Care Coordination: Serious Illness Management & Advocacy

The Serious Illness Management and Advocacy (SIMA) model is a population health initiative focused on complex chronic illness. It is an episodic, home-based, and interdisciplinary care model dedicated to optimize current and future clinical planning. SIMA integrates the paradigm of care coordination and the traditional roles of palliative medicine including symptom management and goals of care. BPP RN care coordinators and social workers form the foundation of SIMA bolstered by a strong interdisciplinary team of Pharmacy, Spiritual Care, and AgeWell HouseCalls.

Key Pillars of SIMA

Using empathetic communication, data gathering and resource management, SIMA targets four consultation outcomes: establishing the active plan of care and ensuring elements of the plan are in place such as medications and appointments; understanding the patient’s goals of care; developing a preparedness plan for anticipated decline; and identifying drivers of utilization or decreasing quality of life. Once identified, interventions can be targeted medically, pharmaceutically, psychosocially, and/or spiritually to improve patient wellbeing and prevent unwarranted utilization.

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Function

Function is a key clinical marker for prognostication, an important component of populationhealth planning, maximizing clinical wellbeing.

Symptom

Assessment and Management

Addressing and managing symptoms to increase quality of life and decrease tertiary utilization.

Resource Optimization

Standardizing internal and external resource allocation and follow-through.

Goals of Care

Establishing patient directives to honor their health care objectives and best understand potential incongruencies between patient and provider expectations.

Utilization Prevention

Ensuring that the care plan is implemented as directed by the provider. This includes follow-ups and medication management targeting SDoH to impact reversible factors that drive utilization.

Preparedness Planning

Including advance care planning, discussions for potential placement needs, and discussions of next steps in case of clinical decline.

Despite receiving in-home nursing assistance and monthly home visits from a nurse practitioner, Evelyn Lammert still needed high-level clinical assistance in managing her husband’s medically complex conditions, which included home infusion therapy.

Over the past year, her husband, Bruce, was hospitalized with complications related to chemotherapy and radiation treatment for metastatic prostate cancer. A cystectomy was also planned but delayed due to persisting osteomyelitis.

Thankfully, their first Serious Illness Management and Advocacy (SIMA) home visit was scheduled for the day after the postponement. Their distress was evident. Shawna Watson, MSN, RN, CCRN, Bruce’s SIMA RN care coordinator, took the lead in helping plan their next steps.

Along with ensuring the delivery of medications for the unexpected continuation of in-home antibiotics, Shawna addressed their apprehension, completed a medication review, and helped Eleanor prioritize her questions for Bruce’s nurse navigators at