Sutter Health Advanced Illness Management (AIM) 2016 Program Update (QI815)

Abstract

•Identify three measures of success for innovative palliative care programs serving the seriously ill patient population.•Identify three characteristics of the advanced illness population. Sutter Health’s AIM program began in 2009. We received a CMMI First Round HCIA three year grant in 2012. The ability to demonstrate value is critical to sustainability of innovative care models. The poster provides AIM program outcomes for 2016, as well as strategies for financing the program post-grant. The AIM program demonstrates the impact an innovative program to improve the experience and quality of care while lowering the cost. AIM program development included creating metrics for operational, clinical, and financial outcomes, and patient satisfaction. The team monitors process measures on a daily, weekly, monthly and quarterly basis to ensure program quality and effectiveness. Metrics demonstrate program value and identify opportunities for performance improvement. The program was evaluated by an independent review through the CMMI grant and determined to be of significant value. The 2016 AIM program highlights include an average daily census of approximately 2,700 patients receiving 119,000 contacts via phone or visit. The program serves patients over 19 counties in Northern California and received referrals from 1,900 physicians. 81.7 percent of patients served were Medicare age, and 32 percent had a primary diagnosis of cancer. 43 percent of AIM patients transitioned to hospice care. The AIM patient population experienced an 8 percent reduction in emergency room visits; a 60 percent reduction in hospitalizations; a 64 percent reduction in ICU utilization; and a 6 percent reduction in the average length of a hospital stay. Overall patient satisfaction was 86 percent. Advance Care Planning documentation was completed within 90 days for 97 percent of AIM patients. AIM is an effective model to support seriously ill patients. The reductions in high cost health care utilization translates into significant total cost of care savings. Sutter Health’s ability to implement and sustain AIM in a variety of markets demonstrates the ability to replicate the program within other health care organizations.