Problem Addressed

• Growing need for end-of-life care: Between 2009 and 2030, the number of Americans age 65 and older is expected to grow from approximately 39.6 million (representing 12.9 percent of the population) to 72.1 million (19 percent of the population).¹ As the elderly population increases, the need for advanced illness care will grow as well.
• Focus on (often unnecessary and unwanted) acute interventions: Elderly patients with advanced illness and their family members often do not understand the potential benefits and burdens of medical treatments, and have inaccurate perceptions of the likelihood of recovery from late-stage illness.² Consequently, medical treatment at this stage of life often consists of acute interventions that yield little benefit in terms of health, mortality, or quality of life.³ When patients and family members have a better understanding of the prognosis and the pros and cons of various interventions, they often choose comfort-focused treatment rather than acute interventions; for example, nearly one-fourth of patients with severe heart failure state they would rather receive such treatment than life-prolonging interventions.^3,4
• Unrealized opportunity to educate and support patients: Hospice services focus on symptom management, pain control, and emotional and spiritual support. Evidence suggests they can improve outcomes, reduce costs, and generate high levels of patient and family satisfaction.⁴ Yet only about 42 percent of patients who die in the United States receive hospice care,⁵ with the vast majority of these patients being white (roughly 92 percent of Medicare beneficiaries enrolled in hospice care are white).⁴ Innovative programs can help terminally ill patients and family members become aware of their treatment options—including hospice care—and help them in making end-of-life care decisions, but relatively few health systems offer such programs.^4,6

Description of the Innovative Activity

• The AIM care team: AIM services are provided by an interdisciplinary team consisting of nurses, social workers, health coaches, and physicians, who provide specialized care for patients in the hospital, in the physician’s office, and at their residence, whether at home or in a facility, through personal visits and by telephone.
• Identification and referral of eligible patients: AIM case managers based in both the hospital and physician offices work with hospitalists, members of the medical staff, hospital staff, community physicians, and home-care providers to identify patients who could benefit from the program. Appropriate patients include those with advanced disease(s) who meet any of the following criteria:
  • One or more chronic diagnoses
  • Questionable benefit from further aggressive treatment
  • Decline in functional and/or nutritional status in the past 30 days
  • Hospice eligible but not ready for hospice care
  • Frequent emergency department (ED) visits or hospitalizations in the last 6 months
• Ongoing dialogue related to patient wishes: The care managers meet with referred patients and families to describe the program, either in the hospital or office-based setting as noted above. They explain that patients need not forgo curative treatment to receive AIM services. Next, in the patient's home, through multiple conversations over time, the care managers engage with patients using motivational interviewing techniques, with conversations centering on the ill person's emotions, values, and personal goals, and the role of the AIM program in helping them achieve these goals. Specific topics covered include the following:
  • Advance directives: Advance care planning occurs over time at the ill person’s own pace. The care managers determine whether patients have an advance directive and help them create this document and modify it over time as illness advances.
  • Personal health record: The care managers introduce patients and families to a personal health record tool they can use to document health status, medications, and any questions they may have about care. The care managers encourage patients to use the personal heath record as a communication device to facilitate discussions with providers.
  • Wishes related to end-of-life interventions: Once immediate needs have been met and goals established, the care managers help patients and families complete a Physician Orders for Life Sustaining Treatment (POLST) form that outlines specific end-of-life treatment decisions in the form of a doctor’s order.
• Transition support for hospitalized patients: AIM care liaisons and social workers who are positioned in the hospital facilitate a smooth transition to home for AIM patients who are hospitalized. The goal is to further AIM care by ensuring that the patient, family, and hospital care team are coordinated and prepared for the discharge plan and that the primary physician is connected to the AIM team. Areas of work include initiation of advance care planning, medication management, symptom control, and planning for followup care.
• Provision of home-based care: The AIM team works with physicians to coordinate home-based care, which includes a custom mix of comfort care and disease-modifying treatment (e.g., intravenous therapy). Sutter's home health program provides AIM services to patients who have insurance covering these services, while the AIM transitions team provides home services to patients who are not eligible for home health. In both cases, patients receive 30 to 60 days of home care (more if necessary), including at least 4 to 6 visits from a nurse and several visits from a social worker. These team members solidify the care plan with patients and families; care plan elements include care planning, symptom self-management through the development of a proactive crisis plan for red flag symptoms, medication management, and safety.
• Telephone monitoring: Once patients have been stabilized and no longer require home health services, they receive regular telephone calls from the AIM care managers (either office-based or in a call center) who quickly alert the patient’s physician if the patient begins to decline. At this point, the patient might be admitted to the hospital, transitioned back into home care, or receive palliative care services, according to his/her stated wishes.
• Transition to hospice: AIM services continue until patients are transferred to hospice (if desired) or reach the end of life. During this process, the AIM team helps patients transition from medical interventions to comfort-focused care, depending on their wishes, and helps them complete and/or modify advance directives.

References/Related Articles

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Results

• Increased use of hospice care: A retrospective study found that 47.2 percent of terminally ill Medicare patients participating in an early version of the AIM program were discharged to hospice care between 2003 and 2005, well above the 33.8-percent and 15.8-percent hospice discharge rates in two similar groups of patients who did not participate.⁴ African-American patients (who tend to be ambivalent about hospice care) who participated in AIM chose hospice care four times as often as African Americans in the other two groups, making them about as likely to choose hospice care as white AIM patients.⁴ Preliminary, unpublished data indicate that roughly two-thirds of the 400 patients enrolled in AIM between November 2009 and September 2010 chose to enter hospice care.⁷
• Lower inpatient and ambulatory utilization: Preliminary, unpublished data from November 2009 through September 2010 indicate that 413 AIM patients who lived at least 90 days following enrollment experienced 54 percent fewer hospitalizations over those 90 days (compared with the 90-day period before enrollment). Over the same period, intensive care unit days were reduced by 80 percent and length of stay on subsequent admissions was reduced by 26 percent. A 52-percent reduction in physician visits was also seen, although telephone encounters between doctors and their patients increased by 10 percent.
• Lower costs and health system savings: The decline in utilization translates into average cost savings to Medicare of $760 per AIM enrollee per month.⁷ Net of all revenues and direct costs for hospital, physician, home health, and hospice, health system savings amounted to $213 per enrolled patient per month.
• High satisfaction: Survey data show that patients, family members, and physicians are highly satisfied with the AIM program.⁷
• Ongoing evaluation: Sutter is evaluating AIM’s impact on various quality indicators, including readmissions within 30 days of discharge, emergency department use, falls at home, patient and caregiver satisfaction, patient quality of life, and hospice use. This analysis will also examine the program's impact on revenues and costs at the hospital, medical group, and home care levels.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Design group: The senior executive responsible for the Sutter Medical Network created a design group comprising physicians, the chief medical officer and chief hospice executive from Sutter Care at Home, home care and hospice providers, and others. The group gathered evidence-based research on best practices in care for advanced illness and then took a fresh look at Sutter’s care processes for these patients. The group designed a new care model based on best practices, taking into account unique features of Sutter’s care environment. The team also designed a plan for implementing the new model.
• Training: AIM staff attended a 4-day, case-based training session. Sessions covered topics and communication strategies relevant to AIM participants, such as the definition of and philosophy behind palliative care; a review of the AIM program's purpose and key features, steps in identifying patients who could benefit from AIM; and education on disease processes, symptom management, goal clarification, advance care and contingency planning, facilitating difficult conversations, and death and dying. Hospice and home health social workers, physicians, and nurses served as trainers. After completing the sessions, participants completed an examination and then attended a 1-hour review session 2 weeks later. On an ongoing basis, care managers and other AIM staff participate in biweekly case conferences that promote team learning, and new AIM staff attend similar training sessions as part of their orientation to the program.
• Integration into electronic medical record: An AIM profile was created as part of Sutter’s electronic medical record to integrate AIM documentation and care.
• Launch and expansion of revamped program: The revamped AIM program was launched in two Sutter hospitals and three large medical groups in the Sacramento/Sierra region in November 2009. In 2012, Sutter plans to expand the program to another region, and will eventually roll it out across all five Sutter regions, at which point it will serve an estimated 5,000 patients annually.

Resources Used and Skills Needed

• Staffing: Although AIM relies primarily on existing staff, several new staff positions were created to provide new care management services. Current staffing to provide AIM services in three hospitals consists of three care liaisons (one at each hospital), two full-time equivalent (FTE) case managers (nurses, social workers or nonclinician health coaches), six home care nurses, one social worker, and a part-time medical director (0.2 FTEs).
• Costs: Program costs average roughly $900 per participant per month.

Funding Sources

Getting Started with This Innovation

• Recognize potential negative financial impact: This program involves some services that may not be eligible for reimbursement by Medicare (e.g., care coordination, hospital-to-home transition care, and home-based care for non–home-health-eligible patients), and, if successful, it may reduce use of inpatient and other services that would have qualified for reimbursement under traditional fee-for-service payment (thus having a negative impact on revenues). Consequently, in some circumstances payers may accrue much of the program's benefit, while the sponsoring organization absorbs a financial hit. Would-be adopters, therefore, will need to analyze the potential financial impact and decide accordingly. For their part, Sutter executives accepted the modest negative financial impact of the program because they wanted to provide better care at the end of life and to position Sutter at the leading edge of preparing for new, risk-sharing and shared savings reimbursement models.
• Develop interdisciplinary team: Include people with complementary skills and viewpoints on the project design team, allowing them to build on each others’ input.
• Implement program system-wide: Placing staff in nonhospital settings is necessary to manage patients over time and prevent readmissions.
• Start with modest goals; enhance over time: Start the program with modest, concrete goals, such as increasing hospice admissions by a realistic amount. Over time, enhance the program based on lessons learned from patient and staff experiences.

Sustaining This Innovation

• Cultivate senior management liaison: Cultivate a senior leader who serves as a program advocate and liaison to the rest of the senior management team.
• Push for continued system integration: Providers may become overly focused on their own roles and lose sight of larger program goals related to patient transitions. To overcome this tendency, continually emphasize the importance of care coordination and communication among providers in all care settings.
• Advocate for better reimbursement: Program leaders should look for opportunities to advocate for reimbursement of care coordination and other value-added AIM services.

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