CASE STUDY CARE MODELS FOR HIGH-NEED, HIGH-COST PATIENTS JANUARY 2018 Supporting Patients Through Serious Illness and the End of Life: Sutter Health’s AIM Model Martha Hostetter Sarah Klein Douglas McCarthy Consulting Writer and Editor Consulting Writer and Editor Senior Research Director The Commonwealth Fund The Commonwealth Fund The Commonwealth Fund PROGRAM AT A GLANCE KEY TAKEAWAYS KEY FEATURES: Nurses and social workers in Sutter Health’s By proactively managing care Advanced Illness Management (AIM) program engage terminally for seriously ill patients, Sutter Health’s Advanced Illness ill patients, elicit and document their goals, and support them as Management program has they navigate their physical and emotional challenges. produced annual savings of TARGET POPULATION: Patients who are deemed by their providers $8,000 to $9,000 per patient. to be in the last 12 to 18 months of life, including those who may be eligible for hospice services but not ready to use them. While the savings from reduced hospitalizations and emergency WHY IT’S IMPORTANT: Even though most people say they want department care are substantial, to stay home and avoid stress and discomfort near the end of life, many of the program’s services are not reimbursable. health care interventions tend to increase dramatically during the final months, often producing little benefit and much suffering. Broader dissemination of the BENEFITS: By honoring patients’ wishes and better coordinating model may require policy and care, the program reduces total health care spending by as much as payment changes that reward $9,000 per year, chiefly by reducing acute care use. providers for investments in advanced illness management CHALLENGES: Knowing what level of care to provide to which services. patients and for how long, as well as overcoming workforce shortages. Negotiating new payer contracts to cover the unreimbursed expense of the program, which does not pay for itself under fee-for-service reimbursement. Supporting Patients Through Serious Illness and the End of Life: Sutter Health’s AIM Model 2 INTRODUCTION reticence and talk through options when curative In the recent documentary, Extremis, filmed in an ICU, a treatments no longer work. physician caring for extremely ill patients with no hope This is inherently challenging because the path between of recovery helps families understand their options and a terminal diagnosis and the decision to forgo curative decide whether to unplug the machines keeping patients’ treatment is rarely a straight line. Patients with serious alive. It’s wrenching to watch; all the more so because the illnesses are often caught in flux. They may have good and patients have not communicated their wishes to their bad days, or months, and their needs and goals change families, though one who is semiconscious repeatedly tries to pull out her breathing tube and another attempts, accordingly. They also may be struggling to make sense unsuccessfully, to scrawl a note. of new symptoms, their disease progression, and their prognosis, or harboring false hope, all of which make it Over the past decades, health care professionals — often more difficult to reach decisions. led by specialists in palliative care — have promoted advance care planning and urged patients to consider it The result can be a startling disconnect between what earlier in the course of serious illness. This gives patients, happens at the end of life and what most people say they family members, and providers time to overcome their want — to stay home with their loved ones and avoid Health Care Spending Trajectories of Medicare Decedents in the Last Year of Life With sudden illness, spending accelerates in the last month of life, but is persistently high for patients with chronic diseases who are entering the final year of life. AIM serves both groups. HIGH PERSISTENT High initial spending and steadily increasing spending throughout the last year of life (48.7% of decedents) MODERATE PERSISTENT Moderately high spending HIGH PERSISTENT initially followed by a dip and then an increase in the last four months of life (29%) MODERATE PERSISTENT PROGRESSIVE Spending Spending that started relatively low but increased steeply throughout the time period (10%) LATE RISE PROGRESSIVE Spending that was very low up to four months before LATE RISE death and then increased exponentially (12.1%) Months before death Copyrighted and published by Project HOPE/Health Affairs as M. A. Davis et al., “Identification of Four Unique Spending Patterns Among Older Adults in the Last Year of Life Challenges Standard Assumptions,” Health Affairs, July 2016 35(7):1316–23. The published article is archived and available online at www.healthaffairs.org. commonwealthfund.org Case Study, January 2018 Supporting Patients Through Serious Illness and the End of Life: Sutter Health’s AIM Model 3 stress and discomfort, rather than extend life as long as HISTORY OF ADVANCED ILLNESS possible.1 Instead, as people edge closer to death, they are often subject to a crescendo of medical interventions — MANAGEMENT AT SUTTER surgeries, fourth-round chemotherapies, respirators, PILOT In 1999 Sutter piloted an approach to and feeding tubes — often with little benefit and much improving care for patients with advanced illness who were enrolled in Medicare+Choice suffering. Seriously ill people who do make use of hospice plans, a precursor to Medicare Advantage services often enroll just days before their death.2 plans. Conducted in the San Francisco Bay Area, the pilot fielded a nurse and social “It’s what happens when you don’t focus on the transition worker to patients’ homes and borrowed concepts from Project RED (Re-Engineered from curative care to terminal illness,” says Brad Stuart, Discharge), a widely used approach to M.D., a hospice medical director who helped develop a planning and education for patients being discharged from hospitals, and the Chronic new approach to managing advanced illness at Sutter Care Model, which encourages proactive Health, a large nonprofit integrated delivery system management and planning for patients with chronic disease. in Northern California. Known as Advanced Illness Management (AIM), the program relies on nurses and EXPANSION In 2009, Sutter extended the program to the Sacramento area using nurses social workers to help patients with terminal conditions and social workers from the health system’s and limited prognoses (i.e., those in the last 12 to 18 Care at Home division, which offers home health and hospice services to some 160,000 months of life) navigate their physical and emotional patients a year. The teams were assigned to challenges. Stuart and others describe advanced illness support patients with high needs who did not qualify for home health care. The program management as a “transitional service” for people as they then served about 550 patients a year. move from intensive curative treatments to end-of-life SCALING ACROSS THE DELIVERY SYSTEM care. Describing it this way also helps enlist the support In 2012 Sutter won a $13 million grant from of clinicians, who may be wary of referring their patients the Center for Medicare and Medicaid Innova- tion, which enabled it to test and expand the to palliative and hospice care, which many see as “death model with Medicare beneficiaries in the care.” fee-for-service program. The health system invested an additional $26 million and used AIM staff coordinate often complex treatment regimens the combined funds to hire and train new staff and adapt the health system’s electronic and educate patients and families on recognizing signs medical record platform to serve AIM patients. of decline and asking for help to avoid complications. Over the three-year grant period, AIM served nearly 10,000 patients across 19 counties. The program also places a heavy emphasis on advance care planning to ensure patients’ goals and treatment preferences are elicited as their conditions evolve, which may mean more or less intensive care at the end of life. Sutter’s experience with AIM demonstrates the financial benefit of proactively managing care for seriously ill patients and honoring their wishes. After accounting for the expense of the program — between $2,400 to $2,500 per patient per year — it has produced savings to payers of between $8,000 and $9,000 per person annually, principally from reduced hospitalizations and emergency department care during the final months, and particularly the final month, of life. commonwealthfund.org Case Study, January 2018 Supporting Patients Through Serious Illness and the End of Life: Sutter Health’s AIM Model 4 This case study focuses on the development and effects THE AIM PROGRAM AT SUTTER HEALTH of AIM at Sutter, which has more than 5,000 affiliated physicians and 24 hospitals across Northern California. Patients Served The health system is working to spread its approach to AIM currently serves some 2,700 patients a day. Common advanced illness care across the organization by training conditions include heart failure, cancer, chronic staff in primary care, specialty care, and emergency obstructive pulmonary disease, end-stage renal disease, department and hospital settings to identify and refer and end-stage neural disease. Patients can be referred patients to the program. by providers at Sutter’s hospitals; about half enter the program that way. The rest are referred by primary or Programs like AIM are preparing for the so-called “gray specialty care physicians or home health and hospice tsunami:” by 2060, one-quarter of Americans will be 65 or providers. They can be any age and have any type of older, up from 15 percent in 2015.3 Given this demographic insurance coverage as long as they are patients of a trend, many more providers — not just those in the Sutter-affiliated clinician. When referring, physicians palliative care and hospice fields — will need to become attest that their patients have an irreversible disease and proficient in managing advanced illness and comfortable they “would not be surprised if they died in the next 12 talking about end-of-life options. months” — language that AIM leaders say is vague enough Shannon Hartman, one of AIM’s social workers, has been visiting once a week with Lon Pray, a 63-year-old retired teacher whose prostate cancer has metastasized to his bones. Two years ago, doctors told Pray he had between 18 months and two years to live. As the clock ticked by, he become obsessed with the amount of time he had left but felt he couldn’t open up in a doctor’s office. Pray says Hartman has helped him come to terms with a number of losses — from his physical stamina to his desire to socialize. “I went from going 90 miles an hour, taking care of the house, taking care of rental properties, to the point where I can’t do anything,” he says. His conversations with Hartman have helped him understand what’s happening to him and communicate with his wife of 27 years, Lynette, about his concerns about abandoning her. “I don’t know where I’d be without this program. It was a godsend,” he says. Lynette agrees. “They let you know what you’re going through is normal.” Hartman says a large part of her job is helping patients work through the same stages of grief that the bereaved contend with: denial, anger, bargaining, depression, and acceptance. “What I see over and over again is that when the patient gets to acceptance, the family follows,” she says. This comes easier to some patients than others. She works to dispel preconceived notions of what dying will be like. “Some have seen an unpleasant death and think the same will happen to them. I am constantly telling people, it’s not going to be your experience.” In the process she’s learned not to make predictions about what patients will want in terms of life-sustaining treatment. “I’ve seen 107-year-olds who want all resuscitation measures taken. I try to make it clear what that means so people understand it’s not like what you In addition to Shannon Hartman, L.C.S.W., Lon Pray meets with Carol see on television. You never stop finding new ways to talk Michel, R.N. about it.” commonwealthfund.org Case Study, January 2018 Supporting Patients Through Serious Illness and the End of Life: Sutter Health’s AIM Model 5 to accommodate uncertainty but clear enough to identify Program Structure appropriate patients. To be eligible, patients must also 4 To engage patients and their caregivers, the program is meet at least one of the following criteria: described as an “extra service” that offers educational tools and round-the-clock access to clinical staff for those • be deemed hospice appropriate, but not ready to with advanced illness. It is housed in Sutter’s Care at Home enter hospice (about 30 percent of AIM patients fit this division, alongside Sutter’s home health and hospice category; for them AIM may serve as a bridge) operations. The program draws staff from different parts • have experienced rapid or significant functional decline of the organization and accommodates variation in the type and frequency of contact, from weekly home visits • have experienced nutritional decline, and/or with nurses and social workers to regular phone calls, • have had two or more hospitalizations or emergency giving patients a baseline of support and timely responses department visits in the previous three months. when help is needed. On average, patients spend about Stoplight Tools Are Used by AIM Nurses to Help Patients Understand How to Manage Their Conditions and Know When and Whom to Ask for Help Controlling shortness of breath at home How do I feel today? Green Zone Yellow Zone Red Zone You are in control. Take action today. Take action now! Call: Call: How is my breathing? My breathing is normal. I have trouble breathing I feel confused or sleepy. while doing the things I want to do. I feel like I cannot get enough air. I feel like there is not enough air in the room. My face, fingers or toes are turning blue. Is my medicine for My medicine feels My medicine does not My medicine does not shortness of breath like it is helping. feel like it is helping as feel like it is helping at all. helping? much as it usually does. I am not sure which I am not sure what to do medicine to take. now. If I use oxygen, is it My normal flow of I feel like I need to turn My oxygen does not feel helping? oxygen is helping. up (increase) the flow like it is helping at all. of oxygen to be able to breathe. Do I feel comfortable? I feel comfortable. I am starting to feel I feel very uncomfortable. uncomfortable. I am starting to feel anxious or afraid. Developed by the Sutter Center for Integrated Care, 2013. commonwealthfund.org Case Study, January 2018 Supporting Patients Through Serious Illness and the End of Life: Sutter Health’s AIM Model 6 190 days in the program before moving to hospice (about TRAINING 50 percent), dying (15 percent), or stabilizing so much that they can be supported through one of Sutter’s disease To prepare staff to provide advanced illness management programs (10 percent). The remainder leave management, Sutter trains all its employees the program for other reasons, including moving out of the service area. in techniques for engaging patients, including motivational interviewing, which is used to elicit Patients entering the program — either through Sutter’s patients’ goals and discern underlying motivations. home health division or a referral from a Sutter physician or hospital — receive an initial home visit by nurse or The training also covers techniques of adult social worker to assess their clinical and social needs, learning, such as breaking down information into including measuring their nutrition, cognitive ability, digestible “chunks” and using teachback to ensure emotional state, and level of social support. The nurse patients and caregivers have mastered instructions. and social worker then partner with patients’ primary care providers to develop a supportive care plan, make This approach builds on Sutter’s systemwide additional home visits (four to six is typical) to check on integrated care management training, which patients’ status, provide education and reinforcement encourages the use of plain language and open- on how to follow the care plan, and offer counseling to discuss concerns. ended questions to counteract clinicians’ tendency to rely on medical jargon and checklists. Most AIM patients are eventually moved to the program’s telesupport service, which relies on registered nurses To help shape what may be confusing or fraught trained in the AIM approach to make regular check-in calls conversations with patients, staff draw on a shared and provide case management services. The telesupport language, including groups of questions for different service allows Sutter to achieve efficiencies and sustain the program, given that insurance does not typically cover the situations and scripts to break down conversations costs of ongoing home visits (see section on Financing). into different steps that can be taken over time A triage nurse is available after hours and on weekends as staff earn patients’ trust. “We talk a lot about to answer urgent questions. A call to the triage line may denial because denial is such an important thing prompt a home visit. Patients with greater needs (e.g., among our patients and families,” says Dennis Cox, those who lack family support) may also receive closer oversight, including additional home visits. L.C.S.W., Sutter Care at Home’s clinical education manager. “We explore ways to approach denial, and For patients who are eventually enrolled in hospice, the Medicare benefit provides physician and nurse to have respect for that as a psychological defense practitioner services, respite care, and spiritual care. mechanism, that it’s there for a purpose.” Patients who unexpectedly improve may be moved off Nurse preceptors reinforce initial training by hospice and back to the AIM program. About 10 percent of patients do so.5 shadowing new staff on home visits to model certain behaviors, such as introducing Physicians’ Interdisciplinary Team Care Orders for Life-Sustaining Treatment (POLST) forms, Just as AIM does not make patients dependent on any one and to provide ongoing oversight and advice. part of the program, it does not designate any one staff member as the patients’ main care navigator. Instead, an commonwealthfund.org Case Study, January 2018 Supporting Patients Through Serious Illness and the End of Life: Sutter Health’s AIM Model 7 interdisciplinary team collaborates to help patients with A systemwide electronic health record allows AIM staff to their medical, social, and emotional needs. “There’s no communicate with other Sutter clinicians. AIM staff also recipe for the right level of support,” says Jim McGregor, use a database to review all new patient cases and the M.D., a geriatrician and the program’s medical director. status of patients as they move through the program. Having access to real-time data on patients’ progress and The program requires close coordination among staff being able to track trends across groups enables this work, members to ensure patients are receiving the appropriate says Praba Koomson, D.N.P., AIM executive director. “You level of care. To facilitate this, AIM nurses and social get all the essential information that you need to plan workers, their managers, and a nurse practitioner meet critically for this patient.” in daily huddles to discuss any unexpected events, such as an after-hours call for severe pain or an emergency department visit. Staff then plan and prioritize home Honoring Patients’ Wishes visits, calls, and other follow-up steps accordingly. AIM During initial visits, AIM staff introduce Physicians’ staff members are joined by the medical director, hospital Orders for Life-Sustaining Treatment (POLST) forms, liaisons, and representatives from home health, hospice, which outline what interventions patients would like and telesupport for biweekly conferences, during which providers to perform during a medical crisis. Once forms staff members bring forth patient cases for discussion. are completed, they review them with patients upon TEAM ROLES Telesupport nurses Hospital liaisons working from a central who are registered location in Utah call patients nurses work at Sutter within 48 hours of handoff, hospitals to educate then weekly, then at least patients and twice a month when their providers about the symptoms are well AIM program and managed. make warm handoffs to AIM staff for At the request of nurses in patients enrolling in Nurses Social workers Hospice- and palliative the field, they may make check on patients’ may accompany care–certified physicians the program. additional “tuck-in” calls to conditions, review any nurses on initial home and nurse practitioners check on a patient’s bladder changes, and provide visits. They help provide guidance and support to the infection, for example. education using 40 ensure patients nurses and social workers. The nurse “stoplight” tools, each understand their practitioners make occasional home Frequent contact with a focused on a different prognosis and talk visits to offer their perspective to designated nurse “helps condition, medication, through their options patients and communicate with other people develop confidence or complication. These for end-of-life care. providers, for example to help determine in the service and use it,” guidelines help patients whether a patient is ready for hospice. says Sharyl Kooyer, R.N., an and their caregivers They may also help AIM clinical manager. Each recognize when all patients find sources They also make home visits to address nurse supports a panel of appears to be well of support in the symptom exacerbations that might about 90 patients. (green light), when to community such as otherwise lead to an emergency call AIM staff (yellow Meals on Wheels. department visit or explore why patients light), and when to call continue to experience pain. their primary care doctor (red light). commonwealthfund.org Case Study, January 2018 Supporting Patients Through Serious Illness and the End of Life: Sutter Health’s AIM Model 8 SPEAKING A SHARED LANGUAGE To open a dialogue with patients about their concerns AIM staff use open-ended questions and goals of care, team members often ask questions like: to uncover the nature and cause of patients’ suffering and how best to • How are you within yourself? address their needs. For some patients, • What questions do you have? I have time. pain may be physical and for others, existential. The common practice of asking patients to • What outcomes are important to you? rate their pain on a scale of 1 to 5 does not distinguish between the two. request or whenever patients’ conditions change or they of life in 2016 vs. 29.2% nationally in 2009).7 They are move to a different part of the program. McGregor says also less likely to die in the hospital (8.8% in 2016 vs. carving out this time for these discussions is important. 37% nationally in 2015).8 While transfers to hospice and Primary care and other physicians may be reluctant to deaths in hospice are on par with national averages, AIM broach the subject of advance directives because “if you patients are admitted to hospice earlier, with a median have 15 minutes in an office visit you’re afraid to start a length of stay of 26 days in 2016 vs. 23 nationally in conversation that may take longer.” In the absence of a 2015.9 Patients give the AIM program high marks, with POLST form, if a patient with any kind of advanced illness more than 80 percent responding positively to survey shows up in the hospital, “physicians automatically go into questions about care coordination and communication, treat mode and ask questions later,” he says. symptom management, and knowing their rights and responsibilities. Nearly all AIM enrollees (97%) complete advance care planning documents within 30 days of enrollment. Sutter also measured utilization of hospital care in the Sutter has found two-thirds modify them one or more 90 days before and after enrollment in the program. times while enrolled in the program, demonstrating the Reviewing care for 2,231 Medicare patients, Sutter saw importance of maintaining an ongoing dialogue about dramatic declines, including a 60 percent reduction patients’ goals and preferences. in hospitalizations, a 13 percent decline in emergency department visits, a 70 percent reduction in ICU days, and In about half of AIM cases, family members disagree about a 12 percent reduction in the average length of stay. what course of treatment to pursue. When this occurs, so- cial workers facilitate group conversations and make sure While Sutter’s financial analysis of the program shows the patients’ views are heard. 6 the program reduces total health care expenditures by as much as $9,000 over the course of a year, much of the RESULTS savings are concentrated in the last month of life, when According to Sutter, patients in the AIM program spend the intensity of medical care might otherwise escalate. fewer days in the hospital in the last three months One analysis found the program reduced the total cost of of life relative to the most recently available national care per beneficiary by almost $5,000 in the last 30 days benchmarks (7.3 days in 2016 vs. 8.2 days nationally in of life, which the researchers said was likely attributable 2009) and make less use of intensive care units (9.2% to reduced hospitalizations and emergency department of patients were admitted to the ICU in the last 30 days visits.10 commonwealthfund.org Case Study, January 2018 Supporting Patients Through Serious Illness and the End of Life: Sutter Health’s AIM Model 9 Acute Care Use, Before and After Enrollment in AIM Acute Care Use, Before and After Enrollment in AIM Change in utilization, 90 days post-AIM enrollment 11 sites reporting; Q4 2015 to Q3 2016 (n=2,231) 12% 2,151 6.5 reduction 5.7 60% 13% reduction reduction 1,196 986 871 860 70% reduction 358 Hospitalizations ED visits ICU days Average LOS (days) Pre-AIM Post-AIM Note: ED = emergency department; ICU = intensive care unit; LOS = length of stay. Sources of Insurance Coverage for AIM Patients Data: Sutter Health. Note: ED = emergency department; ICU = intensive care unit; LOS = length of stay. Data: Sutter Health. Sources of Insurance Coverage for AIM Patients 7% 7% Medicare fee-for-service 9.60% Private Medicaid 10.50% Dual eligibles 56% Medicare Advantage Unspecified 10.60% Notes: Private includes Sutter’s own health plan. Segments may not sum to 100 percent because of rounding. Data: Sutter Health, as of late 2016. Notes: Private includes Sutter’s own health plan. Segments may not sum to 100 percent because of rounding. Data: Sutter Health, as of late 2016. commonwealthfund.org Case Study, January 2018 Supporting Patients Through Serious Illness and the End of Life: Sutter Health’s AIM Model 10 FINANCING ICU days and unnecessary hospital admissions and Sutter allocates roughly $12 million each year to pay for provides a per-member per-month fee to cover the the staff and other resources needed to operate the AIM program’s infrastructure. Based in part on Sutter’s program, which translates to a per-enrollee cost of $12.53 experience, the Coalition to Transform Advanced Care has per day. This investment is necessary because the work of proposed an alternative payment model to the Centers telesupport nurses, as well as most home visits by nurses for Medicare and Medicaid Services (CMS) to pay for and social workers, is not reimbursed under fee-for-service advanced care management that would combine a $400 contracts with public and private insurers.11 per-member per-month fee with opportunity for shared savings, though AIM’s leaders say the proposed monthly The program produces dramatic savings for payers, fee may be too low to cover its upfront investment.13 primarily by reducing hospital and emergency department use. In a recent 12-month period, the AIM LESSONS program was associated with a reduction of $24.4 million in billed charges ($10,953 per AIM enrollee), mainly as Knowing what level of care to provide to which a result of fewer hospital admissions. Sutter’s decline in patients and for how long are keys to effective revenue from hospital and emergency department use and efficient advanced illness management. AIM’s was partially offset by indirect savings — $14.4 million leaders say that to make judicious use of resources under in the year ending September 30, 2016, or $6,476 per current reimbursement, they’ve had to figure out how enrollee — which was achieved in part by reducing length to deploy their services in ways that benefit the greatest of stay for patients who were hospitalized.12 AIM also numbers of very sick patients — an effort that’s facilitated generated revenue by facilitating earlier admission to by their panel management tools and flexible, responsive Sutter’s hospice program. model of care. Leaders hope to use predictive analysis to identify patients who would benefit from AIM services, Sutter’s strategy for reducing its outlay for the program making the program less dependent on physician and is to pursue managed care contracts and accountable home health referrals. At the same time, they want to care arrangements that allow it to recover or share in gauge whether patients who remain in the program for the savings to payers that result from reduced hospital longer than a year still need this level of care or would be utilization. As of 2017, about 20 percent of Sutter’s revenue better served by less expensive complex care management came from capitated or value-based contracts. That share programs. They also seek opportunities to increase the will likely increase as the delivery system adds members efficiency of care. Centralizing care management support, to its health plan and assumes risk for more Medicare which Sutter did in October 2016 after testing various Advantage patients. “It’s a strategic advantage as we move models, enabled the system to achieve efficiencies (nurses’ into value-based arrangements that we have this type salaries are lower in Utah than in California), while also of program ready, willing, and able to meet the needs allowing for tighter quality control, according to Lori of patients,” says Elizabeth Mahler, M.D., Sutter Health’s Bishop, M.H.A., R.N., AIM’s former chief executive. vice president of clinical transformation. Sutter’s leaders estimate that the transition to value-based payment will Workforce changes may be needed to meet the cover the direct costs of the AIM program (not accounting demand for advanced illness care. Expanding advanced illness management at Sutter is constrained for indirect savings it produces) when about 35 percent of by challenges in recruiting nurses, social workers, and participating patients are enrolled in capitated payment others. “In smaller communities, we hit a saturation arrangements. point in hiring,” says Kooyer. To help meet demand, AIM’s Sutter has already entered into one accountable care leaders may more frequently send nurse practitioners to arrangement with a commercial insurer to serve this visit patients; this could also increase reimbursements population — one that offers shared savings for reducing since these providers are able to bill for their services. commonwealthfund.org Case Study, January 2018 Supporting Patients Through Serious Illness and the End of Life: Sutter Health’s AIM Model 11 Sutter may also add lay workers to its workforce. “We’re looking at using community health workers both within Our patients emotionally telephonic case management and as boots on the ground in are right in the middle of the home to complement our interdisciplinary care team,” says Monique Reese, D.N.P., Sutter Care at Home’s chief it all. They’re struggling, clinical executive.14 Replacing some home visits with virtual they’re probably on an visits may be another way to scale the program in order to aggressive plan, but maybe offer services to more people who need them, she says. it’s not working for them, Clinicians must be prepared and willing to engage patients in conversations about end-of-life care. and they’re trying to figure Sutter estimates that AIM could benefit roughly 5 percent out what to do. of the delivery system’s patient population. Because there is far greater demand for AIM services than the program Dennis Cox, a social worker who leads can meet, program leaders say that all health system AIM’s clinical education programs providers need to understand how to elicit patients’ preferences and broach conversations about end-of-life care. “We’re taking our AIM principles and empowering our colleagues to do some of this themselves because there’s no way we can do it all with a specialty,” says Bishop. AIM’s leaders say their work has already changed Although Sutter has been able to sustain AIM by the broader clinical culture at Sutter, with more physicians subsidizing it with profits made through other services, now willing to refer to their program. “I think that’s it has done so in anticipation that the program will help probably one of the strongest effects we’ve seen. They it move from fee-for-service to value-based payment. value the ability to refer to this program to help their Opportunities for health systems to replicate Sutter’s patients,” says Jeff Burnich, M.D., senior vice president of approach may depend on the degree to which they can medical and market networks. use value-based payment arrangements to recoup their Policy and payment changes will be needed to investment by, for instance, sharing in the savings from spread this approach. Many health care regulations, reducing hospital use and shifting care to home- and clinical guidelines, and quality measurement practices community-based settings. The Coalition to Transform are built around curative treatment and the expectation Advanced Care and the American Academy of Hospice it will lead to improved health outcomes. This can induce and Palliative Medicine have proposed alternative behavior that runs counter to patients’ interests. For payment models for adoption by Medicare under the example, the Outcome and Assessment Information federal government’s new MACRA Quality Payment Set — the survey CMS uses to monitor the quality of Program framework.16 home health care — tracks and rewards improvement in patients’ functioning. But most advanced illness patients The payoff to society will come in tangible and intangible aren’t going to improve. An effort led by the National ways, AIM’s developers insist. “It’s almost a spiritual thing, Committee for Quality Assurance to create new measures where you’re doing the right thing, and lo and behold, you assessing the quality of serious illness care may facilitate can create financial savings by doing the thing that we all policy change; such measures could encourage assessing went into this business to do, and that’s not just caring. It’s quality from patients’ point of view.15 healing,” Stuart says. commonwealthfund.org Case Study, January 2018 Supporting Patients Through Serious Illness and the End of Life: Sutter Health’s AIM Model 12 NOTES 8 M. D. Aldridge and E. H. Bradley, “Epidemiology and 1 L. Hamel, B. Wu, and M. Brodie, Views and Experiences Patterns of Care at the End of Life: Rising Complexity, with End-of-Life Medical Care in Japan, Italy, the United Shifts in Care Patterns and Sites of Death,” Health States, and Brazil: A Cross-Country Survey (Henry J. Affairs, July 2017 36(7):1175–83. Kaiser Family Foundation, April 2017). 9 National Hospice and Palliative Care Organization, 2 While more patients are receiving hospice care Facts and Figures: Hospice Care in America (NHPCO, and dying at home, this tends to happen only after Oct. 2017). increasingly intensive interventions. ICU use among 10 NORC, HCIA Complex/High-Risk Patient Targeting: Medicare beneficiaries during the final months of life Third Annual Report Addendum (NORC at the increased from 24 percent to 26 percent between 2000 University of Chicago, April 2017). and 2009, while the number of very short hospice stays (fewer than three days) rose from 4.6 percent to 9.8 11 Sutter Health’s ability to subsidize the AIM program percent. See J. Teno, P. L. Gozalo, J. P. W. Bynum et al., under fee-for-service reimbursement may be related “Change in End-of-Life Care for Medicare Beneficiaries: to its competitive market position. A study of hospital Site of Death, Place of Care, and Health Care Transitions pricing in California found that Sutter Health and in 2000, 2005, and 2009,” Journal of the American Dignity Health, the two largest multihospital systems Medical Association, Feb. 6, 2013 309(5):470–77. in California, received $4,000 more in reimbursement per admission from a major insurer than did other 3 U.S. Census Bureau, Profile America Facts for hospitals in California in 2013; see G. A. Melnick and Features — Older Americans Month, May 2017, CB17- K. Fonkych, “Hospital Prices Increase in California, FF.08 (U.S. Department of Commerce, March 27, 2017). Especially Among Hospitals in the Largest Multi- 4 For more information on the effectiveness of the Hospital Systems,” Inquiry, June 9, 2016 53:1–7. “Surprise Question,” which has been used as a Separately, Sutter is the subject of an antitrust lawsuit screening tool in the U.S. and the U.K., see N. White, in which employers and labor unions have accused the N. Kupeli, V. Vickerstaff et al., “How Accurate Is the health system of abusing its market power to charge ‘Surprise Question’ at Identifying Patients at the End inflated prices; see C. Terhune, “Health Giant Sutter of Life? A Systematic Review and Meta-Analysis,” BMC Destroys Evidence in Crucial Antitrust Case Over High Medicine, Aug. 2, 2017 15:139. Prices,” Kaiser Health News, Nov. 17, 2017. 5 Nationally, about 20 percent of patients are discharged 12 The cost savings are realized in part by reducing the from hospice. See I. Jaffe, “Nearly 1 in 5 Hospice Patients length of hospital stays for Medicare patients, who Discharged While Still Alive,” Health, Inc., National bring less revenue than do privately insured patients. Public Radio, Aug. 11, 2017. 13 Sutter is also considering a contract with Partnership 6 When conflicts arise, AIM staff defer to the patient’s Health Plan, a private insurer, that would pay AIM a wishes or those of his or her designated proxy. larger per-member fee for the first 14 days one of their members is enrolled to account for the additional 7 J. Teno, P. L. Gozalo, J. P. W. Bynum et al., “Change in assessments needed during this time. The contract also End-of-Life Care for Medicare Beneficiaries: Site of would provide bonuses to reward Sutter for taking Death, Place of Care, and Health Care Transitions in part in public quality reporting and for achieving 2000, 2005, and 2009,” Journal of the American Medical benchmark performance levels related to decreasing Association, Feb. 6, 2013 309(5):470–77. utilization of the emergency department. commonwealthfund.org Case Study, January 2018 Supporting Patients Through Serious Illness and the End of Life: Sutter Health’s AIM Model 13 14 AIM’s leaders are studying Minnesota-based Allina 16 Coalition to Transform Advanced Care, Advanced Health’s use of community health workers to support Care Model (ACM) Service Delivery and Advanced patients with advanced illness, which has been Alternative Payment Model, Submitted to the shown to improve patient and caregiver experiences, Physician-Focused Payment Model Technical Advisory reduce total costs of care, and increase use of hospice Committee, Oct. 4, 2017; and American Academy and inpatient palliative care. See K. Krypel and M. of Hospice and Palliative Medicine, Patient and Hutchison, “GrantWatch: How Lay Health Care Workers Caregiver Support for Serious Illness, Submitted to Can Add High Touch to High Tech,” Health Affairs Blog, the Physician-Focused Payment Model Technical June 11, 2015. Advisory Committee, Aug. 15, 2017. For background on the MACRA Quality Payment Program, see Centers 15 See National Committee for Quality Assurance, “NCQA’s for Medicare and Medicaid Services, What’s MACRA? Serious Illness Care Measures Project Awarded: $2.2 (CMS, n.d.). Million Grant from the Gordon and Betty Moore Foundation,” News release (NCQA, July 17, 2017). commonwealthfund.org Case Study, January 2018 Supporting Patients Through Serious Illness and the End of Life: Sutter Health’s AIM Model 14 ABOUT THE AUTHORS ACKNOWLEDGMENTS Martha Hostetter, M.F.A., is a partner in Pear Tree The authors gratefully acknowledge the following Communications. As a consulting writer and editor for the individuals who generously shared information and Fund and a contributing editor to its quarterly publication insights: Lori Bishop, M.H.A., R.N.; Jon Broyles M.S.; Transforming Care, she conducts qualitative research on Jeff Burnich, M.D.; Dennis Cox, L.C.S.W.; Kristine Evangelista, health care delivery system reforms and innovations. Ms. L.V.N.; Shannon Hartman, L.C.S.W.; Beth Hennessy, R.N., Hostetter has an M.F.A. from Yale University and a B.A. M.S.N.; Sarah Houser, N.P.; Sangeeta Joshi; Praba Koomson, from the University of Pennsylvania. D.N.P.; Sharyl Kooyer, R.N.; Oliver Kromminga; Elizabeth Mahler, M.D.; Nick Martin; Jim McGregor, M.D.; Carol Sarah Klein is editor of Transforming Care, a quarterly Michel, R.N.; Khue Nguyen, Pharm.D.; Sibel Ozcelik, M.L., publication of the Commonwealth Fund that focuses M.S.; Lon Pray; Lynette Pray; Jessica Ragadio, R.N.; Monique on innovative efforts to transform health care delivery. Reese, D.N.P.; Noelle Rosales, R.N.; and Brad Stuart, M.D. She has written about health care for more than 15 years The authors also thank the Commonwealth Fund’s as a reporter for publications including Crain’s Chicago communications staff for editorial support and layout. Business and American Medical News. Ms. Klein received a B.A. from Washington University in St. Louis and attended For more information about this case study, the Graduate School of Journalism at the University of please contact: California at Berkeley. Martha Hostetter Douglas McCarthy, M.B.A., is senior research director Consulting Writer and Editor for the Commonwealth Fund. He oversees the Fund’s The Commonwealth Fund mh@cmwf.org scorecard project, conducts case-study research on delivery system reforms and innovations, and serves About the Commonwealth Fund as a contributing editor to the Fund’s quarterly The mission of the Commonwealth Fund is to promote a publication, Transforming Care. His 30-year career has high performance health care system. The Fund carries spanned research, policy, operations, and consulting out this mandate by supporting independent research on roles for government, corporate, academic, nonprofit, health care issues and making grants to improve health care and philanthropic organizations. He has authored and practice and policy. Support for this research was provided coauthored reports and peer-reviewed articles on a range by the Commonwealth Fund. The views presented here of health care–related topics, including more than 50 case are those of the authors and not necessarily those of the studies of high-performing organizations and initiatives. Commonwealth Fund or its directors, officers, or staff. Mr. McCarthy received his bachelor’s degree with honors from Yale College and a master’s degree in health care Commonwealth Fund case studies examine health management from the University of Connecticut. He was a care organizations that have achieved high per- public policy fellow at the Hubert H. Humphrey School of formance in a particular area, have undertaken Public Affairs at the University of Minnesota during 1996– promising innovations, or exemplify attributes that 1997, and a leadership fellow of the Denver-based Regional can foster high performance. It is hoped that other Institute for Health and Environmental Leadership during institutions will be able to draw lessons from these 2013–2014. He serves on the board of Colorado’s Center for cases to inform their own efforts to become high Improving Value in Health Care. performers. Please note that descriptions of prod- ucts and services are based on publicly available information or data provided by the featured case Editorial support was provided by Deborah Lorber. study institution(s) and should not be construed as endorsement by the Commonwealth Fund. commonwealthfund.org Case Study, January 2018