1. Advanced Illness Management (AIM®)
Introduction

2. AIM Overview Learning Objectives
After participating in the presentation and discussion, participants will be able to:
Explain why the AIM Program was created
Describe the 5 Pillars of AIM
Describe the basic structure of the AIM Program

3. Defining Advanced Illness Management (AIM®)
AIM is a Care Management Model that Employs Evidence Based Principles of:
Care Coordination & Transitions Management
Palliative Care
Patient Engagement
Health Literacy
Self Management Support
AIM Is a Care Management Model that employs Evidenced Based Principles of:
Care Coordination and Transitions Management – these are areas that patients notoriously fall through the cracks or return home from the hospital with not enough support to adjust to their current state of health.
By becoming more aware of health literacy, and developing tools and skills associated with working with patients with various levels of health literacy, we can decrease errors, improve patient engagement and the consistency with which they use all the resources they have to help them manage more successfully at home
Palliative care – symptom management and advance care planning are two aspects of care that more community physicians either don’t have the time or expertise to do. Patients receive ongoing expertise in symptom management 24/7 and continuing dialog about their disease progression and their preferences for care and support.
Patient Engagement is about ‘turning on’ the button where they feel involved, accountable, confident, and knowledgeable enough to act on their own behalf at home. This includes active caregivers and this helps prevent unnecessary trips to the ED for symptoms that could have been otherwise managed at home. It helps stabilize the array of symptoms the patient may have been experiencing for a long time.
Self Management Support – is about having tools that either a clinician or patient uses to improve the skills of the patient in managing their care, communicating their concerns and goals, and addressing symptoms early before they escalate so much they can’t handle it alone.
Relies heavily on Integrated Care Management principles, another Sutter Health educational initiative to have all clinicians education and confident in use of health literate tools and principles across the health care continuum.

4. Coordinated Across Time and Sites of Care Evidence Based Practices
Recap of AIM:
Palliative Care
Coordinated Across Time and Sites of Care
Evidence Based Practices
Person Centered
Beginning in the middle – Person centered care – focused on understanding personal goals and then ensuring care remains aligned with and supports those goals, whatever they may be.
AIM Uses Evidenced Based Principles – research based practices of many types for care management and palliative care. We will regularly update those practices when needed.
Coordinating care, not just after the hospital, is essential to helping all the providers stay aligned with the medication regimen and treatment plans. Staying connected to all the places the patient is receiving care, allows the loop to be tightened up and everyone involved to be aware of the person’s goals and most recent health status.
By adding palliative care into the AIM team, we provide access to symptom management support not otherwise available to the physicians supporting their patients. We also provide ready support for persons as their condition progresses.

5. What is the real need for a program like Advanced Illness Management?
Why AIM was Developed
In 2008, Sutter Health assessed the best practices across the nation to develop a system wide home based palliative care program and AIM was created.
Some of the best practices assessed were inpatient palliative care programs from other health systems, outpatient transitions of care models like Eric Coleman Transitions of Care Model.
Sutter had some best practices already in place with the Sutter Care Coordination program and Disease management which are telephonic care management programs, these programs provided strengths upon which to build the AIM program in the greater Sacramento area.

6. Physicians and Home Care Across Sutter Identified the Fragmented System Patients Experience
Patients have a 25% chance of receiving hospice care where they will spend 8 days on service before dying
Medicare will spend 28% of all their payments on a patient in the last year of life
Medicare will spend ~$214M per year for 5,000 patients in the last year of life
Patients living with advancing illness represent 5% of the population that spends the highest amount of Medicare dollars and take the most time and resources from providers
This information was gathered from a large 2008 research project called the Dartmouth Atlas Study. It looked at care to Medicare decedents in the last 2 years of life.
This slide recasts some of the utilization data included in the research study to illustrate what a person living with advancing illness in the Sutter Service area might have experienced in just the last year of life.
If I’m a person with advanced illness, I will likely spend 17 days in the hospital in the last year of my life, 12 of which will be in the ICU.
I will visit one of 9 different physicians some 54 times in that last 12 months. I will take many medications, at different times of the day, some of which are taken with food , some not with food, some need to be refrigerated and some don’t. Some my doctors know about, some they don’t.
I would have about a 25% chance of going onto to hospice care, where I’ll spend 8 days out of a 6 month benefit. The other 75% chance I have is to remain at home, get sicker, and most likely die in the Emergency Department or Hospital.
Amazingly, Medicare paid approximately $214 Million per year for the care of 5000 patient in the last year of life. 5% of patients spend the highest amount of Medicare dollars and take the greatest amount of time and resources to care for them.
Source: Data of Sutter Experience –”The Care of Patients with Severe Chronic Illness”. Dartmouth Atlas, 2006

7. Total Medicare Spending
28%
28% in Last Year of Life
8% in Last Month of Life
Variation = Overtreatment:
Hospitalization
Readmissions
ICU days
LOS
ER Visits
Specialty consults
Tests, procedures 8%
$ per Decedent
This graph simply shows where Advance Illness Patients are receiving their care in the last year of life. 28% of what Medicare spends on a beneficiary in their lifetime, is spent in the last year of life. The red portion of the bars on the graph show the increasing utilization hospital based care. Consider the exhaustion the patient and their family experience during this time The top three diagnosis groups are heart failure, metastatic cancer and end stage renal disease on dialysis with comorbidities
Some health systems have created programs focusing on specific diagnosis, such as heart failure as a place to begin to build their programs.
Dartmouth Atlas 2008
Months Prior to Death
US Dept. of Health & Human Services 2003

8. AIM Program Implementation (AIM®)
As of June 2014…
Person Centered, Evidence Based, Coordinated Care + Palliative Care
For Persons with Advancing Illness:
Last Months of Life
High Symptom Burden
Clinical, Function or Nutritional Decline
5 Pillars of Care
Advance Care Planning; Symptom Management; Medication Management; Physician Follow-up Visits; Patient Engagement/Self Management Support
Fills in Gaps of Care;
Continues even when feeling well;
Frequent and predictable MD communication
Integrated Care Management
Skills and Competencies
94% Depression Screening completed in 30 Days, 97% Advance Care Planning initiated w/in 30 days
Reduces Hospitalizations by 59%
Reduces ED Visits by 19%
Reduces ICU Days by 67%
Estimated to Reduces Total Cost of Care by 52%*
CMMI Grant ended in June 2015
– Sutter Health continues to fund and offer this program, operated by Sutter care at Home, , despite operating at a loss given current reimbursement methods
Outcomes have not yet been independently evaluated by CMMI.
“The project described is supported by Grant Number 1C1CMS from Centers for Medicare & Medicaid Services, Center for Medicare and Medicaid Innovation.”

9. Contributing Factors to These Adverse Trends
Uncontrolled symptoms
Gaps in service
Lack of regular MD follow-up
Short-sighted care plans
Learned behavior :
“Call 911”
Lack of focus on patient goals
These are factors that are contributing to that exhausting cycle of care in and out of the ED and hospital.
Challenge of Healthcare Providers to Uniformly Focus on Patient’s Goals, Preferences, and Values in Developing and Executing Care Plans
Traditional Prescriptive Care Model Not Hitting Its Mark Leading to Uncontrolled Symptoms
Gap in Services When Patient No Longer Meets Home Health Care Eligibility
Intermittent Visits with Physician Driven by Schedule or Acuity of Symptom
Disease Management and Transitions Management too Narrow in Scope or Too Short in Time Frame
Patient/Family Have Learned Pattern of Response – Increased Symptoms/ED/Hospital/Home

10. Creating A new model of care
Improving the patient experience
Creating A new model of care

11. 911 System Fragmentation System Integration New AIM staff & services
EHR
Patient Registry
HOSPITALS
• Emergency Dept.
• Hospitalists
• Inpatient palliative care
• Case managers
• Discharge planners
• Telesupport
• Triage
911
HOME-BASED SERVICES
• Home health
• Hospice
CRITICAL EVENTS
• Acute exacerbation
Pain crisis
Family anxiety
Hospital Liaisons
Standard explanation emphasizing the intent to move from system fragmentation to system integration
The new services added are found in BLUE: Hospital Liaison’s ( in Sutter Hospitals), Transitions RN and MSW, Triage RN’s and Telephonic RN case manager’s
MEDICAL OFFICES
• Physicians
• Office staff
Transitions Team
New AIM staff & services 11 11

12. Who is an AIM Patient? Target Population AIM Patient: Edward Fogarty
> 2 Chronic Illnesses; >1 Illness Advancing
Poly-pharmacy
Clinical, Functional, and/or Nutritional Decline
High Symptom Burden leading to repeat utilization
MD ‘Surprise Question’ 12 Months
AIM Patients have a variety of health states, depending upon when we receive the referral, patients may be ambulatory and 12 weeks post hospitalization. In other cases, they may just be getting discharged from their 5th inpatient stay in 6 months. Generally, this model of care targets patients with these characteristics.
Patients may also be hospice eligible, but not ready to discuss hospice with their care providers.
AIM Patient: Edward Fogarty

13. AIM Eligibility
High burden of disease and provider would not be surprised if patient died in the next 12 months AND at least ONE of the following:
Rapid/significant functional or nutritional decline
Recurrent hospitalizations or ED use
Hospice appropriate
AND the patient must have a “Sutter Connection”
Participants will be asked to “teach back” this slide

14. ARMS of AIM

16. AIM At-a-Glance Referral Sources Hospital Hospice Physician Death
Discharges
Referral Sources
Hospital
47%
Physician
35%
Home Health
17%
Hospice
55%
Death
18%
Other reasons
27%
55% of patients die at home on hospice services
Patients can chose to have AIM to the end of their life, whether at home, in a SNF or other facility, or in a hospital (if there are qualifying symptoms to manage
Patients do graduate from AIM with a prolonged prognosis and some move out of our service area to be closer to family and support systems

17. Arms of AIM: Hospital Liaison
Hospital based
Assesses AIM eligibility
Starts the AIM intervention
Provides ongoing follow-up for existing AIM patients
May triage patients to Hospice in the hospital
Active team member as opposed to more passive role of someone who accepts referrals and processes them

18. Arms of AIM: Home Health
Accesses Medicare and other insurances under Home Health Benefit
Offers RN, MSW, PT, OT, ST, HHA, RD
Time Limited, depending on insurance
Patients must be homebound, with skilled need

19. Arms of AIM: Transitions
Offers RN and MSW home visits
Provide teaching and health coaching
Not billed under Home Health benefit
No Cost to Patient
Skilled care, homebound not required
Sutter funded

20. Arms of AIM: Telesupport
Provide telephone contact with patients not receiving home visits
Provided by RNs in one central location
Frequency of contact dependent on patient needs
Provided by Sutter funding

21. After Hours Triage
Provide 24 Hour telephone availability to all AIM patients
Have access to Epic and HH EHR for all patients
Provide “Tuck In” calls when requested
Provide an explanation of a Tuck In call and when and why we use this service – clinical team requests Triage follow up evenings and weekends to support patient thru a change in medication, a change in symptom management or to continue to assess ability to self manage at home
Provide patient experience examples of building confidence in the AIM team and the coordination After Hours and weekends with physicians to obtain MD orders
Triage algorithms are based on national best practices and include the option to make a hospice referral prn 24/7

22. 5 Pillars of AIM

23. The 5 Pillars of AIM AIM Pillar Posters
You will hear a lot about the 5 pillars of AIM. They form the backbone of our interventions with patients and families.
These are unique to the Sutter Health AIM program. You’ve probably seen them before. However, in the AIM Model of Care, we are very intentional and proscriptive about how we use them to support patients. Review list and quickly define then move to detailed slides that follow
AIM Pillar Posters

24. AIM Pillar: Personal Goals and Advance Care Planning
Focus on patient values, needs, and preferences (goals).
Assess level of understanding of disease.
Facilitate choice of DPOA and completion of POLST.
Assess Hospice readiness.
Values, needs, and preferences change with advancing illness….ask about POLST and person-centered goals at every opportunity.
Advance Care Planning
We use Motivational Interviewing techniques to establish what matters most to the person and their family as the center, guiding principle for AIM
We use the concepts of Sutter Health Integrated Care management which includes best practices used across the health system when a person sees their doctor or specialist who can discuss how the person is meeting their personal life goals

25. AIM Pillar: Red Flag Symptoms
What is a Red Flag?
What symptoms are most likely to cause this patient to decompensate and go back to the hospital or emergency room?
Patients/caregivers identify signs of worsening illness and get help before they lead to a full fledged problem and/or possible ED visit.
Red Flag Symptoms
AIM staff coach people using evidence based best practices including Stoplight Tools developed by Sutter Health.

26. Examples of Red Flag Symptoms:
Pain
Anxiety
Depression
Shortness of breath
Nausea/vomiting
Constipation
Falls
Signs/symptoms of infection
Red Flag Symptoms
We have more than 40 stoplight tools that are health literate, written at a 5th grade level and are easy to teach and use. These include disesases, symptoms, high rigk medications and quality of life tools for use by our social work team members.

27. AIM Pillar: Medication Management
Reconcile meds ordered by physicians with what is taken at home.
Provide patient-friendly medication list to patient and caregiver.
Coach to develop strategies for remembering and adhering to medications.
Medication Management
Quiz question : What steps would you take to reconcile medications when there is confusion among EPIC list, hospital d/c list, and meds in the home?
 Have patient describe techniques for remembering and adhering to medications
“in the last week/few days/yesterday, how many times have you missed a dose of any of your medications?”
what, when, how, why, and adverse effects
Health literate tools: High alert medication Stoplight tools, Morphine tools.

28. AIM Pillar: Follow-up
AIM RN to make home visit to patient within hours of hospital/ED discharge.
Ensure follow up physician appointment for patient within 7 days of discharge.
“Patients who received follow up with PCP within 7 days of discharge, had the lowest readmission rates” (Lin et al., 2011).
Lin C, Barnato A and Degenholtz H. (2011). Physician Follow-Up Visits After Acute Care Hospitalization for Elderly Medicare Beneficiaries Discharged to Noninstitutional Settings. The American Geriatrics Society. 59 (10), p
Follow up
Question : In what amount of time should an AIM patient have a follow up visit with a primary physician scheduled after a hospitalization?

29. AIM Pillar: Patient Engagement and Self Management Support
Health literate tools and methods used in AIM for Patient Engagement:
Person-centered goals
SMART Goals (Specific, Measurable, Achievable, Realistic, Timely)
Motivational Interviewing
Personal Health Record (PHR)
Patient-friendly medication list
Stoplight tools
Chunk and check (Teachback method)
Patient Engagement
Patient Engagement refers to how AIM clinicians encourage and support patients and families to be active participants in managing their own health. Effective patient engagement requires clinicians to integrate health literacy into health care delivery. Patient engagement incorporates the use of effective tools and teaches self management methods to improve self-assessment of health status. In addition, patient engagement uses respectful ongoing dialogue to ensure that patient preferences, values and needs guide all clinical decisions. Open ended questions to promote dialog without judgement.
All Sutter care at home staff are educated in use of Open Ended Questions, Motivational Interviewing, identification of barriers to health literacy, et al

30. AIM with the Sutter Health System
AIM Program results

31. How Do We Know AIM is Working?
Care at the End of Life
Outcomes, Resources and Costs
% Transferred to Hospice
LOS of Hospice Stay
% Died in Hospital
Hospital Days in Last 6 months of life
ED Use in Last 30 Days of Life
ICU Use in Last 30 Days of Life
Inpatient and ED visit Rates per 100 patients
30, 90 and 180 Day Pre/Post Enrollment Utilization
Hospital ED
ICU
90 Day Payer Impact, Hospital Cost Impact, Total Cost of Care
Independent Research and Evaluation
Click here for AIM Results
These things make life easier and better for the patient—AND they save money. It is truly a win-win.
This just shows some of the other times of measures we are tracking – some 50+ measures in all.

32. Number of AIM Patients on Service (Quarters are noted per CMMI Award Cycle; Last reporting Quarter was through March 2015)
This shows the growth in the AIM census going back to July 2012 thru March 2015, during the CMMI grant period.
Each color shows the census for that segment of the program.
Each quarter, our census grows. Today we have over 2500 patients census per day
To serve this large population, we continue to develop an infrastructure to support i ongoing operations and create a sustainable model

33. AIM Locations Across Sutter’s Service Area
Theses are the Aim locations across the Sutter Health footprint

34. Where does AIM Get Its Funding?
For home health, care is funded by traditional insurance reimbursement
For other arms of AIM, care is funded by:
Sutter Health System
Payer Contracts
Payer contracts are PMPM

35. As AIM Continues to Grow and Improve, We Continue to Seek Permanent Payment Solutions
Successful Pilot
Successful Expansion Demonstration; CMMI Program Evaluation Completion
Test of Payment Model and Multi-Site Expansion; Continued Work with CMS, as well as other payers
Changing models of care takes time. That is the message we continually hear in DC. Sutter Health is committed to AIM and its continued growth and expansion. We have our own internal research team within Sutter Health validating our results. We are working with CMS on possibly moving to a multi-site (multi-state) expansion that would also test a new payment model.
Changing a health care model takes time. With continued support from Sutter Health and other sources, our work will continue into the future as we continue influencing payers to formalize an Advanced Illness Model of Care for this population of patients.

36. Better Health, Better Care, and Lower Costs
AIM…
Better Health, Better Care, and Lower Costs
The RIGHT Care
The RIGHT Time
The RIGHT Place
Overall, AIM is trying to help a patient receive the right care, at the right time, in the right place in order to achieve the TRIPLE AIM of Better Health, Better Care, and lower costs.

37. What Questions do you have? I have time.