AIM 2.0 Eligibility and Care Processes Eligibility Enrollment requires: –Identified PCP –Utilizes Sutter hospital or SMN physician Clinical criteria: –End stage chronic illness, or –Would not be surprised at death in next 12 months, or –Clinical, functional, or nutritional decline, or –Eligible for hospice, but not ready 5 Pillars of Care – Red Flag symptom management Customized treatment + comfort care Home crisis management plan –Medication management –Follow-up visits –Ongoing advance care planning –Personal health record
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