Integrated Care for Patients With Late-Stage Chronic Illness Advanced Illness Management (AIM) Medical Foundations & Groups Home-Based Services Hospitals.

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

Sutter Sacramento: AIM 2.0 Pilot Jan. 15, present Sutter Health: committed to lower Medicare costs Sutter Sacramento: Dartmouth Atlas benchmark 1 – Ranked with Mayo Clinic, Intermountain HC IP/OP case management in place Sutter VNA & Hospice: 10 year AIM experience 2 hospitals, 3 medical groups 1 Dartmouth 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 Telesupport ELECTRONIC PATIENT REGISTRY DISCHARGE TO HOSPICE

Care Coordination: Time Dimension AIM Enrollment Advance Care Planning End-of-Life Planning Hospice Referral Death Illness Trajectory Multimorbid Chronic Illness Advanced Chronic IllnessTerminal Illness Home-Based Evolution of Preference-Driven Care Learn ConsiderUpdateDiscussChooseDocument

AIM 2.0 Preliminary Outcomes Sample period: 11/9/09-9/30/2010 Days Pre/Post AIM Enrollment N  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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