Member Clinical Innovations

Our members have demonstrated extraordinary success in providing the help people need and want during advanced illness.  We are working to develop national models of care from these and other successful programs.

Advanced Illness Management (AIM), Sutter Health

The Advanced Illness Management (AIM) Program was created to help patients with advanced chronic illness experience better quality of life.  AIM helps people with serious illness take control of their health, so they can stay independent and comfortable at home.

AIM focuses care on people with advanced illness, which often involves more than one chronic diagnosis such as cancer, heart failure, or dementia.  Their general health is declining and their care needs are increasing, as are unwanted emergency visits and hospitalizations.  AIM helps them anticipate and prevent these health crises.

The AIM team of nurses and social workers partner with doctors to enable people to live on their own terms.  Care may start in the hospital, at the at 90 days following AIM enrollment, hospitalization rates are reduced by 58%, ICU days are reduced by 63% (29 days per case), and inpatient length of stay is reduced by 29% (2 days per case). At 6 months, hospitalization rates are reduced by 66%. AIM does not simply postpone hospitalization; it helps to prevent it.ontent goes here physician’s office, or at home.  The first priority is to get to know the ill person’s health issues, lifestyle, and personal preferences.  Only then can a care plan be developed in partnership with the patient.  Overall objectives include:

  • Empower people to manage their own health
  • Help manage symptoms and assure comfort
  • Help manage medications
  • Coordinate care with clinicians to make sure everyone is up to date
  • Help with personal planning for the future

AIM’s person-centered approach moves the focus of care out of the hospital and into home and community where it belongs.  At 90 days following AIM enrollment, hospitalization rates are reduced by 58%, ICU days are reduced by 63% (29 days per case), and inpatient length of stay is reduced by 29% (2 days per case).  At 6 months, hospitalization rates are reduced by 66%.  AIM does not simply postpone hospitalization; it helps to prevent it.

As a fortunate but unintended benefit, AIM also reduces health care costs.  At 90 days post AIM enrollment, direct inpatient care costs are reduced by over $2,000 per patient per month.  Few other health care innovations promote personal choice, increase quality, and also achieve savings of this magnitude.

You can read more about the AIM model on Sutter Health’s website.

References and Other Resources:

Meyer, H. (2011). Changing The Conversation In California About Care Near The End Of Life. Health Affairs, 30(3), 390–393.
An Evaluation of the Advanced Illness Management (AIM) Program: Increasing Hospice Utilization in the San Francisco Bay Area. (2006). Journal of Palliative Medicine, 9(6), 1401–1411.

Compassionate Care, Randall Krakauer, MD, Aetna

Compassionate Care is a nationally recognized case management program through which Aetna’s Medicare Advantage specialized case managers facilitate high quality of care for members with advanced illness. Aetna’s Medicare-specialized case managers and nurses are trained specifically to assess and manage members’ care in a culturally sensitive manner; to coordinate medical care, benefits and community-based services; and to provide personal support. They provide education and resources for both members and their caregivers, including in the areas of advanced directives, assessment for pain and symptom management, and support for informed decision-making.

The program has achieved considerable success in improving quality of care for Medicare members.  The program was initiated in 2004, and its impressive impact has been published (Health Affairs, September 2009, 1357-59).  Members engaged in the program in 2010 elected Hospice 81% of the time.  As of August 2011, more than 3,000 members had participated in the program year to date resulting in an average of 46 days in Hospice year to date, compared to 16-21 days prior to the program, a sign that members are taking advantage of palliative care options sooner. Member and family caregiver surveys show very high levels of satisfaction with the program. The Aetna program demonstrates the strengths of providing case management services to those with advanced stages of illness, and underscores the importance of member-centered care that removes barriers and facilitates the care options chosen by members and their caregivers.

You can read more about Compassionate Care here or visit the website for more information.

Respecting Choices, Bud Hammes, PhD, Gundersen Health

The Respecting Choices® advance care planning program, developed in La Crosse, Wisconsin, is a multi-faceted approach that depends on the re-design of the health care system in 4 domains:

  • Redesign of health systems or processes to integrate advance care planning into the routine of care;
  • Creation and training of advance care planning facilitators to provide high quality advance care planning services;
  • Continuous quality improvement of the developed systems to assure the best outcomes possible; and
  • Engagement of both patients and the community in the value of advance care planning.

The implementation of this program creates a patient-centered, shared decision model of care that leads to the understanding of patient preferences and goals through time that can be recognized and honored in all transitions of care.   As a more patient-centered approach, the program helps to create a healthcare delivery system that allows for complex treatment plans rather than a simplistic choice of either full treatment or comfort care only.

Respecting Choices in Action: Gundersen Health System’s advance care planning program was featured in September, 2012, on NBC’s Rock Center with Brian Williams:

The most recent data from the La Crosse community demonstrates the success of this approach.  At the time of death 90% of decedents have some type of written advance directive and 96% have some type of documented care plan; these documents are available in the medical record where the decedents receive their final care 99% of the time; and the preferences expressed in the plans are consistent with treatment 99% of the time[1].   A randomized, controlled, clinical trial of this planning intervention has demonstrated great benefit to both patients and their family members as it demonstrated that patients who participated in the Respecting Choices approach to advance care planning were more satisfied with their overall care, were more likely to have their choices known and honored, and family members were less likely to suffer from high levels of distress, anxiety, and depress after a loved one’s death[2].

Since one of the clearest preferences of patients on a care plan is not to receive treatment that will only prolong dying and suffering, the effect of knowing and honoring patient preferences is the lower utilization of hospital, acute services.   In fact the health region in La Crosse is one of the lowest utilizers of acute services in the USA.  According to the Dartmouth Atlas, the La Crosse health region, between 2003 and 2007, used an average of 11.1 days per Medicare decedent compare to a national average of 18.5 days (range 11.1 to 32.5 days)[3].

A more detailed description can be found at

VA Home-Based Primary Care, Thomas Edes, MD, US Department of Veterans Affairs

The Department of Veterans Affairs (VA) Home-Based Primary Care (HBPC) began in 1972.  HBPC is a unique home care program that provides comprehensive longitudinal primary care by an interdisciplinary team, in the homes of veterans with complex chronic disabling disease for whom routine clinic-based care is not effective.  HBPC is a model of home care designed for persons with chronic disease that addresses medical, physical, social and behavioral conditions.

HBPC is very different from and complementary to more typical models of home care such as Medicare home care; HBPC is different in target population, in process and in outcomes.  HBPC targets chronic disease rather than short-term remediable conditions, is comprehensive rather than focused on a specific problem, and provides longitudinal rather than episodic care, often for months to years through the end of life.  HBPC outcomes demonstrate effectiveness in managing chronic disease, associated with a substantial reduction of inpatient days and total cost of care.   HBPC provides care to those who are too sick to go to clinic.

HBPC in Action: In coordination with volunteer families, the VA arranges residential homes for older veterans.  The program is called Medical Foster Homes and each veteran, who is often frail and elderly and living with multiple chronic conditions, receives care from the HBPC team in the comfort of a caring family environment.  In this segment that was featured in November on NBC’s Making a Difference,  Dr. Peter Bolling describes the program as a “win for doctors, win for Medicare, and a win for folks like Isaac and Olga Graves”, who you can hear more about in the clip below:

The core HBPC interdisciplinary team members include physician, nurse, social worker, dietitian, mental health provider, rehabilitation therapist and pharmacist.  Others are added or involved depending upon local factors and veteran needs.

HBPC serves primarily three types of patients in need of home care:

(a)  Longitudinal care patients with chronic complex medical, social, and behavioral conditions, particularly those at high risk of hospital, nursing home or recurrent emergency care.

(b)  Longitudinal care patients who require palliative care for an advanced disease that is life limiting or refractory to disease modifying treatment.

(c)  Patients whose home care needs are expected to be of short duration or for a focused problem, when such services best help the VA facility meet the needs of this population.

Characteristics of Veterans in HBPC:  average age 78, half are impaired in at least two Activities of Daily Living, serious co-morbidities with 24% annual mortality.

The goals of care for HBPC are determined by each patient, and include:

  • Promote the veteran’s maximum level of health and independence by maintaining optimal physical, cognitive and psychosocial functioning.
  • Reduce the need for, and provide a preferred alternative to, hospitalization, nursing home care, emergency room and outpatient clinic visits, through close monitoring and a creating a therapeutic and safe environment in the home.
  • Assist in the transition from a health care facility to home by providing patient/caregiver education, guiding rehabilitation and use of adaptive equipment in the home, adapting the home as needed for a safe and therapeutic environment, and arranging and coordinating supportive services.
  • Enhance quality of life through symptom management and other palliative care measures.
  • Meet the changing needs and preferences of the veteran and family.
  • Support the caregiver in the care of the veteran.
  • Provide comfort by managing pain and other symptoms.

Differences between HBPC and Medicare home care

  • HBPC differs from Medicare home care in target population, in process, and in outcomes.
  • HBPC targets patients with complex chronic progressive disease; Medicare home care targets patients with short-term problems that resolve or improve in a relatively short period of time. HBPC medical complexity is comparable to the PACE population, and 64% have 4 or more Hierarchical Chronic Conditions.
  • HBPC provides longitudinal care throughout the course of chronic conditions that worsen over time, often through the end of life; Medicare home care provides episodic care, generally discontinued when the problem resolves or fails to show improvement.
  • HBPC provides comprehensive care for advanced chronic disease by an interdisciplinary team; Medicare home care provides focused care for time-limited conditions, only while they require skilled services.
  • HBPC has demonstrated outcomes in substantially reducing hospitalizations, hospital and nursing home days of care, and total cost of care; Medicare home care has not been demonstrated to achieve these outcomes.  In an analysis of combined VA plus Medicare utilization for all VA HBPC enrollees in FY2006 who were concurrently enrolled in Medicare fee for service (n=6951), enrollment in VA HBPC was associated with a 25% reduction in hospital admissions, 36% reduction in hospital days and 13% net reduction in total costs of care, after accounting for the cost of HBPC.

You can read more about HPBC in Kinosian B, Tompkins H, Edes T. Factors associated with reduction in inpatient days by Home Based Primary  (HBPC). J Am Geriatr Soc 2008;65(Suppl 4):S197–8.

Palliative Care Programs, Ascension Health

In 2006, Ascension Health, the nation’s largest Catholic and nonprofit healthcare system, chose seven pilots site with established palliative care programs to test improvements.  The goal of the initiative was to spread leading strategies across the continuum of care throughout the System.  An Ascension Health task force established volume, process and quality measures based on the eight domains of quality identified by the National Consensus Project’s Clinical Practice Guidelines for Quality Palliative Care.

Over four years, patients were seen earlier in their disease process.  During that same period, the number of patient discharges increased, as providers began to understand that palliative care was not just for end of life patients.  All three quality indicators for symptom management improved.  Well over 90 percent of patients had pain and dyspnea controlled within 48 hours of admission. At ministries with well integrated and well-staffed palliative care teams, patients had spiritual assessments completed within the first day of admission and there was a significant increase in the completion of advance directives.  One home health palliative care team in the system saw a patient readmission rate of 1 percent versus the national average of 20 percent and a 60 day readmission rate of only 3 percent. This model is now being spread and piloted in other ministries.

You can read more about Ascension’s palliative care programs in: Pryor D et al.  The Quality “Journey” at Ascension Health: How We’ve Prevented at Least 1,500 Avoidable Deaths a Year – And Aim To Do Even Better.  Health Affairs 2011;30:604-11.


For more information about C-TAC’s Advanced Care Model, please click here.

For information about C-TAC’s professional and public outreach, please click here.

To hear more about our Clinical Models Workgroup as well as the Professional Education, Policy Advocacy, and Public Engagement Workgroups,  please contact us.

[1] Hammes BJ, Rooney BL, Gundrum JD.  A comparative, retrospective, observational study of the prevalence, availability, and specificity of advance care plans in a county that implemented an advance care planning microsystem.  JAGS 2010;58:1249-1255.

[2] Detering KM, Hancock AD, Reade MC et al. The impact of advance care planning on end of life care in elderly patients: Randomized controlled trial. BMJ 2010;340:c1345.

[3] Care of chronically ill patients during the last two years of life.  Death occurring 2003-07.  Accessed September 30, 2011.

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