Slide 1 - Health Affairs

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					Advanced Illness Management (AIM)
Integrated Care for Patients With
Late-Stage Chronic Illness
Brad Stuart, M.D.
Senior Medical Director
Sutter VNA & Hospice
Fairfield, CT




                          Home-Based   Medical Foundations
     Hospitals             Services         & Groups
  Sutter Sacramento: AIM 2.0 Pilot
  Jan. 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
                                                        CALL
                                                        CENTER
                               ELECTRONIC
                                                        • Telesupport
                                 PATIENT
     HOSPITALS                  REGISTRY                                 DISCHARGE
 • AIM Care Liaisons                                                     TO HOSPICE
 • Hospitalists
 • Inpatient palliative care
 • Case managers
 • Discharge planners
 • Emergency Dept.
                                                           CRITICAL EVENTS
                               HOME-BASED SERVICES          • Hospitalization
                               • AIM Transitions Team       • ER visit
                               • Home health                • Physician request
        PHYSICIAN              • Hospice                    • Acute exacerbation
         OFFICES
   • AIM Office-Based
   Care Managers
   • Telesupport
Care Coordination: Time Dimension
                               Illness Trajectory
 Multimorbid             Advanced Chronic Illness        Terminal Illness
Chronic Illness



                    Advance
      AIM                            End-of-Life      Hospice        Death
                      Care
   Enrollment                         Planning        Referral
                    Planning




  Learn       Consider     Discuss       Choose     Document     Update

          Home-Based Evolution of Preference-Driven Care
AIM 2.0 Preliminary Outcomes
Sample 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

				
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posted:2/16/2012
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