LAKEPORT, Calif. – Even with a history of cervical cancer and heart problems, 92-year-old Enes Cereni of South San Francisco says she enjoys time with her husband of 63 years and their children, grandchildren and great-grandchildren thanks to Sutter Health’s Advanced Illness Management program, which covers 16 counties across Northern California.

Beginning this week, patients in the Sutter Lakeside Hospital service area with late-stage chronic illness can access the same resources and support available to Mrs. Cerini through AIM’s next major expansion in Northern California.

The expansion extends access to patients within the Sutter Lakeside Branch of Sutter Care at Home.

The AIM program provides nurse-led care management, palliative care and advance care planning for patients with late-stage chronic illness.

AIM employs a nurse-led interdisciplinary team to bridge the gaps between the hospital, the community physician’s office and home.

With a pilot program in Sutter Health’s Sacramento Sierra Region showing positive outcomes, the Center for Medicare & Medicaid Innovation awarded Sutter Health a three-year, $13 million Health Care Innovation Award to support the expansion of AIM throughout Northern California.

The AIM program focuses on the patient’s personal goals, and ensures the plan of care is aligned with these preferences. 

The AIM program improves the patient’s ability to self manage their care at home, thus reducing the need for repeated emergency department visits and hospitalizations.  

Most recently, the AIM Data shows:

• 56-percent reduction in hospital stays;
• 19-percent reduction in emergency room visits;
• 59-percent reduction of time spent in the ICU;
• 97-percent patient satisfaction.

“Before AIM, I had a choice of calling 911 and that’s it, and I’d end up in the hospital,” said 81-year-old AIM patient Edward Fogarty. “I don’t want to go to the ER. What AIM gives me is that I can call someone besides 911, and they give me advice and counsel, which really helps.”

For more information about AIM, visit http://www.sutterhealth.org/quality/focus/advanced-illness-management.html .