The Advanced Illness Care (AIC) team at this time, provides outpatient palliative care support to only CareOregon members living with a serious illness. The AIC team includes nurses, social workers, community health workers, a pharmacist and a chaplain who all have the flexibility to make home, clinic and hospital visits.
The team works closely with patients and their health care team, focusing on the patients’ goal of care, symptom management and care coordination. They identify and align additional community resources while providing support as the illness progresses.
Program Objectives and Services
The AIC program’s primary objective is to support the best possible quality of life for CareOregon members living with serious illness. There are three primary strategies utilized to meet this objective:
1. consistent coordination of care by expert social workers and nurse case managers, including the facilitation of early referrals to additional resources such as home health, in-home primary care and/or hospice when appropriate;
2. improve symptom management through ongoing patient education and medical management, and;
3. identifying and documenting patients’ goals of care and preferences for end-of-life care including advanced directives and Physician Order for Life Sustaining Treatment (POLST) forms and identification of health care representative when possible. Our aim for the health system is that by providing this type of patient-driven, high-touch support, AIC patients will avoid unnecessary hospitalization and/or emergency department (ED) visits.
The goal for our patients is to relieve suffering and give our patients a voice to determine how they want their care delivered.
For more information about the AIC program or to refer a patient, please call 971-202-5504.