NORTHERN SAN JOAQUIN VALLEY — Sutter Health has brought a program to the Northern San Joaquin Valley that's a new approach to care for people in advanced stages of chronic illness.
It emphasizes care at home and is designed to prevent repeated hospital stays that are costly for government health programs such as Medicare and can be avoided. Such programs could become the model for millions of baby boomers who will rely on Medicare during their final phase of life.
Hospitals are expected to reduce patient re-admissions or otherwise face reimbursement penalties from Medicare, the national health program for people age 65 and older.
The Sacramento-based health system said the Advanced Illness Management program achieved more than promising results during a pilot project in Sutter's Sacramento-Sierra region.
"We got very good clinical results and cut hospitalization rates by two-thirds for these folks," said Dr. Brad Stuart, senior medical director for the program, which recently was expanded to the Bay Area.
Sutter reported other results from AIM in the Sacramento area:
A 75 percent reduction in hospital intensive care days
Patient and family satisfaction scores of 4.7 out of 5
Reduced costs to Medicare of $5,000 per patient
The national Centers for Medicare & Medicaid Innovation awarded a $13 million grant for Sutter to expand AIM throughout Northern California, but Sutter has committed to continue with the program after three years.
Sutter estimates that 936 patients meet the criteria and could benefit from the program in Stanislaus, San Joaquin and Merced counties.
The program is voluntary. Most of the patients are seniors who receive their health care through the Sutter system. They suffer from ailments such as heart failure, kidney disease and emphysema. Often, it's difficult for these patients and their family members to navigate the traditional health system, so they suffer acute episodes and land in hospital intensive care units.
Stuart said it makes far more sense for a team of nurses and social workers to manage their care at home.
It starts with a face-to-face visit in the home to assess the person's needs. That's followed by a lot of phone contact as the patient and loved ones become more confident with managing their care.
In some cases, palliative care may be the preferred option for people who are terminally ill. The team can assist the patient with advanced care planning, and the program often transitions to hospice care, Stuart said.
The director said nurses and other care team members can spend more time talking with the patient about their medical needs. "They are trained to discuss things that doctors don't always have time to talk to their patients about," he said.
People often are identified for the program through contact with a hospital and can talk with their primary care physician about their options.
Sutter said the expansion extends access to eligible people through Memorial Medical Center in Modesto, Sutter Tracy Community Hospital, Memorial Hospital Los Banos, Sutter Gould Medical Foundation, Sutter Care at Home and Central Valley Medical Group.
Bee staff writer Ken Carlson can be reached at email@example.com or (209) 578-2321.