Young Hand Holding Senior's HandIn the first two parts of our end-of-life care series, we explored the current state and new innovations in the field of end-of-life care.

Today, we are featuring an email and phone conversation with Betsy Gornet, program lead for Sutter Health’s Advanced Illness Management® (AIM) program, where we explored the AIM program in depth and discussed the challenges presented when building these kinds of programs more broadly.

Can you briefly tell me about your organization, Sutter Health?

Sutter Health is a not-for-profit health system comprised of hospitals, physician organizations, outpatient surgery centers, research organizations and additional health care services across Northern California. Sutter Care at Home, which is part of the Sutter Health network, provides home health, hospice, home infusion therapy, home medical equipment, respiratory therapy, and private services (such as private duty nurses) to the patient in their home.

Generally speaking, what’s broken, missing or lacking when it comes to end-of-life care today?

What is lacking is the ongoing conversation between a health care provider and a person living with chronic illness regarding life goals, care options, care choices, and other important quality-of-life decisions. These things evolve over time and, frequently, health care providers only have intermittent methods of discovering what their patients are thinking and feeling.

Across the health care industry, each component of the health care delivery system – physicians, hospitals, mental health providers, and home care providers – does not have an effective way to share information and coordinate care between their function and the patient. Each is able to do that individually with the patient, particularly as it relates to a visit or hospitalization, but not necessarily over time and certainly not between each component.

When a patient is more stable or is at home, particularly if they are living with advancing chronic illness, they are often riding a roller coaster of symptoms and are living from health crisis to health crisis. Without current information, planning and care management, patients and their health care providers often merely react to manage the immediate crisis.

The failure in having a comprehensive, patient-developed care plan frequently results in patients receiving care that they didn’t really want or care that is mismatched with a patient’s goals. This cycle is evidenced by patients’ multiple trips to the emergency department, frequent hospitalizations, frequent physician appoints, and/or undergoing batteries of never-ending tests. If asked, patients will often express frustration or confusion over the necessity of such care, as well as a desire to stay home and find better ways to manage their illness in a more predictable and less complex way.

Why aren’t primary care physicians able to be more involved in “bridging the gap” and serve as a more continual point of contact?

It is incorrect to assume that every patient has a primary care physician identified or that the patient has an ongoing relationship with that physician or that the patient even knows who the primary care physician is.

These are patients with multiple chronic illnesses that, for example, may be seeing as many as 15 different physicians in a year. Patients can have complex things going on—particularly as their diseases progress. They may have multiple physicians ordering medications, ordering tests, making decisions, interpreting what the patient’s wishes and desires are, or updating or not updating their patient’s goals. With so many physician and other provider interactions, it should come as no surprise that the patient is faced with conflicting health care approaches, goals, and advice.

What is commonly needed is a framework for effective decision-making and someone with a sound understanding of the patient and her goals to serve as a tie-breaker in instances such as: who gets to decide if there’s a serious medication conflict? Who’s going to facilitate the negotiation or intervention? It is not necessarily essential that that person be a specific type of physician, but they should be a physician.

Also important to understand is that, in this care environment, a health care provider such as Sutter Health needs to actively create or facilitate that primary care relationship because it may not exist naturally.

What was the impetus for the creation of the AIM program (learnings or gaps witnessed by the Sutter Health team)?

A desire to better match care and services with the actual goals of a person living with advanced illness provided the real impetus for the creation of the expanded AIM program.

Physicians within Sutter Health recognized the need to expand the level of coordination and continuity in care management available to people living with chronic illness. They recognized that there were opportunities to improve the experience of patients living with advancing illness through a more comprehensive and continuous approach of staying connected.

Initially, a care design team was formed through the network of physicians, nurses, care managers, and other leaders throughout the Sutter Health System. This team went to the available research to uncover what were the best practices and some of the failed practices of care management, advance care planning and palliative care. That information was then leveraged to design a new approach to caring for patients with advancing illness.

Four key conceptual underpinnings of the effort have been:

1) Evidenced-based care management and symptom management;
2) Active support of the patient/physician relationship through frequent communication and information sharing;
3) Primary focus on keeping up-to-date with the potentially changing care goals of the individual living with advancing illness; and
4) Improving the ability of a patient and his/her family to manage conditions or symptoms at home

Can you describe the AIM program?

The AIM program uses a nurse-led interdisciplinary team to bridge the gaps with ongoing conversations, planning and sharing between the hospital, the community physician’s office, and the home for our sickest patients. This means providers and hospitals have the most up-to-date information regarding their patients. AIM supports coordinating the provision of the right care, at the right time, at the right level of care for the personal goals of someone living with advancing chronic illness.

When a patient first comes into AIM, there’s a period of time when we’re providing these support services in the patient’s home. At that stage, the focus is on assessing the home environment and caregiver arrangements. We have a set protocol that AIM team members follow regarding identifying each patient’s personal goals such as: how they want to live, their care choices, what type of symptoms typically cause problems, the crisis plan to manage those problems, and/or at what point should the physician or the AIM team be called to help mitigate the progression of symptoms that may necessitate a call to 911.

We teach the use of a personal heath record so that the patient and family may have a structured way to record their goals, list questions for their doctors and write instructions provided by the AIM team or physicians. This helps the patient and family engage more fully in their own self-management and communication with their providers.

After this initial phase of home-based visits focused on assessments, stabilization of symptoms, and initiation of the care management elements, the patient is transitioned to on-going support via a tele-management team. The tele-management team consists of nurses who are sometimes embedded in physician offices and sometimes stationed at a remote call center. If the nurses are embedded, they have the added advantage of being able to have real time interaction with a patient’s physician.

If the tele-management team sees another problem or a symptom worsening, the nurse can talk with the physician rather than sending the patient to the emergency room and, if more intensive tracking is immediately needed, we can send an AIM team member to the home to do an assessment and then update the physician. This is an example of how the AIM team can help coordinate care and address the patient’s situation before it escalates into an emergency. Additionally, the tele-management team continues the ongoing discussion with the patient and family regarding their personal goals and advanced care planning needs. These notes are viewable by the patient’s physician at any time.

What are the key success factors for the program (what does the success of the program hinge on)?

Key success factors of AIM include the structure and collaboration of the AIM team across sites of service (e.g., the hospital, in physician offices and in the patients’ homes), the consistent training received by all members of the AIM team, and a team priority that focuses on keeping the patient’s provider’s up-to-date on the patient’s status.

Fundamental to all of this coordination, though, is that the AIM care team has an ongoing awareness of the patient’s goals, care choices, quality-of-life decisions, and – overall – what’s most important to that individual.

What have been the results to date from the program?

After initial analysis of data since 2010, our Sacramento area pilot showed reduced unnecessary hospitalizations, mitigation of acute episodes, and improved care transitions, contributing to an improved quality of life for patients enrolled in AIM.

Some specific examples:

    • Reported a 75% reduction in ICU days, an average decrease of one or more days for hospital stays, and more than 50% reduction in hospitalizations at 90 days post-enrollment
    • Showed high patient and family satisfaction (4.7 out of 5)
    • Reduced costs for payers by $5,000 per patient at 90 days post-enrollment

Based on these results, the Centers for Medicare & Medicaid Services (CMS) recently awarded Sutter Health a three-year, $13 million Health Care Innovation Award to support the expansion of AIM throughout Northern California.

What are some of the challenges or constraints to building out these kinds of programs more broadly?

One of the things we learned in designing the AIM program was that different populations of patients, based on the status or progression of illness, have very different needs and a care management program that fits one population is not necessarily effective for all populations.

Even with that specific focus on the needs of these patients, we have encountered other challenges such as:

The multiplicity of options in which advanced illness individuals seek and receive care presents a coordination challenge for programs such as AIM. For example, it is very difficult to create and maintain various care providers up-to-date on a patient’s goals and health status when the patient has received or does receive care from multiple hospitals, physicians, and other providers, that may not have any processes in place for communicating with each other.

As we extend the program into different communities within Sutter Health’s regional footprint, we learn that each location has different relationships and arrangements, each of which must be considered and each of which may impact the implementation in some way. Examples are that each area may have different contractual arrangements, different payment arrangements, different levels of physician engagement in care management, different mixes of primary care physicians and specialists, and/or different information systems.

Another barrier to implementing programs such as this includes the lack of a payment model that recognizes this type of ongoing care management model and comprehensive approach to care. Changes in federal policy are necessary to facilitate national implementation of AIM-like programs. If ACOs and bundled payments were to be implemented, the patient-centered, cost-saving advantages of AIM would be obvious.

Part of the innovation grant process is to deploy a program that has shown initial successes and determine if that success can be more broadly replicated. The grant program is looking for improved approaches to spreading programs which bring positive change in terms of better care, better health and lower costs to a greater number of beneficiaries.

The CMS Health Care Innovations Award program includes a self-monitoring plan and an external program evaluation plan. The self-monitoring plan is intended to help the awardees better evaluate the outcomes of the program. The external program evaluation plan is focused on validating results and evaluating the applicability of the program to a larger population of patients. Both plans overlap and collaborate on resources and benchmark opportunities, and share lessons learned. We’re also trying to work with other CMS awardees who are working with a similar population of patients. We’re trying to align indicators that we can benchmark against each other. We conduct conference calls to facilitate this, and as we all begin producing outcomes data, we’ll be sharing results and best practices.

That’s also the value of these innovation grants. This particular grant program will look at whether we’re getting the care outcomes for the individual living with advancing illness that we’re looking for, if it is lowering the cost, and what might be the best mechanism to reimburse this service in the future.

Interestingly, with all the health care reform legislation and the different opportunities for projects, demonstrations and innovations, many new models of care are being tested. I think that’s very courageous of the health system – to get so engaged and really try to develop innovation before there’s a clear mechanism for paying and investing in it. I think globally there is a real commitment to change and improvement, that – in my career – I’ve not seen before. It’s a really exciting time to be a part of the health care delivery system and to have the opportunity to see positive outcomes for those we serve.

About Betsy Gornet

Betsy has more than 25 years of experience managing and leading health care organizations across the continuum of care, including acute and specialty hospitals, long-term care, physician practices, home health and hospice. Currently, she is the AIM executive for the Sutter Health AIM Program and Chief Hospice Executive for Sutter Care at Home, a home-care-based affiliate of Sutter Health in Northern California.

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