Sutter Health Advanced Illness Management
(AIM®) Program
Jeff Burnich, M.D. SVP Medical and Market Networks
Sutter Health
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
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 triage 4
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
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
2423 2477 2668 1973 1042 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
% R
educ
tion
Inpa
tient
Adm
issi
ons
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
% Red
uc.o
n
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
% Red
uc.o
n
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)
