Advanced Illness Care
The Advanced Illness Care (AIC) team provides outpatient palliative care support to CareOregon, OHSU IDS and PacificSource (Medicaid) health plan 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 other health care providers, focusing on the patients’ goals 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 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 AIC patients to avoid unnecessary hospitalizations and emergency visits, benefiting the patient as well as the health system.
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 Advanced Illness Care program or to refer a patient, call 971-202-5504.
“Whatever I need in the moment, they are there, and I can’t tell you what that means to me. This service has been amazing.”