SYSTEM Sutter Health, a not-for-profit integrated delivery system in Northern California with 24 hospitals and 5,000 physicians. KEY INNOVATION The Advanced Illness Management ( AIM) program, launched in two Sutter hospitals and three large medical groups in the Sacramento/Sierra region. AIM is an integrated system of care for patients with late-stage chronic illnesses that provides home-based transitional and palliative care and counsels patients and families with the goal of increasing hospice use and decreasing the use of unwanted acute care. COST SAVINGS Preliminary, unpublished data from November 2009 through September 2010 show that 185 patients who enrolled in AIM and lived at least 30 days experienced 68 percent fewer hospitalizations during the 30 days after enrollment compared with the 30 days before. For 96 patients who enrolled and lived at least 90 days, there were 63 percent fewer hospital admissions compared with the 90 days prior. Overall, the average savings per patient was about $2,000 a month. QUALITY IMPROVEMENT RESULTS Published data from 2006 show that 47 percent of terminally ill Medicare home care patients enrolled in AIM were discharged to hospice during 2003-05, compared with 20 percent of patients who did not receive AIM services. Preliminary, unpublished data show that about two-thirds of patients who enrolled in AIM between November 2009 and September 2010 chose to go into hospice. CHALLENGES The current reimbursement system does not pay for AIM-type services such as care coordination and hospital-to-home transition. Reduced hospitalizations cost Sutter hospitals more in lost revenue than they gain from dollar savings. Staffing enough nurses, social workers, and others to help operate the program has been difficult.
