Center to Advance Palliative Care


Sign Up for Email Alerts!
Get CAPC news
and updates.

For Patients and Families
  Print this page

Advanced Illness Coordinated Care

Dan Johnson, MD Send Email
Clinical Lead for Palliative Care, Care Management Institute
Kaiser Permanente
2550 S Parker Rd, Suite 400
Aurora, CO 80014
<< previous next >>
(Click on poster to view full image in pop up window)


To create a continuum of care for palliative care services, Kaiser Permanente (KP) implemented the outpatient Advanced Illness Coordinated Care (AICC) program. KP studied this social work intervention in collaboration with Dan Tobin, MD, Care Support of America, in a randomized control trial across three Kaiser regions. The model incorporates health counseling and care coordination matched to needs of patients with advanced illness, and delivered in cooperation with the referring physicians. The AICC components include a communication model (what we do), conceptual framework (how we do it), and six structured visits (when we do it). Key successes to implementation include enlisting leadership support, marketing the services to referring providers, starting the program in settings favorable to integration and adoption, and recruiting and training social workers with interest and expertise in palliative support. The program has resulted in improved communication about discomfort, support for decision making and problem resolution, and attention to caregiver needs. AICC also resulted in increased formulation of advance directives, and fewer inpatient admissions and ER visits, with no change in survival (Am J Manag Care. 2009; 15(11):817-825).

<< previous next >>