AIM (Advanced Illness Management)

 Care Coordination 
 CMS Demonstration 

Agency
Sutter Care at Home, Fairfield, California.
 
Agency Description
Sutter Care at Home (SCAH) is one of the largest not-for-profit home health care and hospice agencies in northern California. Founded in 1906, SCAH is committed to compassion and excellence in home care, hospice, home medical equipment, home infusion therapy, and respiratory care, serving more than 150,000 patients in 23 counties each year. As an affiliate of Sutter Health, SCAH is leading the transformation of home care to achieve the highest levels of quality, access, and affordability. 
 
Population Impacted
AIM caters to patients with advanced chronic illness, specifically an oncology diagnosis, heart failure, end stage neurological diseases, chronic obstructive pulmonary disorder, and end stage renal disease (ESRD). Sutter Health's AIM Care Team helps more than 7,000 patients in 15 counties of northern California to better manage their health in the comfort and privacy of their home. The current census is more than 2,100 patients and there were 85,000 patient contacts in the last 12 months. These patients are in their last year of life and do not have to qualify or be eligible for hospice at the time of admission to AIM.  This is palliative care and curative care provided concurrently.  
 
Strategic Partners
CMMI awarded Sutter Health a three-year, $13 million Health Care Innovation Award to support the expansion of AIM throughout Northern California. SCAH works closely with CMMI to report program results on an ongoing basis.
 
Project Description
AIM is a nurse-led care management program caring for patients with advanced chronic illness in their last 12 to 18 months of life. Currently, 335 staff members are trained in the AIM program. 
 
AIM integrates and navigates the health care system for the patient and their family, while tailoring symptom management and other care and treatment plans to the patient’s personal goals. The program is designed to extend and enhance the relationship patients have with their physician.  

All patients receive home visits initially when they are enrolled. During this time the clinical team learns about the patient’s health issues, lifestyle, and personal preferences to tailor a care plan that meets the patient’s needs. Once in the program, the nurse initiates the pillars of the program: 
 
  • Patient engagement in self-management
  • Medication management
  • Physician follow up, with communication and coordination
  • Advanced care planning and goal setting
  • Symptom management, including the identification of red flags
     
Physicians are highly satisfied with this program and appreciate the collaboration and teamwork from AIM. SCAH documents monthly summary notes into the physician's electronic medical record (EMR) so they are informed and are able to follow patients' progress. These notes include person-centered goals and status of advance care planning. The referring physician and/or primary care provider (PCP) are included in the plan of care and are partners with AIM and the patients mutually served by SCAH.
 
Results
The AIM program sees results in the following key areas:

Improving Health:
  • Improve transitions of care 
  • Improve quality of life of patients with advanced chronic illness  
  • Provide high patient, caregiver, and physician satisfaction  
Improving Care
  • Goals of care and advance care plans within 30 days of  enrollment 
  • Increase access for patient/family to comprehensive palliative care  
Lowering Cost of Care:
  • Medicare and other payer cost savings (aggregate and per enrollee)
  • Cost savings in providing care overall  
     
Outcome Measures:
After 90 days on AIM program, there was a 59 percent reduction in hospitalizations, a 19 percent reduction in emergency department visits, and a 67 percent reduction in ICU days.

Barriers to Implementation:
Barriers to successful implementation include difficulty with EMR integration. Currently AIM charts in two distinct Electronic Medical Records (EMRs); one for home health and another for the physician services. One of the biggest challenges for AIM is integrating this information while not creating more work for clinicians. An additional challenge is creating simple communication that allow for better care coordination across the health care continuum.