title: Program helps at-risk patients stay healthy.
abstract: At Carolinas HealthCare System, an Advanced Illness Management (AIM) team targets patients with multiple health issues and frequent hospitalizations and emergency department visits. The program is staffed by five LPNs, two social workers, one RN, and one nurse practitioner who work with patients in many hospitals in the system. Members of the AIM team visit eligible patients in the hospital, explain the program, and ask if they would like to participate. After discharge, the LPN, RN, and social worker conduct an assessment in the home. Patients stay in the AIM program until they transfer to another point of care, such as a skilled nursing facility, or they no longer need the services.
mesh_terms: D019090:Case Management; D003266:Continuity of Patient Care / Q000458:organization & administration*; D006792:House Calls; D006801:Humans; D009657:North Carolina; D019982:Organizational Case Studies; D010348:Patient Care Team; D010351:Patient Discharge; D040242:Risk Reduction Behavior; D013022:South Carolina