within 30 days and they are added to the advanced illness list. Once a patient is identified as an advanced illness patient, the attending physician will hold a goals-of-care conversation with the patient and/or family. As a result, the care received will be in line with the patient’s wishes, and hospice or palliative care referrals can be initiated when necessary.

Palliative care involves emotional support and helps patients manage the symptoms and pain of their chronic illness. Studies show that patients who receive palliative care report improved quality of life and are less likely to be readmitted to the hospital due to their health condition.

An important piece of the AIM program is education. Patients who learn about their disease process and how to manage their disease are empowered to make thoughtful decisions about their own health. The AIM team provides COPD and CHF education through the use of videos and printed materials.

Appropriate discharge planning is also crucial. All advanced illness patients will receive appropriate, disease-specific services upon discharge and will have a follow-up appointment with their primary provider within 72 hours of discharge.

The AIM program at Forest Hills is increasing communication on every level. It helps patients live better by aligning their care with their wishes and providing the services and education they need in the hospital and after discharge.

Topics: News

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