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NEW VISITOR POLICY WILL TAKE EFFECT ON APRIL 13, 2022  Click Here

What is the Scotland Health Advanced Illness Team?
When facing an advanced chronic illness, people need a partner who understands their health concerns and goals for care. Scotland Health Care System’s Advanced Illness Team will help your patients better align their goals of care with an individual approach to healthcare services. The Advanced Illness Team is a collaborate effort between Scotland Regional Hospice and Scotland Health Care System. The plan is to use the end-of-life goals expertise commonly associated with hospice and apply it to anyone with a chronic illness so that they can make informed healthcare decisions.

What will Advanced Illness Team Facilitators provide?

  • Life goals conversation
  • Help patients and families develop realistic care goals
  • Explore the individual’s goals for life-sustaining treatment in the event of a severe, neurologic illness where a full cognitive recovery is unlikely
  • Assists families/caregivers in understanding patient choices and the importance of honoring those choices as it relates to transitions of care
  • Assist in the selection and preparation of a qualified agent/proxy (HCPOA)
  • Assists the patients/families in making healthcare decisions based on facts, after verbalizing understanding and discussion has occurred
  • Assist in developing and adjusting goals based on disease and its progression
  • Assist with making informed advanced care planning choices that are consistent with their individual goals, beliefs, and values while preserving patient dignity
  • Explain Power of Attorney (POA), Healthcare Power of Attorney (HCPOA), Medical Orders for Scope of Treatment (MOST), Physician Orders for Scope of Treatment (POST),
  • Do Not Resuscitate (DNR), and Living Will
  • Develop a patient-centered approach to advanced care planning based on the patient/families readiness to participate, anxieties or misconceptions, religious or cultural beliefs
  • Makes referrals to other resources, as needed (ie. grief or family counseling) 

 

Who are the Advanced Illness Team Facilitators?

  • Jill Ward –Scotland Regional Hospice director of clinical operations
  • Tanya Williams –Scotland Regional Hospice director of family support services

 

How will this help you and SMH?

  • These discussions can be difficult and very time consuming
  • Reduce Unnecessary Admissions / Readmissions
  • EC Turnaround
  • Assist with explaining D/C Instructions (Need simple form explanation—MOST/POST Forms, DNR, HCPOA)
  • Improve overall patient experience and satisfaction
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