1. Potera, Carol


Collaboration revolving around patient goals and preferences drives the care plan.


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According to the SCAN Foundation, 12 million Americans today need long-term care; by 2050, 27 million will need help managing chronic illness and disabling conditions. Yet older patients with advanced illness, defined as "one or more major health conditions and associated functional impairments that substantially compromise the patient's daily life," often don't fit easily into the current health care system, which focuses on curing disease and prolonging life. And many such patients would rather receive care at home than in hospitals. A recent trend in care called "dignity-driven decision making" aims to improve care in these patients by integrating the concepts of quality of life, dignity, and the patient's specific wishes into care plans.

A nurse notes the tr... - Click to enlarge in new windowA nurse notes the treatment preferences of an older patient during a discussion about his care. Photo by John Birdsall / Press Association Images / The Image Works.

In the dignity-driven care model, patients and families play a central role in deciding what services they want and don't want. Traditionally, physicians have made key decision and patients were passive recipients of interventions. The newer model involves a collaborative relationship based on multiple conversations with patients and their caregivers to determine goals and preferences, which then drive the care plan. It requires interdisciplinary teams of physicians, nurses, social workers, and other staff to help patients remain at home.


One promising example of dignity-driven decision making is the Advanced Illness Management (AIM) program at Sutter Health, an integrated care system of 24 hospitals serving northern California. The program strives to make health care seamless for people with advanced illness. "Nurses carry the primary work-load. They're the eyes, ears, and hands of AIM," Brad Stuart, chief medical officer of Sutter Care at Home, told AJN. Much of the work is accomplished through home visits and telephone support. The AIM program, which was started about 10 years ago, has reduced hospital admissions by 50%, ICU admissions by 80%, and visits to physicians' offices by 20%. The main cost savings are to Medicare and Medicaid, according to Stuart.


When patients enter the AIM program, nurses endeavor to learn about their personal lives, values, and goals. Discussions about advanced directives and other technical issues come later. Most people have been hospitalized numerous times and hope to avoid readmissions. "They want to maintain their dignity and be safe and happy at home," said Stuart. If a person's goal, for example, is to walk to the dinner table to eat with the family, nurses arrange for physical therapy and equipment to get them there. Most importantly, said Stuart, the process is "driven by mutual collaborations among nurses, ill people, physicians, and caregivers."-Carol Potera




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