SHM Converge Scientific Abstract ePoster Gallery-Aiming High: Elevating Visibility and Goal-Concordant Care in Advanced Illness

Pdf Summary

This project describes an initiative at a tertiary hospital to improve goal-concordant care for older adults with advanced illness. The team found that the hospital’s existing LACE readmission risk tool did not adequately identify patients with mid- to late-stage chronic illness and significant frailty. In response, clinicians and the advanced illness committee developed a new Advanced Illness Model (AIM) score to better flag patients who would benefit from goals-of-care (GOC) conversations.<br /><br />To make the process visible during daily workflows, the AIM score was integrated into the hospital’s digital interdisciplinary rounding tool, NORA, as a prominent pink flag. When patients aged 65 and older or those with a positive AIM score were identified, hospitalists were encouraged to complete structured GOC notes addressing advance directives, code status, and treatments aligned with patient values. Hospice evaluation was also considered for patients with a life expectancy of six months or less.<br /><br />After implementation in July 2023, documentation of GOC notes increased from 15–17% to 25–28%. Patients who had GOC documentation also showed a lower 30-day readmission rate than those without GOC notes (15% vs. 20%). In addition, hospice discharges were much more common among patients with GOC discussions (6.1% vs. 0.12%).<br /><br />Overall, the AIM flag within NORA improved identification of frail patients, increased meaningful GOC documentation, and was associated with fewer readmissions and more hospice referrals, supporting higher-quality, patient-centered care.

Asset Subtitle

Semie Kang

Meta Tag

Author List Jessica Cohen, M. Isabel Friedman, Nicholas DaCosta, Salonie Pereira, Semie Kang

Category Research

Concept AIM Score

Concept Serious Illness Conversation

Concept Goal-Concordant Care

Concept Hospitalized Older Adults

Concept Goals of Care Note

Distinguished Non-Finalist

Presenter Organization Northwell Health - Long Island Jewish Medical Center

Presenting Author Semie Kang

Track Quality Improvement

Keywords

advanced illness

goal-concordant care

goals-of-care conversations

frailty

older adults

AIM score

NORA tool

hospice referral

readmission reduction

patient-centered care

AIM Score

Serious Illness Conversation

Goal-Concordant Care

Hospitalized Older Adults

Goals of Care Note