A Retrospective Evaluation of the Impacts of a Multidisciplinary Care Model for Managing Patients with Advanced Illness on Acute Care Utilization and Quality of Care at End of Life

Jarrod T. Bullard, Marc Kowalkowski, Alica Sparling, Jason Roberge, and John E. Barkley
Peer-Reviewed Article
September 2022


Home-based advanced illness management program shows reductions in end-of-life acute care utilization.


Advanced illness management (AIM) programs engage interdisciplinary teams to provide home- and community-based care to help identify patient goals and coordinate care as patients’ illnesses advance. These programs are associated with reduced spending on preventable health care utilization and improved health outcomes at the end of life. One challenge in implementing these programs is identifying which patients would most benefit. This study identified eligible patients for program participation and evaluated the impact of the AIM program on end-of-life acute care utilization, compared to usual care.


AIM enrollment was associated with lower rates of care utilization (as measured by days away from acute care in the last 30 - 180 days of life) as well as fewer deaths in an acute care hospitals. This study used electronic health record data to create a definition of advanced illness that may be valuable in increasing patient access to AIM and other home-based palliative care programs.


While home-based palliative care programs such as AIM have generated significant evidence on improved outcomes, these programs have been limited in their growth due to the lack of a singular definition of advanced illness. This study shows how a health system used readily accessible data to identify eligible patients, and the benefits of these programs.

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