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Profiles on the Promise of Advanced Illness Management

For more background on this series of profiles, see “The Promise of Advanced Illness Management to Improve Care at the End of Life.”


Organization: Health insurer with $63 billion in annual revenue serving 23 million members in medical plans nationwide, including 1.4 million in Medicare Advantage plans.

Year created: 2004

Area served: Nationwide

Population served: Health plan members with advanced illnesses for which therapy to reverse the pathological process is no longer effective or appropriate and who are at risk of dying within the next 12 months. Eligible members are mostly identified through analysis of claims data, but also may be referred by health plan care managers or other staff, contracted providers, and members themselves.

Number of patients: 3,500 to 4,000 members are served during the course of a year.

Payment model: Funded by the health plan for any member eligible for case management services. Aetna extends hospice benefits for commercial health plan members with a life expectancy of up to 12 months to receive concurrent hospice and curative treatment. (Under federal rules, Medicare Advantage members with a life expectancy of less than six months must disenroll from the plan to receive Medicare hospice benefits.)

Patient mix: Approximately 95% of members participating in the program are enrolled in Medicare Advantage plans; the remainder are enrolled in commercial health plans.

Average time in program: 220 days. Staff continue to provide program support for up to 90 days after members elect hospice.

Delivery model and staff: Nurses provide support to members and their caregivers via telephone, focusing on advance care planning, decision support, symptom management, and care coordination. Social workers link members to support services and provide counseling to members and their caregivers. Staff also provide support to family caregivers after members’ deaths. Nurses and social workers are supported by medical directors, behavioral health specialists, and pharmacists.

Training: All new staff receive training on motivational interviewing and other techniques to conduct conversations about advance care planning. Ongoing monthly training by subject matter experts on topics relevant to the advanced illness population. Nurses visit physician offices to educate them about the program and encourage referrals.

After-hours care: Members have 24-hour access to nurses through Aetna’s Informed Health Line.

Care coordination and transitions: Patients’ cases may be reviewed during multidisciplinary team rounds. Team members reach out to physicians and other clinicians as needed.

Results: A published study reported that deceased Medicare Advantage plan members served by the program from 2005 through the first quarter of 2007 experienced substantially lower hospital use compared to a retrospective control group: 79 percent fewer emergency department visits (92.7 vs. 436.8 visits per 1,000 members), 85 percent fewer acute inpatient days (2,308.9 vs. 15,216.8 days per 1,000), and 88 percent fewer days in the intensive care unit (1,188.9 vs. 9,839.5 days per 1,000). Reductions in service use were associated with approximately $12,000 in avoided medical costs per Medicare Advantage plan member served by the program.

Among commercial health plan members, the program led to a more than doubling in hospice use as well as an increase in hospice lengths of stay (13 to 15 days longer). Extending hospice benefits to 12 months did not result in increased costs compared to those without extended hospice benefits. Changes in utilization among commercial plan members followed a similar pattern but were smaller in magnitude than among Medicare Advantage plan members.

More recent data, pending publication, continues to show positive impact: significantly lower hospital visits and medical costs in the last months of life, higher rates of hospice acceptance, and earlier engagement in hospice among participants, according to Aetna.

For more information: Alena Baquet-Simpson, M.D., senior director of medical services for the Aetna Medicare team, [email protected]; or Katherine Peterson, continuum of care manager for Aetna Compassionate Care, [email protected].


Organization: For-profit, risk-based medical group that specializes in providing advanced illness management, especially to those without access to palliative care programs.

Year created: 2011

Area served: Local markets in 25 states and Washington, D.C.

Population served: Patients with advanced illnesses who appear to be in their last 12 months of life. Patients are referred by their primary care or specialist physicians (in markets where Aspire has significant market presence) or by care managers of health plans contracting with Aspire. Aspire uses an algorithm to analyze clients’ claims data to identify patients who may be appropriate for its service.

Number of patients: 15,000 on average daily; 22,500 are served during the course of a year.

Payment model: A blend of capitated payments, performance bonuses, and shared savings from contracts with health plans and other risk-bearing entities that carry downside risk for the total costs of care.

Patient mix: Approximately 80 percent of patients are enrolled in Medicare Advantage plans; the remainder are enrolled in Medicaid managed care plans, commercial health plans, and accountable care organizations.

Average time in program: 8 to 10 months.

Delivery model and staff: Nurse practitioners manage care by conducting comprehensive, in-home assessments, developing care plans in consultation with a patient’s physicians, and making home visits typically every two to four weeks. Nurses, social workers, and chaplains also make home visits as needed. Physicians focus on coordination with other physicians. Local field teams are supported by nurses, social workers, and administrative staff, who work in Nashville but focus on particular regions of the country; the administrative staff arrange visits and make check-in calls. One or two board-certified palliative care physicians offer oversight in each region.

Training: All staff receive professional development and mentoring centered on managing complex conditions, building rapport with patients, and developing strategies for discussing advance care planning.

After-hours care: A centralized nurse triage line is available during the day. Physicians and nurse practitioners in each region take calls at night and on the weekends.

Care coordination and transitions: Nurse practitioners coordinate care with patients’ existing primary care providers and specialists by sending them post-visit assessments and care plans. Patients’ cases are reviewed at weekly meetings by the full team. Aspire’s information system tracks patients and produces reports for physicians, patients, caregivers, and client health plans.

Results: Seventy-six percent of patients transition to hospice, where their median length of stay is 42 days (compared with national median of 19.7 days in 2010). Eighty percent of patients have completed an advance care plan and nearly all (96%) would recommend the service to a friend. According to Aspire, average medical cost savings are about $10,000 per patient who died after being served by the program; savings are shared among Aspire and its clients.

For more information: Brad Smith, chief executive officer of Aspire Health, [email protected].




Organization: Integrated delivery system serving the New York City metropolitan area with 20 hospitals and $11 billion in total revenue. AIM is offered by Northwell’s care management organization, Health Solutions.

Year created: Evolved from a House Calls program started in 2007.

Area served: Nassau, Suffolk, and Queens counties in New York.

Population served: Medicare beneficiaries with a continuum of chronic, complex, or advanced illnesses and functional limitations, high symptom burden, recent hospitalization and risk of readmission, and difficulty getting to a primary care provider; most meet the Medicare definition of homebound. The program is not limited to patients nearing the end of life.

Number of patients: Average daily census of 1,350; serving over 1,700 patients a year.

Payment model: Accepts patients with any form of payment, though patients covered through alternate payment models such as Independence at Home are actively recruited.

Patient mix: Thirty-eight percent are covered by traditional fee-for-service Medicare; 27 percent are enrolled in Medicare Advantage plans; 24 percent are enrolled in Medicare’s Independence at Home demonstration; and 9 percent are enrolled through shared savings arrangements with regional payers.

Median time in program: 22 months. Three of four patients expire at home. Almost half are referred to hospice prior to death.

Delivery model and staff: The AIM program is centered on eliciting and meeting patients’ goals for care. Interdisciplinary teams include physicians (geriatricians, palliative care physicians, and internal medicine physicians), social workers, nurses, and medical coordinators. Following a comprehensive in-home assessment, patients receive home visits and telephone support on a flexible schedule determined by their needs. Physicians visit the most complex patients while nurses visit more stable patients. Social workers link patients to social services and offer counseling. Highly unstable patients may be seen multiple times per week; stable patients may be seen as infrequently as every 12 weeks. Given that a high proportion of patients are homebound, many rely on the program for their primary care as well as for care management, palliative care, and other services.

Training: All providers are trained in palliative care. Providers are hired based on their willingness to help ill patients remain at home without the support of hospital-level evaluation tools.

After-hours care: Physicians or nurse practitioners are available by phone 24/7. Calls initially flow to a nurse triage center. Using algorithms, staff guide patients to appropriate next steps, e.g., self-care, primary care, or the emergency department (ED). Northwell’s community paramedicine program lets providers dispatch specially trained paramedics to patients who need urgent evaluation; on average they are in patients’ homes within 21 minutes. The majority of patients seen by community paramedics (78%) are treated at home by the paramedic in consultation with a physician, thereby avoiding unnecessary ED visits.

Care coordination and transitions: For most patients the AIM program assumes primary care responsibilities, while coordinating with subspecialists. Providers receive real-time notification when their patients are hospitalized, enabling them to coordinate care with hospital staff. Social workers visit patients in a number of high-volume hospitals to facilitate discharge. More than three-quarters of patients are seen at home within 48 hours of discharge.

Results: Almost half (46%) of patients transition to hospice, where their average and median length of stay is 51days and 28 days, respectively (compared with a national median of 19.7 days in 2010). More than 90 percent of patients have completed Medical Orders for Life-Sustaining Treatment, which authorize specific treatments that patients want to receive in an emergency. Almost all AIM patients seen by community paramedics reported they would use the service again and 91 percent said they would have sought emergency care if the service were not available, according to a published study. AIM patients enrolled in Medicare’s Independence at Home demonstration experienced a 53 percent reduction in hospitalizations, 73 percent reduction in ED visits, and $8,700 in cost savings per patient year, according to Medicare. The program achieved all six quality targets under the demonstration.

For more information: Kristofer Smith, M.D., senior vice president for Population Health Management, Northwell Health, [email protected].



Organization: Large integrated delivery system with 24 hospitals and $11.9 billion in operating revenue. Roughly 20 percent of the 3.4 million patients Sutter serves are covered by value-based payment arrangements.

Year created: 1999

Area served: 19 counties in Northern California

Population served: Patients with an irreversible disease whose referring physicians attest they “would not be surprised if they died in the next 12 months.” Also must be deemed hospice appropriate, have experienced rapid or significant functional decline, have experienced nutritional decline, and/or have had two or more hospitalizations or emergency department visits in the prior three months.

Number of patients: 2,700 average daily census; serves roughly 6,500 patients over the course of a year.

Payment model: Accepts any patient who has an existing relationship with a Sutter Health physician. Bills Medicare and other fee-for-service payers for some services and receives per- member-per-month funding through Medicare Advantage plans, with the remainder of program costs subsidized by the health system.

Patient mix: In late 2016, most AIM patients were covered by the fee-for-service Medicare program (56%), the state’s Medicaid program (10.5%), or were dually eligible for Medicare and Medicaid (9.6%). About 7 percent were enrolled in Medicare Advantage plans. The remainder were covered by private insurance, including Sutter’s own health plan (10.6%).

Average time in program: 190 days (including time spent on home health and telesupport).

Delivery model and staff: The goals of AIM are to engage patients and their caregivers in managing their health conditions, elicit and document goals for end of life, and respond in timely ways to changes in conditions. Patients receive a comprehensive assessment and care plan that may include supportive home visits by nurses and social workers and/or telephone care management from AIM-trained nurses. Team members confer with patients’ providers as needed. Two nurse practitioners and a geriatrician offer oversight.

Training: All nurses and social workers receive training in techniques for engaging patients, including motivational interviewing, as well as principles of adult learning, such as breaking down information into digestible “chunks” and using “teach-back” to ensure patients and their caregivers have mastered instructions.

After-hours care: A triage nurse is available after hours and on weekends to answer urgent questions; home visits are made if patients appear to have worsening conditions.

Care coordination and transitions: New patients and those who move from one part of the program to another (e.g., from home visits to telesupport) are reviewed at weekly meetings. Nurses in Sutter hospitals educate patients as well as providers about the AIM program; the hospital nurse makes a “warm handoff” to AIM staff when a hospital patient enrolls in the program. After home visits, AIM nurses report on patients’ status to primary care physicians, who can then review their notes and exchange messages with them in the shared electronic health record.

Results: Roughly half of patients transition to hospice, where their median length of stay is 26 days (compared with national median of 19.7 days in 2010). Almost all patients (97%) have completed an advance care plan within 30 days of enrollment. After accounting for program expenses of $2,400 to $2,500 per patient per year, AIM has produced annual net savings to payers of between $8,000 and $9,000 per person served by program, principally from reduced hospitalizations and emergency department visits during the final months and particularly the final month of life.

For more information: Praba Koomson, D.N.P., executive director, Advanced Illness Management, Sutter Health, [email protected].




1 This profile was based on personal communications with Alena Baquet-Simpson, M.D., senior director of medical services for the Aetna Medicare team; Dawn Spiridakos, R.N., manager, health care quality management for Aetna Community Care; and Randall Krakauer, M.D., formerly national medical director at Aetna. See also: Claire M. Spettell et al., “A Comprehensive Case Management Program to Improve Palliative Care,” Journal of Palliative Medicine 12, no. 9 (Aug. 31, 2009): 827–32,; Randall Krakauer et al., “Opportunities to Improve the Quality of Care for Advanced Illness,” Health Affairs 28, no. 5 (Sept./Oct. 2009): 1357–59,; and Andrew Smith, “Q&A [with Randall Krakauer] on Palliative Care,” AJMC Evidence-Based Oncology, April 16, 2015,

2 This profile was based on a personal communication with Brad Smith, cofounder and chief executive officer of Aspire Health.

3 This profile was based on a personal communication with Kristofer Smith, M.D., senior vice president for Population Health Management at Northwell Health. See also: Karen A. Abrashkin et al., “Providing Acute Care at Home: Community Paramedics Enhance an Advanced Illness Management Program — Preliminary Data,” Journal of the American Geriatrics Society 64, no. 12 (Aug. 30, 2016): 2572–76,

4 This profile is adapted from: Martha Hostetter, Sarah Klein, and Douglas McCarthy, Supporting Patients Through Serious Illness and the End of Life: Sutter Health’s AIM Model (Commonwealth Fund, Jan. 2018),


Publication Details



Douglas McCarthy, Martha Hostetter, and Sarah Klein, Profiles on the Promise of Advanced Illness Management (Commonwealth Fund, May 2018).