Concord Regional VNA Finds Success in Advanced Illness Management 

Concord Regional Visiting Nurse Association (VNA) in New Hampshire has developed a financially sustainable advanced illness management (AIM) model that incorporates palliative care principles. The program is designed to meet patient and family needs, and it allow for smooth transitions to hospice when appropriate.

The VNA for several years has collaborated on palliative care with local acute care provider Concord Hospital. This began with the pilot of solo provider palliative consults, primarily for oncology patients, and was later developed into a full interdisciplinary team approach jointly staffed and supported by Concord Hospital and the VNA. The Concord Hospital collaboration has focused mostly on inpatients and skilled nursing facilities, but the VNA began considering how they could roll those services out to more patients receiving care in their homes.

“[The palliative care collaborative with Concord Hospital] is a nice partnership that has worked well. Where we really started to feel that we had a big gap was those 1,100 or so patients on our home care service on an average day, and how we could provide the same level of service and timeliness to that patient population,” Andrea Patrick-Baudet, chief clinical officer for Concord VNA said in a presentation at the National Hospice & Palliative Care Organization’s Virtual Interdisciplinary Conference.


When it came time to develop their community-based AIM program, Concord began to apply lessons learned from a similar program designed by Sutter Health. Through its advanced illness management program, established in 2003, Sutter Health provided home-based coordinated care to 2,000 patients with advanced illness per day in 19 communities in a mix of urban, suburban and rural locales.

“We chose to really pull from the Sutter Health definition of advanced illness management. The Sutter Health model, it’s really important to note is home-based, which is the population that we are serving as well. It is nurse-led and really involves a lot of coaching with patients and helping them understand and be able to verbalize their goals and how we can help them achieve them.”

Compared to matched Medicare beneficiaries in similar regions, the Sutter Health program cut the number of hospital days by 1,361 per 1,000 patients. The number of patients who died in the hospital fell by more than 8% and reduced inpatient costs by $6,127 per patient and overall health care costs by $5,657, according to a June 2019 Health Affairs study.


Beneficiaries with advanced illness, defined as late-stage chronic illness that threatens health and the patient’s ability to function, represent 4% of Medicare beneficiaries but account for 25% of its costs, according to the Sutter Health study. These patients, who often reach a point where treatments begin to lose their impact, frequently experience avoidable hospitalizations close to the end of life.

“This is about providing the right care at the right time, whatever that is. It might be symptom management, or it might be more conversations around goals of care and fleshing that out,” Patrick-Baudet said. “We wanted to make sure that we were not setting this program up to be all about the transition to hospice. One of our strategies really was to think about embedding the advanced illness management program, not within the hospice teams, but within the home care teams, and really wanted to align the advanced illness management coordinator as a consultant and a specialist.”

Staff education became a key aspect of the roll out. The VNA made advanced illness management, hospice and palliative care education a part of their employee orientation process for all clinical disciplines and provided them with access to the program coordinator, Alycia Harpell, to answer their questions or provide support.

As the program solidified internally, the VNA began to bring in collaborators. Concord reached out to local physician practices to inform and educate them about advanced illness management and their program.

“We knew it was time to start thinking outside of the agency itself. We still have a very intense focus on relationship building. Collaboration really began with our locally established palliative care team. This was very organic, because in our case patients known to the palliative care team were also being referred to our [advanced illness management] program,” said Advanced Illness Management Coordinator Harpell. “When consulted [the program] really ensures that there is an emphasis given around the benefits of that social work and spiritual care component. Working with physician practices, [the advanced illness management program] advocates the benefit of engaging that full team. The program helps remove barriers to timely hospice care by facilitating smooth transitions and promotes upstream access to our palliative care interdisciplinary team.”

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