Advanced Illness Care Coordination

This project was designed to improve the care of patients with life-limiting cancer by (1) improving the quality of care (2) improving communications around end-of-life planning and (3) increasing use of advance directives. By providing psychosocial support to patients, the project expected to improve physician satisfaction as well. The intervention consisted of Advanced Illness Coordinated Care (AICC), a 6-part structured conversation between a social worker and a patient diagnosed with a life threatening illness that is carried out over the last 12-24 months of life. The model did not strive to direct the patient toward more or less aggressive care; instead it elicited patient preferences and ensured that they were communicated to the treating physician. It supported the physician by ensuring that the psychosocial needs of the patient were addressed by the AICC care coordinator, in collaboration with the physician. In other settings, e.g., the VA system, AICC has increased referral and length of stay in hospice.

The evaluation conducted by Partners in care Founation found that the AICC intervention to be effective in improving both rate and level of depression, communication with medical team regarding issues of treatment preferences, pain and emotional discomfort, generating Advance Directives, and facilitating transitions to palliative and hospice levels of care.