Shahbazim are paid approximately 10 percent more than CNAs for their additional responsibilities and training hours (NCB Capital Impact, 2007). The additional pay is made possible through stabilization of the direct-care workforce (i.e., lower costs due to decreased turnover rates), operational efficiencies, and diminished need for middle-management positions. However, GHs do require providers to adapt to new roles. For example, attending physicians and medical directors provide care in disaggregated homes where shahbazim are central to the care of residents and are responsible for monitoring their status based on the direction of physicians (Kane et al., 2007). This is different from the situation in the typical nursing home setting, where physicians have traditionally had little communication with direct-care staff.

The Advanced Illness Management (AIM) Program

Numerous studies have shown deficiencies in the quality of care at the end of life. Many older adults die with inadequate palliative care (Zerzan et al., 2000), and often patient preferences are not assessed, communicated, or followed (Haidet et al., 1998; Hofmann et al., 1997). Most patients prefer to die at home, yet most deaths occur in the hospital (Brumley et al., 2007; Grande et al., 1999). And although hospice care can lead to higher patient and family satisfaction at a lower cost (Brumley et al., 2007), many individuals do not receive hospice care (NHPCO, 2005), and those who do receive it rarely use the full Medicare hospice benefits (Ciemins et al., 2006).

In an effort to bridge the gap between curative care and hospice care, Sutter Visiting Nurse Association and Hospice created the Advanced Illness Management (AIM) program, which provides both disease-modifying care and comfort care in the home setting to those with advanced illnesses who are eligible for home care but not yet eligible for hospice care (Ciemins et al., 2006). Patients are included regardless of Medicare eligibility or insurance coverage. The program coordinates hospital services, home health care, and, when needed, hospice services. The goals of the program are to provide seriously ill patients with an array of home-based services, to ease their transition from home health care to hospice care, and to avoid unnecessary hospitalizations.

The program uses a combination of home care and hospice staff. Nurse case managers (known as AIM nurses) are the primary providers for AIM patients. They educate patients on disease process and prognosis, treatment alternatives, advance care planning, avoidance of unnecessary hospitalization, management of pain and symptoms, and hospice enrollment. Additionally, AIM nurses receive training classes that cover such topics as palliative care definition and philosophy, insurance coverage, home care

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