Abstract
Patients with advanced illness receive fragmented, hospital-based care that is unaligned with their preferences near the end of life. We describe a team-based intervention that provides home-based, coordinated care to more than 2,000 seriously ill patients daily in nineteen urban, suburban, or rural counties in California. In the last month of life, compared to matched Medicare beneficiaries in similar counties, this program reduced hospital days by 1,361 per 1,000 beneficiaries, hospital deaths by 8.2percent, inpatient payments by $6,127, and the total cost of care by $5,657 per beneficiary. The Centers for Medicare and Medicaid Services (CMS) has announced a new Medicare payment model for serious illness care, based in part on this program. To inform model development and implementation, we describe lessons learned about changing the focus of care for advanced illness from hospital to home, broadening care coordination to achieve system integration, and developing methods for payment and quality accountability that transform care delivery.
Highlights
Patients with advanced illness receive fragmented, hospitalbased care that is unaligned with their preferences near the end of life
To inform model development and implementation, we describe lessons learned about changing the focus of care for advanced illness from hospital to home, broadening care coordination to achieve system integration, and developing methods for payment and quality accountability that transform care delivery
In 2003 the program designers replaced CHOICES with Advanced Illness Management, a home-based palliative care program implemented within home health for seriously ill patients who fell through the cracks between hospital, home health, and hospice
Summary
Sutter Health provides comprehensive health care services through its network of hundreds of clinics, twenty-four hospitals, over 5,000 affiliated physicians, and home health and hospice services across Northern California. In 1999 the primary author (Brad Stuart) designed and implemented a home-based transition and support model[7] for Medicare’s managed care program called Comprehensive HomeBased Options for Informed Consent about End-Stage Services (CHOICES).[8] In 2003 the program designers replaced CHOICES with Advanced Illness Management, a home-based palliative care program implemented within home health for seriously ill patients who fell through the cracks between hospital, home health, and hospice. Further program changes occurred in 2012 after AIM received a $13 million grant in the first round of CMMI’s Health Care Innovation Awards to scale up and spread AIM across eleven sites that provided home health and hospice services to the entire Sutter system. The program evolved into a clinical integration model designed to change the focus of care for late-stage chronic illness from hospital to home. AIM continues to operate this way today
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