Sutter Health: Advanced Illness Management (AIM) Program (Jeffrey Burnich)
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Breaking the Mold: Fresh Approaches for Treating High-Cost and Chronically Ill Patients The hospital super-user can eat up almost half of a provider’s resources. But a focus on this population’s overall health – increasing access to primary care, addressing the social determinants of health, for example – is making a big difference. At some institutions, patients who once were routinely admitted to the hospital are now getting care in ambulatory settings, embedded in comprehensive systems of services for primary care and community health. Learn how hospital and health system leaders around the country are managing such transitions, how patients are faring and the outlook for better care and lower costs.
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Sutter Health: Advanced Illness Management (AIM) Program (Jeffrey Burnich)
- 1. Sutter Health Advanced Illness Management (AIM®) Program Jeff Burnich, M.D. SVP Medical and Market Networks Sutter Health
- 3. Advance Illness Management for persons with late-stage illnesses whose health is declining and who are at high risk of death within the next 12-18 months. What are AIM’s Core Principles • Patient Centered care that is coordinated, interdisciplinary, and goal directed • Concurrent Disease modifying and palliative care • Improves patient confidence in self managing chronic illness at home • Integration and coordination across sites of care, providers, and services 3 What is the Focus of the AIM program? • Teaching self efficacy • Enhancing understanding of disease progression and treatment options • Balance of personal goals, illness progression and advance care planning 3-Year Healthcare Innovation Award $13M; Sutter Health $21.4M Achieve $29M Payer Savings Geographic Spread – 19 Counties Achieve Better Health, Better Care, Smarter Spending Enroll 10,000 Evaluate Scalability & Replicability
- 4. High Level Outcomes and Highlights of the AIM Care Model • Continuous, Non-Episodic • In-Home Visits regardless of medical need or homebound status • Telephonic Visits • Hospital base support • Collaborative with patient’s primary and specialty physicians offices • After hours triage4 What are the AIM Interventions? The 5 Pillars of care: • Personal Goals and Advance Care Planning • Red Flag Symptom Management • Medication Management • Physician Follow Up Visits • Patient Engagement Access to AIM Services 19 Counties 9,640 Enrollees 94% Overall Patient Satisfaction Filled in Gaps of Care Estimated $64-91 M Savings What About Care Delivery? Current Census of > 2,800 Person
- 5. HOSPITALS • Emergency Dept. • Hospitalists • Inpatient palliative care • Case managers • Discharge planners MEDICAL OFFICES • Physicians • Office staff HOME-BASED SERVICES • Home health • Hospice • Telesupport • Triage New AIM staff & services • EHR • Patient Registry 911 • AIM Care Liaisons • Care managers • Telesupport • Transitions Team CRITICAL EVENTS • Acute exacerbation • Pain crisis • Family anxiety System Fragmentation System Integration 5
- 6. 6 2423 2477 2668 19731042 1051 1094 827 -57% -58% -59% -58% -100% -90% -80% -70% -60% -50% -40% -30% -20% -10% 0% 0 500 1000 1500 2000 2500 3000 Q3-13 to Q2-14 Q4-13 to Q3-14 Q1-14 to Q4-14 Q2-14 to Q1-15 %Reduction InpatientAdmissions All Sites Change in Inpatient Hospitalizations - 90D (Target Reduction is >50%) Results not yet confirmed independently by CMS evaluator 1160 1135 1230 911 925 966 1055 803 -‐20% -‐15% -‐14% -‐12% -‐100% -‐90% -‐80% -‐70% -‐60% -‐50% -‐40% -‐30% -‐20% -‐10% 0% 0 200 400 600 800 1000 1200 1400 Q3-‐13 to Q2-‐14 Q4-‐13 to Q3-‐14 Q1-‐14 to Q4-‐14 Q2-‐14 to Q1-‐15 % Reduc.on ED Visits All Sites Change in ED Visits -‐ 90D Target Reduc.on is >28% Results not yet confirmed independently by CMS evaluator 1089 1144 1269 936 392 422 404 286 -‐64% -‐63% -‐68% -‐69% -‐100% -‐90% -‐80% -‐70% -‐60% -‐50% -‐40% -‐30% -‐20% -‐10% 0% 0 200 400 600 800 1000 1200 1400 Q3-‐13 to Q2-‐14 Q4-‐13 to Q3-‐14 Q1-‐14 to Q4-‐14 Q2-‐14 to Q1-‐15 % Reduc.on ICU Days All Sites Change in ICU Days -‐ 90D Target Reduc.on is >60% Results not yet confirmed independently by CMS evaluator AIM and Outcomes –More Negative is Better Results not yet confirmed independently by CMS evaluators (N 2281 in last reporting period)