Mills-Peninsula Newsroom

Advanced Illness Management Care Program Launched

Innovative Effort to Reduce Hospitalizations and Health Care Costs

Even with COPD and heart problems, 81-year-old Air Force veteran Edward Fogarty of Rocklin says he leads a fulfilling life thanks to Sutter Health’s Advanced Illness Management (AIM)® program. Now, San Mateo County patients with late-stage chronic illness like Edward can access the same resources and support needed through AIM’s next major expansion in Northern California.  The expansion extends access to eligible Mills-Peninsula Health Services, Mills-Peninsula Medical Group, Palo Alto Medical Foundation, and Sutter Care at Home patients.

Dr. Brad Stuart participated in a Successful Aging event hosted by the David Druker Center for Health Care Innovation in October 2012.

“AIM uses a nurse-led interdisciplinary team to bridge the gaps between the hospital, the community physician’s office, and home for our sickest patients,” said Brad Stuart, M.D., Senior Medical Director for Sutter Care at Home, an affiliate of Sutter Health. “Quality, affordable care for all of our patients is a priority and the expansion of AIM systemwide complements our mission and values. AIM supports giving the right care, at the right time, at the right level of care for the patient’s goals.

The AIM program provides nurse-led care management, palliative care, and advance care planning for patients with late-stage chronic illness. With a pilot in Sutter Health’s Sacramento Sierra Region showing positive outcomes, the Center for Medicare & Medicaid Innovation (CMMI) awarded Sutter Health a three-year, $13-million Health Care Innovation Award to support the expansion of AIM throughout Northern California. The Sacramento Sierra Region pilot showed reduced hospitalizations and improved care transitions, contributing to an improved quality of life for patients enrolled in AIM. The success of this pilot was crucial to Sutter Health receiving the CMMI grant. Since 2010, the Sacramento Sierra Region pilot:

  • Reported a 75 percent reduction in ICU days, an average decrease of one or more days for hospital stays, and more than 50 percent reduction in hospitalizations at 90 days post-enrollment.
  • Showed high patient and family satisfaction (4.7 out of 5).
  • Reduced costs for payers by $5,000 per patient at 90 days post-enrollment.

“Before AIM, I had a choice of calling 911 and that’s it, and I’d end up in the hospital,” Fogarty said. “I don’t want to go to the E.R. What AIM gives me is that I can call someone besides 911, and they give me advice and counsel, which really helps.”


Margie O’Clair, 650.934.6970;

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