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Integrated Care for Patients With Late-Stage Chronic Illness

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

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Integrated Care for Patients With Late-Stage Chronic Illness

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

  2. 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 Sutter Sacramento: AIM 2.0 PilotJan. 15, 2010 - present 1Dartmouth Atlas Investigators. Tracking the Care of Patients with Severe Chronic Illness, 2007

  3. Care Coordination: Spatial Dimension CALL CENTER •Telesupport ELECTRONIC PATIENT REGISTRY • HOSPITALS • AIM Care Liaisons • • Hospitalists • • Inpatient palliative care • Case managers • Discharge planners • Emergency Dept. DISCHARGE TO HOSPICE CRITICAL EVENTS • Hospitalization • ER visit • Physician request • Acute exacerbation HOME-BASED SERVICES • AIM Transitions Team • Home health • Hospice PHYSICIAN OFFICES • AIM Office-Based Care Managers • Telesupport

  4. Care Coordination: Time Dimension Illness Trajectory Advanced Chronic Illness Terminal Illness Multimorbid Chronic Illness Advance Care Planning End-of-Life Planning Hospice Referral AIM Enrollment Death Consider Discuss Choose Document Update Learn Home-Based Evolution of Preference-Driven Care

  5. AIM 2.0 Preliminary OutcomesSample period: 11/9/09-9/30/2010 *Includes savings from reduction in Emergency Department and hospital-based outpatient services

  6. 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 Next Steps & Needs

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