Grand-Aides: Lowering Healthcare Costs and Improving Outcomes

The United States wastes about $1 trillion per year—about one-third of our total healthcare dollars. More than $50 billion of this waste takes the form of “failure of care transitions,” a category that includes unnecessary hospitalizations, readmissions, emergency department visits, and even clinic visits, which not only are expensive but also take a huge toll on patients and their families. Even if all of this waste were eliminated, we still would be faced with increasing demand for medical care as the population ages, with increases in chronic disease and greater expectations for healthcare. In the face of increasing demand, there is a shortage of supply: some have suggested that in the next year, we will face shortages of 100,000 physicians and one million nurses.(1) Only a reduction in unnecessary care will help to alleviate the impending shortages.

The U.S. Institute of Medicine has suggested that there are more efficient ways to meet these workforce needs than increasing the numbers of physicians and nurses. A new approach to workforce and healthcare delivery is needed that improves access, improves outcomes, and reduces costs.

Grand-Aides (GA) is an innovative solution to reducing hospital readmissions and emergency room visits, thus significantly decreasing the cost of care. How does the GA concept work? GAs are certified nurse aides who make frequent home visits to patients with chronic diseases such as congestive heart failure with the goal of keeping them at home and out of the hospital and emergency department. Thomas et al.(2) demonstrated that in patients with heart failure being cared for by GAs, 30-day readmissions decreased from 82% to 2.8%, and the number of emergency room visits also was reduced. Furthermore, there was 92% medication adherence and extremely high patient satisfaction.

GAs act like a surrogate grandparent (hence the name “Grand-Aides”). Each home visit takes approximately 45 minutes and is supervised in real-time for 5 to 10 minutes by a registered nurse using contemporary telemedicine technology. During these visits, the GA develops an understanding of the medical situation of the patient and determines any danger signs that may be present during subsequent visits. A questionnaire that is unique for each patient and his or her medical problem is completed by the GA on each visit and then sent through the cloud for the nurse to review. The physician and team have decided which answers on the questionnaire need medical attention; all the answers are placed in the medical record for the physicians to review at any time. Grand-Aides reports that patients and families confide in the aides and highly respect the nurses and physicians, so communication between patients and healthcare professionals is a seamless process.

The first week after the patient is discharged from the hospital, a GA will visit the patient three times. Then depending on the patient’s condition, the number of visits is slowly decreased over the first month to one visit per week. Once it is certain that the patient is stable, the GA makes only a “telemedicine” visit, which is supervised by the RN. Whenever there is a question about the patient’s condition or there is a need for a home visit, the GA will see the patient within a few hours of receiving a call from the patient or his or her family. GAs also make home visits for primary prevention; to increase efficiency (e.g., reduce “no-shows”), as well as secondary prevention; and provide “intervention” with intense attention to medication adherence (e.g., for asymptomatic patients with hypertension).

Who are the GAs and how are they trained? Grand-Aides USA works with 10 national employment agencies to employ local GAs, nurse supervisors, and social workers, who then interact with the program’s nurses and with the patient’s physicians.

GAs are selected based on their communication skills. Each GA must be able to:

• Be empathetic, but also display “tough love” (like a good grandparent);

• Understand basic principles of verbal and nonverbal communication;

• Communicate with empathy and gather information in a respectful manner;

• Identify barriers to communication;

• Speak and write in the patient’s preferred language; and

• Create concise written documentation of each visit to the patient’s home.

Each nurse supervises five GAs. Depending on the type of program, a GA can help to care for 100 chronically ill or 250 primary care patients per year.

GAs follow the post-discharge protocol by adhering to the following guidelines:

• Reinforce all elements of the discharge plan created by the healthcare provider (e.g. methods for medication adherence);

• Conduct medication reconciliation with the supervisor via live HIPAA-compliant video; and

• Administer symptom questionnaires customized by the supervisor for each patient, sent electronically to the supervisor, who has a video call with the patient on each GA visit. GAs do not make independent decisions; every visit is supervised.

GAs also are helpful for population-based programs. Each GA cares for the whole patient and all of their medical conditions. This is different from home health, where a specific skilled service (e.g., wound care) is being delivered. In fact, for the 20% of patients who have both home health and a GA, the GA program works closely with home health to be sure they are not in the home on the same day and communicate any observed concerns to each other as well as the medical team. The concept has been used with patients who have public insurance such as Medicare, Medicaid, and Accountable Care Organizations, as well as those with commercial insurance.

Some programs begin caring for high-risk patients referred from a clinic. Grand-Aides recently has reported on a group of family medicine patients with diabetes and hypertension who achieved medication adherence greater than 90% at 1 year and a 75% reduction in hypertension.(3)

The United States is projected to experience a physician shortage in the near future.(4) This problem will be even greater in rural areas, because many of those areas are already experiencing a physician shortage. The GA program may help ameliorate that shortage in those areas. The current program allows GAs to meet patients in the hospital or clinic and, ideally, make several home visits, regardless of the distance from the GA to the patient in the rural area, to see the home environment, meet families, and understand the home conditions. The GA makes sure the patient has a way to do video communication—either dedicated television camera, tablet, or smartphone—and understands how to use it. The patient needs only a mobile phone or a tablet. If it is absolutely not practical to make even an initial home visit, then the initial “bonding” between the patient and family and the GA occurs in the clinic or hospital.

The Grand-Aide provides the personal touch, while also using the most up-to-date technology to enhance communication.

The best way to achieve the desired relationship and compliance is with at least three or four visits in the first week. This early frequency is one of the bedrocks of the GA program and is a requirement. Over the following weeks, the visit frequency is reduced at the discretion of the nurse or nurse practitioner (NP) supervisor. The intent of the program is to empower patients and families and have them able to care for themselves after one month. The GA stays involved with the patient as long as the program desires—usually six months.

The GA provides the personal touch, while also using the most up-to-date technology to enhance communication. Every home visit that a GA makes has the supervising nurse or NP on video (using HIPAA-compliant video from a tablet, such as FaceTime or Jabber). Proprietary software also is used for data collection (and transmission to the supervisor), analysis, and reporting.

Patients with chronic diseases such as congestive heart failure experience a reduction in resource utilization (e.g., hospital readmissions) for such conditions and also in emergency department visits. Medicare patients with heart failure who had GAs had a 2.8% 30-day all-cause readmission rate, compared with the control patients who received usual care in the same time period, who had a 15.8% 30-day all-cause readmission rate. This represents an 82% reduction in readmissions. For 30-day all-cause emergency department visits, only 2.8% of those with GAs had at least one ED visit, compared with 45.1% of control subjects.(2)

The GA approach makes economic sense when physicians are “at risk.” Under bundled care or capitation, direct savings would be generated because the reduced expense per visit (GA compared with nurse or physician visit) would be credited against the capitation or bundled revenue per patient. There are several possible payment mechanisms in a patient-centered medical home model, with an added “per member per month” payment for accomplishing the healthcare goals of the patient. In a fee-for-service plan, the clinic could be paid for the supervisor’s work, rather than billing for the GAs directly. The payer would see a reduction in the average cost per visit, because the care provided to patients seen by GAs and the supervisor would cost less.

Bottom Line: These early reports indicate that a GA program supplemented with a supervising nurse could have a substantial impact on helping patients to stay at home and out of the hospital or the emergency department by incorporating standardized protocols. The result would be reduced congestion in emergency departments and doctors’ offices and improved access for those patients who truly need to be seen there. This program also could generate savings and begin to bend the cost curve, as health reform unfolds. The Grand-Aides program is going to work as more than a “Band-aid” to solving the current healthcare crisis.

References

1. The Complexities of Physician Supply and Demand: Projections from 2017 to 2032. April 2019. Association of American Medical Colleges. www.aamc.org/system/files/c/2/31-2019_update_-_the_complexities_of_physician_supply_and_demand_-_projections_from_2017-2032.pdf

2. Thomas SC, Greevy RA Jr, Garson A Jr. Effect of grand-aides nurse extenders on readmissions and emergency department visits in Medicare patients with heart failure. Am J Cardiol. 2018;121:1336-1342.

3. Garson T. Health workforce innovations to support delivery system transformation. Health Workforce Institute. September 12, 2016. www.gwhwi.org/uploads/4/3/3/5/43358451/health_workforce_innovations_meeting_summary.pdf .

4. Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and demographic trends signal an impending physician shortage. Health Affairs. 2002;21(1):140-154.