That's why it's important to have an integrated program that involves hospitals, medical groups, and home- and community-based services, especially for patients with late-stage chronic illness, says Brad Stuart, MD, CMO at Sutter Care at Home, which is part of the 24 hospitals and more than 5,000 physicians affiliated with the Sutter Health system based in Sacramento, Calif.
Sutter has included care management and palliative services under the umbrella of the Advanced Illness Management program that Stuart
team created for what he
terms a "vulnerable and growing population.
While palliative care is often focused on the "relief of symptoms and suffering," Stuart
says, "our focus is much more comprehensive and positive."
Multidisciplinary teams that include physicians, nurses, social workers, therapists, and nutritionists are part of Sutter's palliative care program.
Various elements focus on the specific needsâ€"and wantsâ€"of patients.
While physicians often outline the medication needs for patients, the AIM
program always considers "what does the patient want?
It's the "little things" that matter that are too often lost in traditional medical care, he
"We are taking more seriously those little things that a patient wants or needs," Stuart
program has had substantial impact, Stuart
In a two-year review of 185 patients in the program, those who lived at least 30 days had 68% fewer hospitalizations than similar patients who were not in AIM
Those who lived 90 days had 63% fewer hospitalizations, according to Stuart
There were also significant cost savings, he
says: The average savings per patient was more than $2,000 per month.
Of all patients who entered the program, about two-thirds went to hospice with longer lengths of stay in hospice than those who had not been enrolled in AIM
Patients welcome the program, Stuart