Post on 17-Dec-2015
Integrated Care for Patients With Late-Stage Chronic Illness
Advanced Illness Management (AIM)
Medical Foundations
& Groups
Home-BasedServicesHospitalHospital
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Brad Stuart, M.D.Senior Medical DirectorSutter VNA & HospiceFairfield, CT
Sutter Sacramento: AIM 2.0 PilotJan. 15, 2010 - present
• Sutter Health: committed to lower Medicare costs
• Sutter Sacramento: Dartmouth Atlas benchmark1
– Ranked with Mayo Clinic, Intermountain HC• IP/OP case management in place• Sutter VNA & Hospice: 10 year AIM experience• 2 hospitals, 3 medical groups
1Dartmouth Atlas Investigators. Tracking the Care of Patients with Severe Chronic Illness, 2007
Care Coordination: Spatial Dimension
HOSPITALS• AIM Care Liaisons• Hospitalists• Inpatient palliative care• Case managers• Discharge planners• Emergency Dept.
PHYSICIAN OFFICES
• AIM Office-Based Care Managers• Telesupport
HOME-BASED SERVICES• AIM Transitions Team• Home health• Hospice
CRITICAL EVENTS • Hospitalization • ER visit • Physician request • Acute exacerbation
CALL CENTER• TelesupportELECTRONIC
PATIENT REGISTRY DISCHARGE
TO HOSPICE
Care Coordination: Time Dimension
AIM Enrollment
AdvanceCare
Planning
End-of-LifePlanning
HospiceReferral
Death
Illness Trajectory
MultimorbidChronic Illness
Advanced Chronic Illness Terminal Illness
Home-Based Evolution of Preference-Driven Care
Learn Consider UpdateDiscuss Choose Document
AIM 2.0 Preliminary OutcomesSample period: 11/9/09-9/30/2010
Days Pre/Post AIM Enrollment
30 60 90
N 185 121 96
Hospitalizations -68% -59% -63%
Total Direct Cost Savings*
$394,326 $475,305 $573,581
Savings/Enrollee/Month*
$2131 $1964 $1992
Excellent patient satisfaction
Excellent physician satisfaction*Includes savings from reduction in Emergency Department and hospital-based outpatient services
Next Steps & Needs
• AIM 2.0 Regional, System rollout• Needed from CMMI:
– Funding for unreimbursed AIM services through testing period
– New standards for, and assistance with, outcomes evaluation
– Support for creating a national model of advanced illness care