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