Advanced Illness Management Sutter Health

1. Advanced Illness ManagementSutter Health Lois Cross RN BSN ACM Sutter Health crossl@sutterhealth.org

2. 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:

3. A Missing Link? Chronic Disease Management HF COPD DM etc “Curative” Treatment Advanced Illness Management (AIM) Comfort Care ?

4. 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

5. 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

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

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

8. 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

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

10. 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

11. 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

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

13. General Description of Population *Exclusive category, no patient overlap

14. 90-Day Pre/Post Utilization Summary% Reduction in Utilization 14

15. Hospital Care Intensity90 Day Pre/Post AIM Enrollment 15

16. Medical Group Utilization Impact% Change in Utilization 16

17. Dartmouth Atlas Comparison(External and Historical Benchmarking)Hospital Days Per DecedentLast 6 Months of Life2010- Q1 2012 Q1 2012 17

18. Dartmouth Atlas Comparison(External and Historical Benchmarking) Physician Visits Per DecedentLast 6 Months of Life2010-Q1 2012 Q1 2012 18

19. AIM 2.0 Financial Impact

20. 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