Advanced Illness Management Sutter Health Lois Cross RN BSN ACM Sutter Health

Sutter Health 25 acute care hospitals (multiple facilities do transplants) 3 Patient Transfer Centers Ambulatory Surgery Centers Urgent Care Facilities & Care Centers 5,000 physician members of the Sutter Medical Network (5 Foundations, 4 IPAs) Approximately 48,000 employees Home health, hospice & long-term care services Medical research and training $2 million a week in charity care 5 Regions & 6 Boards of Directors Culturally diverse population Competitive environment w/ heavy Kaiser presence & multiple Academic centers Serving more than 100 cities and towns in Northern California & Hawaii with:

A Missing Link? “Curative” Treatment “Curative” Treatment Comfort Care Comfort Care HF COPD DM etc AdvancedIllnessManagement(AIM)AdvancedIllnessManagement(AIM) ? ?

Goals of Program Patient Centered Evidence Based Patient experience is important across time and all settings Support patient that may be actively pursuing curative treatments Coordinate care around patient’s goals to improve patient well being and quality of life Reduce avoidable hospitalizations, ED visits Reduce physician practice burden Provide improved access to quality comprehensive end of life care for patient and family

Key Elements –Patient (caregiver) Support –Individualized Care Plans Patient-centered: patient’s care goals, that may change as illness progresses Curative and comfort Psychosocial and spiritual Access to decision support & advice Advance care planning –Care Coordination Across Health System Team approach with providers PCP relationship is critical to success Coordinate care over an extended period of time Integrated with inpatient palliative care Data driven continuous improvement 5

Team Members AIM Care Liaison AIM Home Health Team RN/SW/PT/OT Transitions Nurse Office Based Case Manager 6

Changing the Focus of Care HOSPITALS Emergency Dept. Hospitalists Inpatient palliative care Case managers Discharge planners MEDICAL OFFICES Physicians Office staff HOME-BASED SERVICES Home health Hospice New AIM staff & services EHR Patient Registry 911 Care Liaisons Case Managers Telesupport Transitions Team CRITICAL EVENTS Acute exacerbation Pain crisis Family anxiety CRITICAL EVENTS Acute exacerbation Pain crisis Family anxiety

AIM 2.0 Eligibility and Care Processes Eligibility Enrollment requires: –Identified PCP –Utilizes Sutter hospital or SMN physician Clinical criteria: –End stage chronic illness, or –Would not be surprised at death in next 12 months, or –Clinical, functional, or nutritional decline, or –Eligible for hospice, but not ready 5 Pillars of Care –“Red Flag” symptom management Customized treatment + comfort care Home crisis management plan –Medication management –Follow-up visits –Ongoing advance care planning –Personal health record

Staff Training Pillars Symptom management Motivational Interviewing Teach Back Advanced Care Planning Cultural Issues 9

Outcome Measures Adherence to model supports patient centered goals and evidence based practices –Measured in terms of completion of pillars at key times and places Patient Experience – Engagement via crisis planning, use of personal health record, and satisfaction surveys. Provider Experience- Satisfaction surveys; (Advisory Committee) Utilization and cost of all health services – Hospital, physician, home health, hospice, snf, etc. Improvement in number of referrals to and days of care provided by hospice to an AIM patient

Program Evaluation Methodologies Pre / Post utilization and cost data 30 days, 90 days, 180 days - quarterly Comparative analysis with Dartmouth Atlas Data Base -quarterly Comparative analysis with FFS Medicare non Sutter Health patient population – final results pending Concurrent control group- under consideration

Results- What do the trends look like? Descriptive Statistics Utilization Trends Cost Trends

General Description of Population Total Admissions Current Enrollees 1720 ~320 Diagnosis44% Geriatric Frailty 39% Cancer 34% HF 19% COPD 16% Neurologic 54%: 2 or more conditions Advanced Illness Indicators 68% Hospice eligible 30% Self-rated health “poor” 31% Self-rated health “fair” AIM LOSMedian: 43 days Mean: 65.5 days Payer Mix*51% Medicare FFS 21% Medicare Cap 12% Commercial FFS 8% MediCal 5% Dual Eligible Referral Source MD Office=37% Hospital= 35% SCH=24% *Exclusive category, no patient overlap

14 90-Day Pre/Post Utilization Summary % Reduction in Utilization Year Year Current Rolling 12 Months Q to Q Sacramento Number of Patients Percent Change in Hospitalizations -58%-59%-62% Percent Change in ED Visits -14%-38%-40% Roseville* Number of Patients Percent Change in Hospitalizations -33%-51%-52% Percent Change in ED Visits -23%-17%4% Consolidated Number of Patients Percent Change in Hospitalizations -53%-54%-56% Percent Change in ED Visits -16%-28%-21%

15 Hospital Care Intensity 90 Day Pre/Post AIM Enrollment Year Year Current Rolling 12 Months Q to Q Sacramento Number of Patients Percent Change in ICU Days-81%-80%-100% ALOS (Days) Roseville* Number of Patients Percent Change in ICU Days-25%-87%-25% ALOS (Days) Consolidated Number of Patients Percent Change in ICU Days-75%-84%-81% ALOS (Days)

16 Medical Group Utilization Impact % Change in Utilization Year Year Current Rolling 12 Months Q to Q Day Number of Patients Percent Change in MD Visits #-24%-14.29%-15.95% Percent Change in Telephone Encounters #2%27.56%25.09% 90-Day Number of Patients Percent Change in MD Visits #-19%-3.95%-3.88% Percent Change in Telephone Encounters #16%26.24%29.29% 180-Day Number of Patients Percent Change in MD Visits #-12%-5.10%-1.39% Percent Change in Telephone Encounters #16%36.24%41.13%

17 Dartmouth Atlas Comparison (External and Historical Benchmarking) Hospital Days Per Decedent Last 6 Months of Life Q Q1 2012

18 Dartmouth Atlas Comparison (External and Historical Benchmarking) Physician Visits Per Decedent Last 6 Months of Life 2010-Q Q1 2012

AIM 2.0 Financial Impact

Opportunities Infrastructure Every geographic area looks different Incorporating other agencies/hospitals Hiring the right team members Physician Engagement Reports Education IT-Just In Time communication EPIC Home Care Home Base Team Integration 20