By helping patients better manage their advanced illnesses and connect with their primary care physicians, Sutter Health’s AIM program is improving quality of life and reducing unnecessary ED visits and hospitalizations.


A Sutter Health AIM team member with a patient in his home.Now 78 years old, Martha had struggled with diabetes and chronic obstructive pulmonary disease (COPD) for years. But increasingly, her advancing illness made it difficult for her to live on her own. When her symptoms flared to an alarming degree, she had nowhere to turn but the emergency department (ED), and those visits often turned into hospital stays.

Then Martha’s physician referred her to Sutter Health’s Advanced Illness Management (AIM)® program for patients with late-stage chronic illnesses. Working with an AIM nurse, Martha (not her real name) learned how to correctly use her inhalers and nebulizer to prevent COPD flare ups. Easy-to-read charts helped her understand when her symptoms warranted a call to her physician. In addition, physical and occupational therapists helped Martha retain the strength and energy she needed to accomplish things that were important to her, such as cooking her own meals.

“AIM provides a continuity of care for these patients that didn’t exist before,” says Betsy Gornet, chief AIM executive at Sutter Health, a large Northern California health system. “We are engaging patients differently than we have before, and we’re helping them connect to their physicians in more fruitful ways.”

About 30 percent of Medicare dollars are spent on caring for chronically ill patients during the last two years of life, as detailed in a related Leadership infographic. By ensuring that these patients receive coordinated care and avoid unnecessary ED visits and hospital admissions, Sutter Health is not only lowering costs, but improving the patient experience.

Current savings to payers now exceed $9,000 per AIM patient within 90 days of enrolling in the program. At the same time, satisfaction among patients and families is very high (4.7 out of 5). Gornet is confident that, by June, AIM will exceed its goal of $29 million in Medicare savings.

A Pioneering Approach

The concept of advanced illness management has been gathering steam for several years, and is described in detail in two American Hospital Association reports. Advanced illness management often starts months, years, or even decades before a patient’s illness becomes terminal. The point is to provide coordinated care?both curative and palliative?to patients as their health declines (see Exhibit 1 below). Patients are also encouraged to develop advance directives to ensure their end-of-life choices are honored, and they are transitioned to hospice and palliative care as needed.

Exhibit 1
The phases of advanced illness management

With its AIM model, Sutter is considered a pioneer in advanced illness management. After Sutter successfully demonstrated its model at two Northern California pilot sites from 2009 to 2012, the health system was awarded a three-year, $13 million Health Care Innovation Award from the Center for Medicare & Medicaid Innovation (CMMI) to expand the program throughout the Sutter Health service area.

A Sutter Health patient discusses the care he has been receiving with his nurse.A cross-continuum approach. The AIM model works around a virtual care team that follows patients from home to outpatient to hospital. At the center of the team is the patient’s primary care physician. Patients with advanced illnesses often see numerous specialists for various conditions, and the primary care physician can serve as the lead for that group of physicians, ensuring the patient’s curative and palliative goals are met.

Other core AIM team members are registered nurses and social workers who visit patients in their homes. Higher-acuity patients are seen by one of Sutter Health’s existing home healthcare teams, while lower-acuity patients are seen by AIM Transitions home-based teams.

Following the in-home care phase of AIM, patients are connected to one of the AIM tele-support nurses who work for the primary care practices. “If the physician thinks the patient needs additional help during the tele-support phase, one of the team members can go back to the patient’s home or we can get the patient to the doctor’s office,” says Gornet.

In addition, nurse liaisons are available at every hospital in the Sutter system. When AIM patients visit the ED or hospital, these nurse liaisons help coordinate and reinforce patients’ goal-oriented care and help them transition back into their homes.

A growth target. Sutter is on target to expand AIM to 14 virtual teams in 19 counties by this coming June, up from two teams in 2012. Thus far, more than 500 physicians, nurses, and social workers have been trained to serve AIM patients.

The number of patients enrolled in AIM will approach 10,000 by June, compared to just under 600 in 2012. AIM patients meet one or more of the following criteria:

  • Two or more chronic illnesses, at least one of which is advancing
  • A high-symptom burden with evidence of clinical, functional, or nutritional decline in the last six to 12 months
  • A 12- to 18-month prognosis

“We identify the patients by talking to clinicians in doctors’ offices and in hospitals,” says Gornet. “We educate hospitalists, case managers, and nurses about the type of populations we are serving.” The hospital-based AIM liaisons are also critical in helping to identify patients, she adds.

Key Success Factors

Sutter Health is not allowed to release detailed AIM results until the CMMI study is completed. However, a preliminary analysis shows that the AIM program is demonstrating outcomes equal to or better than the pilot experience, including a 59 percent reduction in hospitalizations and a 67 percent reduction in ICU days among patients within 90 days of enrolling in AIM (see Exhibit 2 below).

Exhibit 2
Sutter Health’s AIM program is cutting hospitalizations by 59%.

Gornet believes four factors have been key to AIM’s success:

A consistent approach across settings. At the core of AIM is a respect for the patient’s personal versus clinical goals. “We really focus on the patients’ goals, and center the care activity and support around those personal goals,” says Gornet. “What are the patients trying to achieve, and where do they see themselves in the next three, six, or nine months?”

The AIM model consists of five pillars, which help to ensure that care plans are patient-centered:

  • Advanced care planning, with an emphasis on personal goals
  • Medication management
  • Follow-up care coordination
  • Red flag identification and symptom management
  • Patient engagement and self-care management

“We use these five pillars consistently no matter where the patient is,” says Gornet. “It creates a structure and rhythm that makes it easier for everybody to know what’s going on, which is part of the beauty of what we’re doing.”

A skilled team. To help ensure a consistent approach, all new AIM team members participate in a four-day, 32-hour training program. “We use a lot of real-life case studies and scenario-based learning during training to help prepare AIM teams.”

In addition to teaching the five pillars, training focuses on team building. “We focus on the role of each team member and how the roles relate to each other. This is important because we have virtual teams. The team members would not typically see themselves as a team because they work in different settings.”

The training, for example, illustrates how to hand off information virtually and what the weekly team meetings should focus on. When discussing patients, team members are taught to use SBAR (situation, background, assessment, recommendation) to streamline communications.

Within 90-180 days of initial training, each clinician and team is reassessed to ensure they are using the AIM pillars correctly and consistently. Follow-up training is provided to anyone who needs a refresher.

Patient engagement. AIM embraces the principles and tools of integrated care management, which is a person-centered, evidenced-based approach to engaging patients and improving their self-management skills.

“The first part is making clinicians aware of health literacy,” says Gornet. “So many errors occur because we think we are communicating with patients, and we think patients understand us when they don’t. So the first step is understanding that the materials we give to patients and the way we communicate with patients must reach them where they are at that moment.”

A variety of tools help AIM team members achieve this goal:

  • Personal health records, which are printed booklets that AIM patients bring to physician appointments and use to record self-care notes, questions for their caregivers, etc.
  • Motivational interviewing, or encouraging patients to take ownership for their own care through open-ended questions, reflective listening, and other approaches
  • SBAR, or learning how to communicate with caregivers using the same communication method that AIM team members use
  • A suite of “stoplight” forms for managing various symptoms (e.g., breathlessness, anxiety), which help patients know how to respond effectively to minor issues (i.e., green light), to more serious signs (i.e., yellow light) and in an emergency situation (i.e., red light)

Access related tool: Sutter Health’s Heart Failure Stoplight Form

Data exchange and analytics. The lack of electronic interoperability among Sutter hospitals and affiliated physician practices has been both a challenge and an opportunity. On the pro side, it has forced AIM teams to devise a standardized, simple documentation approach.

“We try to keep documentation short and succinct to move away from physicians having to read a 19-page individualized care plan,” says Gornet. “We designed a note focused around our five pillars that begins with documenting the patient’s personal goals. By using this simple approach, physicians can readily identify new information and get a snapshot of where the patient currently stands. The plans are updated on an ongoing basis so that caregivers can just glance at the updated notes to see what has changed.”

However, ensuring that the AIM team notes are electronically available to hospitals and physicians is easier said than done. “We are dual documenting in multiple EHR systems and, when we can’t do that, we’re faxing,” says Gornet.

Sutter Health is now committed to improving data analytic capabilities to uncover targeted information that would help in better managing the AIM population. “We are looking at the total cost of care, and we are capturing both qualitative pieces of information (such as clinical outcomes, patient-reported outcomes, and patient/family experience), as well as quantitative data regarding utilization and cost of services across the entire care continuum,” says Gornet.

This has been a huge challenge, she adds. “We aggregate information from about 16 IT systems. And we recently layered Medicare claims data on top of that, which will give us a view of any cost or charge information outside of Sutter’s experience of these patients.”

Expansion Hopes

When its three-year Medicare innovation award ends in June, Sutter Health hopes that CMMI will decide to expand the AIM program to other areas of the country. The health system is also exploring other ways to ensure the financial stability of the AIM program, including contracts with commercial payers.

Whatever the future may bring, it is clear that AIM is improving the day-to-day lives of people with advanced illnesses. Take Martha. Instead of having to see multiple physicians frequently, she now only has to visit her primary care physician, pulmonologist, and cardiologist—and in the past year, she has landed just twice in the ED.

“Even though she’s sicker than before, AIM has helped keep this patient out of the hospital,” says Gornet. “She’s able to manage her own symptoms and be in control of her care in a way she never had before.”


Betty A. Marton writes frequently about medical and healthcare issues for a variety of publications and organizations. Maggie Van Dyke is managing editor, HFMA’s Leadership.

Interviewed for this article: Betsy Gornet is chief AIM executive, Sutter Health, Sacramento, Calif.

Related articles:
Communitywide Approaches to Aging

Creating Care Plans for Patients with Complex Needs

Funding Innovations for Aging at Home

Publication Date: Wednesday, January 28, 2015