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Sutter VNA and Hospice

Project Overview

The Sutter Visiting Nurse Association and Hospice developed an innovative project that provided a wide range of end-of-life services to high-risk patients who did not qualify for the Medicare Hospice Benefit or who would not accept a hospice referral.

Through CHOICES (Comprehensive Home-Based Options for Informed Consent about End-Stage Services), Emeryville, California, Medicare risk patients served by North American Medical Management (NAMM), a managed care group, were invited to receive services from a nurse practitioner and social worker team that was available 24 hours a day, seven days a week to respond to, avert or control acute problems that would otherwise result in ambulance trips and hospitalizations.

In addition to the comprehensive services available to all patients, those patients enrolled in CHOICES received home-based services, including comprehensive medical/psychosocial assessment, coordination, advance care planning, communication of preferences to providers and end-of-life services. The team provided special palliative care, focusing on comfort as well as the psychological, social and spiritual well-being of patients and families.

NAMM physicians in two Physician Organized Delivery Systems received palliative care training and used clinical indicators to identify patients who were within two years of death, medically unstable and at risk of receiving potentially unwanted emergency and inpatient services. Alta Bates Medical Center, as a collaborator in the project, ensured that the Medical Center Emergency Department and discharge planners had timely information about the advance directives and treatment preferences of CHOICES patients.

Under the direction of Brad Stuart, M.D., and Carol D'Onofrio, Dr.P.H., the project measured access to end-of-life care, services provided and cost of care to demonstrate that the CHOICES program could be implemented in a managed care environment.



After the Grant

The COICES project became AIM (Advanced Illness Management) and expanded from Emeryville to other areas around San Francisco. Project planners expanded the services to include inpatients at two hospitals.

Contact Information

Principal Investigators:
Brad Stuart, M.D. and Carol D'Onofrio, Dr.P.H.
Sutter VNA and Hospice
5912 Anderson Road
Forestville, CA 95436
Phone: 510.450.8533
Fax: 707.887.7609
Email: [email protected]
Email: [email protected]

Web site:

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Promoting Excellence in End-of-Life Care was a national program of the Robert Wood Johnson Foundation dedicated to long-term changes in health care institutions to substantially improve care for dying people and their families.