ACP and Goals
A legal document that allows you to designate someone to make healthcare decisions for you when you aren't able to.
What is an Advance Health Care Directive or Durable Power of Attorney for Health Care?
A tool used to assess symptoms and well-being of patient.
What is Edmonton Symptom Assessment Scale (ESAS)?
A medication organizer used by patient/caregivers with daily/weekly compartments.
What is a Medi-set?
The timeframe to schedule a home visit after patient is discharged from hospital or ED.
What is 24-48 hrs post-discharge?
An AIM patient has a change in condition and doesn't know what to do.
What is Call AIM First?
A pink legal document that clearly states what kinds of medical treatment patients want towards the end of their lives.
What is a POLST?
Physician Order for Life Sustaining Treatment
A health literacy tool that helps patients quickly assess the seriousness of their symptoms and guides them on what actions they should take.
What is a Stoplight Tool?
A process of creating the most accurate list of all medications a patient is taking.
What is medication reconciliation?
The time frame when patient should be seen by their physician after being discharged from hospital or ED.
What is within 7 days post-discharge?
Patient/family involvement in care and decision making
What is patient centered care?
A palliative care program that aligns care with patient's goals, values, and needs through a medical home model using nurse led interdisciplinary team.
What is the AIM program?
Advance Illness Management
A phone call to the patient/family (usually done after hours) for managing red flag symptoms, medication changes or recent discharge from hospital.
What is a Tuck-in call?
Used by patients to track health information (weight, blood pressure, etc)
What is a health log or vital sign sheet?
The 4 arms of AIM are
AIM Home Health
AIM Transitions
AIM Telesupport
AIM Hospital
The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.
What is health literacy?
Clear written objectives that are specific, measurable, attainable for a patient to work towards in a timely manner
What is SMART goals?
S: Specific
M: Measurable
A: Attainable
R: Realistic
T: Timely
An online patient education library that provides educational information for clinicians, patients and families.
What is Krames on Demand?
A method to Chunk and Check for patient understanding of health information
What is Teach back method?
AIM patient that is not homebound and does not have a skilled need; that was recently seen in ED should be seen by what arm of AIM.
What is AIM Transitions?
A tool used to write personal health history, goals, questions and concerns for you to share with your health care team.
What is a personal health record?
A crucial conversation with AIM patients regarding quality of life and what matters most to them. Discussing concerns, fears, understanding of their prognosis, and hospice care.
What is End of Life Conversation?
Collaborative process that optimizes quality care for patients by conducting assessment, planning, coordination, monitoring, and evaluation to meet their health needs.
What is case management or care coordination?
A comprehensive process of reconciling, monitoring, and assessing medication. Provide coaching to develop strategies for medication adherence, provide a patient-friendly medication list, and care coordination with pharmacy and physician.
What is medication management or reconciliation?
AIM HH patient that has completed the pillars of AIM program should be handed off to which arm of AIM.
What is AIM Telesupport?
A conversation framework for effective communication with patient and families that improves patient satisfaction.
What is AIDET?
A: Acknowledge the patient
I: Introduce
D: Duration
E: Explanation
T: Thank You