A team of palliative care clinicians provides ongoing support for challenges that confront members and caregivers in the home. Relief from the daily stresses of everyday living with a serious illness – including non-clinical issues related to SDoH such as food insecurity, access to transportation and loneliness – improve health outcomes and enhance the quality of life.
The PIM program focuses on the last 6-12 months of life as it relates to the person—not the disease process, putting quality over quantity. It is a highly proactive approach, providing an additional layer of support that addresses the physical, emotional and social aspects of a patient’s experience.
The palliative trained clinical nurses and social workers discuss goals of care, educate about disease processes and progression and explain care options, including discussing hospice when appropriate. Patients and caregivers take advantage of comprehensive home-based consultations and management of chronic disease states, with a focus on establishing goals of care through thoughtful conversations and discussions.
It is this level of specialized home-based support that has gone missing from traditional care models, bringing to reality comprehensive palliative assessments based on care pathways determined by clinician risk evaluation.