Managing care between home and hospice

They call it the gray zone—the gradual deterioration of health experienced by many frail and chronically ill elderly, the condition that lies somewhere between treatable disease and terminal illness.

More than a decade ago, Sutter Health recognized that aggressively treating such patients as their illnesses progressed raised troubling quality-of-life and cost issues. “There was this frequency with which patients with advancing illness would come back to the emergency department or hospital for symptoms that seemed like they should be able to manage at home,” said Sutter Health Chief Hospice Executive Betsy Gornet.

Such patients represent a disproportionate share of overall Medicare spending. Elderly patients with four or more chronic conditions represented about 14% of Medicare beneficiaries in 2010 but accounted for 70% of the 1.9 million hospital readmissions, according to a 2012 CMS report. Nearly two-thirds of patients did not receive any home healthcare visits that year, and hospice care remained underutilized.

But when should providers switch from treatment to hospice, or even begin to dial back on the tests, drugs and procedures they prescribe for the frail elderly? “This population is in the gray zone between treatable and terminal, and that gray zone is expanding really rapidly,” said Dr. Brad Stuart, former senior medical director of Sutter Visiting Nurse Association and Hospice.

“In that gray zone, it's often not appropriate to just stop treatment and go straight to hospice,” he said. “But at the same time, it's also not appropriate to just throw the whole nine yards of treatment at everybody every time, which is what we tend to do in traditional care.”

Stuart was instrumental in helping Sutter develop its Advanced Illness Management (AIM) program, an integrated delivery model that advises patients and their families on how to make the transition to hospice while still delivering desired healthcare services in home settings. The program begins with a team of staffers consisting of home health and hospice nurses, physicians and social workers asking patients questions about their treatment.

Those targeted for entry into the program are usually chronically ill patients who have the possibility of dying within a year and have yet not chosen to enter hospice. Once eligible patients have been identified, AIM staff works with them to chart out a plan for the next steps in managing their care. The goal of AIM is to coordinate care for these patients before they reach the terminal stage in order to smooth the transition into hospice.

Eventually the focus of treatment shifts from administering acute procedures to providing more palliative care. AIM staff also helps patients develop advance directives. As patients get sicker, the team helps them move into hospice.

Sutter expanded the pilot after early results showed the rate at which AIM patients entered hospice was 47% compared with 20% among non-AIM patients, according to a 2006 study published in the Journal of Palliative Medicine. A few years later, Sutter began investing $21.4 million into a system-wide rollout of AIM, which was helped along with a $13 million grant in 2012 from the CMS Innovation Center. The AIM model now serves 79% of Sutter's service territory: The program is in 14 out of 19 counties treating an average of 1,200 patients a day.

The program faces challenges, however. The current fee-for-service payment model used by private and public payers does not reimburse for all of the services AIM provides. For example, while the Medicare-certified home healthcare service is reimbursed, any transitional care provided to a patient to enable entering hospice is not reimbursed.

It also sharply reduces revenue by reducing hospital admissions, which has turned AIM into a money-loser for the system. “The rate of the spread of the program will be in direct proportion to the rate that our system converts from fee-for-service toward accountable care,” Stuart said. “The quicker that transition happens, the quicker this (kind of) program will grow.”

Follow Steven Ross Johnson on Twitter: @MHsjohnson