Advanced Illness Management
Sutter Health
Lois Cross RN BSN ACM
Sutter Health
crossl@sutterhealth.org
Sutter Health
Serving more than 100 cities and towns in
Northern California & Hawaii with:
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25 acute care hospitals (multiple facilities do transplants)
3 Patient Transfer Centers
Ambulatory Surgery Centers
Urgent Care Facilities & Care Centers
5,000 physician members of the Sutter Medical Network (5
Foundations, 4 IPAs)
Approximately 48,000 employees
Home health, hospice & long-term care services
Medical research and training
$2 million a week in charity care
5 Regions & 6 Boards of Directors
Culturally diverse population
Competitive environment w/ heavy Kaiser presence & multiple
Academic centers
A Missing Link?
HF
“Curative”
Treatment
COPD
DM
etc
Advanced
Illness
Management
(AIM)
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Comfort
Care
Goals of Program
• Patient Centered
• Evidence Based
• Patient experience is important across time and all
settings
• Support patient that may be actively pursuing curative
treatments
• Coordinate care around patient’s goals to improve
patient well being and quality of life
• Reduce avoidable hospitalizations, ED visits
• Reduce physician practice burden
• Provide improved access to quality comprehensive end
of life care for patient and family
Key Elements
– Patient (caregiver) Support
– Individualized Care Plans
• Patient-centered: patient’s care goals, that may change as
illness progresses
• Curative and comfort
• Psychosocial and spiritual
• Access to decision support & advice
• Advance care planning
– Care Coordination Across Health System
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Team approach with providers
PCP relationship is critical to success
Coordinate care over an extended period of time
Integrated with inpatient palliative care
Data driven continuous improvement
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Team Members
• AIM Care Liaison
• AIM Home Health Team
RN/SW/PT/OT
• Transitions Nurse
• Office Based Case Manager
6
Changing the Focus of Care
EHR
• Patient Registry
HOSPITALS
• Emergency Dept.
• Hospitalists
• Inpatient palliative care
• Case managers
• Discharge planners
911
• Telesupport
• Care Liaisons
HOME-BASED SERVICES
• Home health
• Hospice
MEDICAL OFFICES
• Physicians
• Office staff
• Transitions Team
• Case Managers
• Telesupport
New AIM staff & services
CRITICAL EVENTS
• Acute exacerbation
• Pain crisis
• Family anxiety
AIM 2.0 Eligibility and Care Processes
• Eligibility
• Enrollment requires:
– Identified PCP
– Utilizes Sutter hospital or SMN
physician
• Clinical criteria:
– End stage chronic illness, or
– Would not be surprised at
death in next 12 months, or
– Clinical, functional, or
nutritional decline, or
– Eligible for hospice, but not
ready
• 5 Pillars of Care
– “Red Flag” symptom
management
• Customized treatment +
comfort care
• Home crisis
management plan
– Medication management
– Follow-up visits
– Ongoing advance care
planning
– Personal health record
Staff Training
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Pillars
Symptom management
Motivational Interviewing
Teach Back
Advanced Care Planning
Cultural Issues
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Outcome Measures
• Adherence to model supports patient centered goals
and evidence based practices
– Measured in terms of completion of pillars at key times and
places
• Patient Experience – Engagement via crisis planning,
use of personal health record, and satisfaction surveys.
• Provider Experience- Satisfaction surveys; (Advisory
Committee)
• Utilization and cost of all health services – Hospital,
physician, home health, hospice, snf, etc.
• Improvement in number of referrals to and days of
care provided by hospice to an AIM patient
Program Evaluation Methodologies
• Pre / Post utilization and cost data 30 days, 90
days, 180 days - quarterly
• Comparative analysis with Dartmouth Atlas Data
Base -quarterly
• Comparative analysis with FFS Medicare non
Sutter Health patient population – final results
pending
• Concurrent control group- under consideration
Results- What do the trends look like?
• Descriptive Statistics
• Utilization Trends
• Cost Trends
General Description of Population
Total
Admissions
Current
Enrollees
1720
Diagnosis
44% Geriatric Frailty
39% Cancer
34% HF
19% COPD
16% Neurologic
AIM LOS
Median: 43 days
Mean: 65.5 days
Payer Mix*
51% Medicare FFS
21% Medicare Cap
12% Commercial FFS
8% MediCal
5% Dual Eligible
Referral
Source
MD Office=37%
Hospital= 35%
SCH=24%
~320
54%: 2 or more conditions
Advanced
Illness
Indicators
68% Hospice eligible
30% Self-rated health “poor”
31% Self-rated health “fair”
*Exclusive category, no patient overlap
90-Day Pre/Post Utilization Summary
% Reduction in Utilization
Year 2
2011
Current Rolling 12 Months
Q2 2011 to Q1 2012
Number of Patients
Year 1
2010
Sacramento
181
229
170
Percent Change in Hospitalizations
-58%
-59%
-62%
Percent Change in ED Visits
-38%
-40%
Number of Patients
-14%
Roseville*
64
270
194
Percent Change in Hospitalizations
-33%
-51%
-52%
Percent Change in ED Visits
-17%
4%
Number of Patients
-23%
Consolidated
245
499
364
Percent Change in Hospitalizations
-53%
-54%
-56%
Percent Change in ED Visits
-16%
-28%
-21%
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Hospital Care Intensity
90 Day Pre/Post AIM Enrollment
Year 1
2010
Number of Patients
Percent Change in ICU Days
ALOS (Days)
Number of Patients
Percent Change in ICU Days
ALOS (Days)
Number of Patients
Percent Change in ICU Days
ALOS (Days)
Year 2
2011
Sacramento
181
229
-81%
-80%
-1.8
-1.0
Roseville*
64
270
-25%
-87%
-1.0
-0.4
Consolidated
245
499
-75%
-84%
-1.6
-0.6
Current Rolling 12 Months
Q2 2011 to Q1 2012
170
-100%
-1.2
194
-25%
0.3
364
-81%
-0.2
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Medical Group Utilization Impact
% Change in Utilization
Year 1
2010
Year 2
2011
Current Rolling 12 Months
Q2 2011 to Q1 2012
30-Day
Number of Patients
Percent Change in MD Visits #
Percent Change in Telephone
Encounters #
354
657
584
-24%
-14.29%
-15.95%
2%
27.56%
25.09%
245
499
364
-19%
-3.95%
-3.88%
16%
26.24%
29.29%
178
322
219
-12%
-5.10%
-1.39%
16%
36.24%
41.13%
90-Day
Number of Patients
Percent Change in MD Visits #
Percent Change in Telephone
Encounters #
180-Day
Number of Patients
Percent Change in MD Visits #
Percent Change in Telephone
Encounters #
16
Dartmouth Atlas Comparison
(External and Historical Benchmarking)
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Sutter Sacram ento
15
20
25
30
Before AIM
Q1 2012
10
Sutter Ros eville
5
Interm ountain Health Care
AIM Pilot
0
Hospital days per decedent, last six months of life
Hospital Days Per Decedent
Last 6 Months of Life
2010- Q1 2012
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Year of death
17
40
Before AIM
30
Sutter Ros eville
20
Sutter Sacram ento
10
Interm ountain Health Care
(2003 - 2007 average)
AIM Pilot
Q1 2012
0
Physician visits per decedent, last six months of life
Dartmouth Atlas Comparison
(External and Historical Benchmarking)
Physician Visits Per Decedent
Last 6 Months of Life
2010-Q1 2012
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Year of death
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AIM 2.0 Financial Impact
Current Roling 12
months
2010
2011
Q1 2011-Q12012
Net Impact
Net Impact
Net Impact
Payers (Hospital, MD Visits, Home Care)
Number of
Patients
Charges Billed
to Payers
Charges Billed
to Payers per
Patient
Hospital Costs
Hospital Costs
Per Patient
All Costs
All Costs Per
Patient
245
499
364
($842,489)
($2,457,651)
($1,848,342)
($3,439)
($4,925)
($5,078)
Hospital Portion ( Inpt., ED, Obs)
($1,568,712)
($2,935,567)
($2,122,709)
($6,403)
($5,883)
($5,832)
Sutter Total Costs (Hospital, Physician Visits, Home
Health, Hospice, Unreimbursed AIM)
($966,470)
($1,435,907)
($815,918)
($3,945)
($2,878)
($2,242)
Opportunities
Infrastructure
• Every geographic area looks different
• Incorporating other agencies/hospitals
Hiring the right team members
Physician Engagement
Reports
Education
IT-Just In Time communication
• EPIC
• Home Care Home Base
Team Integration
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