Advanced illness care

Is palliative care right for you?

The advanced illness care team provides outpatient palliative care support to individuals living with a serious illness. The team includes nurses, social workers, community health workers, a pharmacist and a spiritual counselor who all have the flexibility to make home, clinic and hospital visits.

The team works closely with patients and their other health care providers, focusing on patients’ goals of care, symptom management and care coordination. They identify and align additional community resources while providing support as the illness progresses.

Check the “Insurance we accept” link to see if you or your patient is covered for our advanced illness care services.

Click on the video above to watch patients explain how in-home palliative care is helping them live with serious illness.

Program objectives and services

The advanced illness care program’s primary objective is to support the best possible quality of life for those living with serious illness. There are three primary strategies utilized to meet this objective.

1. Coordination of care: Our expert social workers and nurse case managers coordinate with the patient’s primary care providers, specialists and other members of the health care team across the continuum of care. They also identify additional resources such as home health, in-home primary care and/or hospice when appropriate.
2. Symptom management: We use ongoing patient education and medical management to improve symptoms.
3. Patient goals and preferences: We identify and document patients’ goals of care and preferences for end-of-life care. Whenever possible, we also identify a health care representative.

We hope that our patient-driven, high-touch support enables advanced illness care patients to avoid unnecessary hospitalizations and emergency visits, benefiting the patient as well as the health system.