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
Hospitals
Home-Based
Services
Medical Foundations
& 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
HOSPITALS
• AIM Care Liaisons
• Hospitalists
• Inpatient palliative care
• Case managers
• Discharge planners
• Emergency Dept.
PHYSICIAN
OFFICES
• AIM Office-Based
Care Managers
• Telesupport
ELECTRONIC
PATIENT
REGISTRY
HOME-BASED SERVICES
• AIM Transitions Team
• Home health
• Hospice
CALL
CENTER
• Telesupport
DISCHARGE
TO HOSPICE
CRITICAL EVENTS
• Hospitalization
• ER visit
• Physician request
• Acute exacerbation
Care Coordination: Time Dimension
Illness Trajectory
Advanced Chronic Illness
Multimorbid
Chronic Illness
AIM
Enrollment
Learn
Advance
Care
Planning
Consider
Discuss
End-of-Life
Planning
Choose
Terminal Illness
Hospice
Referral
Document
Home-Based Evolution of Preference-Driven Care
Death
Update
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