Skip Navigation
Policy Innovation Profile

Clinics and Hospitals Use Trained, Certified Community Members To Screen and Support Primary Care and Postdischarge Patients, Reducing Physician Visits and Costs


Tab for The Profile
Comments
(6)
   

Snapshot

Summary

Primary care clinics and hospitals are using so-called "Grand-Aides" as part of the health care team; these individuals have had prior training in medical care (e.g., as nursing assistants) and then go through a rigorous training and certification process. Grand-Aides help ensure that patients receive appropriate treatment in primary care settings; they also monitor and support patients after hospital discharge. Once deemed qualified, Grand-Aides in primary care settings use protocols to assess patients and present the results to a nurse supervisor, who determines if the patient needs to see a provider or if the Grand-Aide needs to make a home visit and connect the patient to the supervisor via telemedicine. In hospitals and after discharge, Grand-Aides ease the patient's transition home through in-person and telephone-based monitoring and support. To date, the model has been tested in two primary care settings, as well as in one hospital setting for readmissions. Data on hospital readmissions show significant reductions for the first 8 months of implementation with Grand-Aides at one site. In year-long pilot tests in two pediatric primary care clinics, the program reduced unnecessary physician visits and demonstrated the potential to generate significant cost savings.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the proportion of patients at the Houston primary care clinic screened by Grand-Aides who did not need to see a physician, along with estimates of the potential cost savings that could be generated by Grand-Aides at the primary care clinic and an ED.
begin do

Developing Organizations

Grand-Aides Foundation
end do

Date First Implemented

2010

Problem Addressed

Nurses and physicians in primary care clinics, emergency departments (EDs), and hospitals often do not have adequate time to assist patients (particularly at sites serving low-income individuals), leading to long wait times in primary care and to poor transitions from hospital to home. These problems undermine the quality of care and drive up health care costs.
  • Manpower shortages as root cause of multiple problems: A shortage of physicians and nurses is forecast for the next decade.1,2 Implementation of the Patient Protection and Affordable Care Act could exacerbate the problem, as coverage is extended to 32 million more people. These shortages lead to long wait times in primary care and to ineffective transitions from hospital to home.
    • Long waits in primary care clinics: Patients at primary care clinics frequently face long waits before seeing a nurse or a physician. In many cases, these visits are not clinically necessary or do not require input from a physician; such visits increase costs and further contribute to long wait times, leaving less time for physicians and nurses to treat those who are seriously ill.3
    • Ineffective transitions from hospitals to home: Patients going home after discharge from the hospital often face deficiencies in the quality of their care, including insufficient education about self-management of their condition, conflicting advice regarding care, and inadequate monitoring during and after the transition. These deficiencies frequently lead to costly ED visits or hospital readmissions.4 Between 20 and 25 percent of Medicare patients are readmitted to hospitals in the first 30 days after discharge.5 It is known that if nurse practitioners visit patients at home, the readmission rate is decreased; however, nurse practitioners are expensive and the supply is short. Nurses and physicians in primary care clinics, EDs, and hospitals often do not have adequate time to assist patients (particularly at sites serving low-income individuals), leading to long wait times and poor transitions from hospital to home. (Updated October 2013.)
  • Effect on low-income patients: The problems stemming from the shortage of doctors and nurses tend to fall hardest on low-income patients, who are often treated at facilities where staff must handle very large caseloads, leaving little time for them to spend with individual patients.6
  • Unrealized potential of trained lay workers: With appropriate added training, certified nursing assistants can potentially address the problems facing many primary care and transitioning patients. For example, under a nurse's supervision, these assistants can help handle all or part of the many primary care visits for common conditions such as colds, fever, and rashes. Certified nursing assistants can also help educate and monitor patients during the critical period after discharge from the hospital; however, few patients have access to such support.

What They Did

Back to Top

Description of the Innovative Activity

Primary care clinics and hospitals are using so-called "Grand-Aides" as members of the health care team; these individuals have had prior training in medical care (e.g., as nursing assistants) and then go through a rigorous training and certification process. Grand-Aides help ensure that patients receive appropriate treatment in primary care settings; they also monitor and support patients after hospital discharge. Once deemed qualified, Grand-Aides in primary care settings use protocols to assess patients and present the results to a nurse supervisor, who determines if the patient needs to see a provider or if the Grand-Aide needs to make a home visit and connect the patient to the supervisor via telemedicine. In hospitals and after discharge, Grand-Aides ease the patient's transition home through inperson and telephone-based monitoring and support. To date, the model has been tested in two primary care settings, as well as in one hospital setting for readmissions. (Updated October 2013.) More details on the certification and training processes and Grand-Aide activities are outlined below:
  • Rigorous certification and training: Grand-Aides complete a rigorous certification and training process before they can work directly with patients.
    • Preliminary State certification: Prospective Grand-Aides generally become certified by the State, as either a nursing assistant (the most common designation) or a medical assistant. Those without such certification can complete an additional month of training to qualify as a certified nursing assistant. (See bullet below for more information on training.)
    • Training and provisional certification: Trainees complete a 180-hour curriculum on basic and disease-specific medical knowledge in which they study a 200-page manual, perform classroom work, and complete simulations and field training. Nurses who have received training from staff at the Grand-Aides Foundation typically lead the sessions. (See the Context section for more information on this organization.) All trainees learn about basic anatomy and physiology, along with the specifics of certain diseases. Trainees on the primary care track learn protocols for 26 common conditions (e.g., headache, vomiting, rash, congestion, fever, diarrhea), whereas those on the transitional care track learn protocols for working with patients with 5 chronic diseases that frequently require hospitalization: diabetes, heart failure, heart disease, pneumonia, and chronic obstructive pulmonary disease. Training generally lasts about 3 months. During this time, trainees take written tests and meet one on one with the instructor on a weekly basis and also undergo formal evaluation during field training. Individuals who pass all tests and are judged capable by the instructor become certified as provisional Grand-Aides for a year and can begin working as a Grand-Aide intern.
    • Full certification and annual recertification: After a year as an intern, those judged satisfactory by their supervisor (the nurse who led the training) earn full certification. These individuals must be recertified each year to continue working as Grand-Aides. Recertification requirements include participating in the care of at least 100 patients to the supervisor's satisfaction, completing 5 hours of continuing education classes, and passing a test.
  • Scope of work: Grand-Aides perform a variety of tasks intended to streamline and reduce the costs of patient care, assist health care teams in providing appropriate care to patients, and free up nurse and physician time to care for the sickest patients. Their work varies depending on the setting (primary care or transitional care after discharge) but typically involves inperson interactions or telephone conversations with patients, with a focus on assessment of needs, education on preventive and self-care, ongoing monitoring, and followup. More details about the role of Grand-Aides in primary care and postdischarge transitional care are outlined below:
    • Role in primary care: In primary care settings, Grand-Aides provide an initial assessment of patient needs by using protocols consisting of a "tiered" series of 20 to 30 yes/no questions about symptoms. The first few questions help determine if the situation is an emergency. For example, the headache protocol includes the following questions designed to identify an emergency situation: "Does the patient have a stiff neck on bending the head forward?" and "Does the patient have blurred or double vision?" If the answers indicate an urgent situation, the Grand-Aide stops asking questions and consults with a nurse supervisor about getting the patient immediate care at the clinic or an ED. For nonurgent patients, the Grand-Aide completes the protocol questions and presents the results to a nurse supervisor, who determines if the patient needs to see a provider or if the Grande-Aide needs to make a home visit and connect the patient to the supervisor via telemedicine. Grand-Aides also provide followup support. The concept was pilot tested for a year at two pediatric primary care clinics. Additional details on the role that Grand-Aides played during these pilots are provided below:
      • Introduction to patient and parent: At the two pilot sites, Grand-Aides typically met the patient and his or her parent in person. After the receptionist introduced them in the waiting room, they moved to a separate room, where the Grand-Aide performed the screening. (Parents had the option of declining to meet with the Grand-Aide, but very few did.)
      • Information gathering: Patients ranged from infants to adolescents, and either the patient or the parent described the problem. Then the Grand-Aide determined which of 26 protocols to follow, with the protocols available electronically via a laptop computer, tablet, or mobile telephone.
      • Consultation with nurse supervisor: After gathering the information, the Grand-Aide consulted with a nurse supervisor, either in person or over the telephone. The Grand-Aide could provide a recommendation to the supervisor, but the nurse ultimately decided on the proper course of treatment. In nonemergencies, options included having the patient see a nurse or doctor, providing home-care instructions (e.g., take an over-the-counter medication), or having the Grand-Aide make a home visit.
      • Followup and monitoring: As the meeting ended, Grand-Aides encouraged patients to contact them by telephone whenever future health problems arose. In this fashion, Grand-Aides gradually built up relationships with a set of patients. Grand-Aides telephoned the home a day or two after the health problem arose to check on the patient's progress. In some instances, Grand-Aides also made home visits, where they could use a mobile telephone to send photos or video to the nurse supervisor.
    • Role in transitional care: Grand-Aides who have completed the transitional care training track help patients transition home after discharge. They meet and familiarize themselves with patients while they are still in the hospital, accompany patients on their trip home, visit them every day during the first week, and follow up as needed through visits and telephone calls. The goal is to help transitioning patients self-manage their condition, adhere to their treatment regimen (including taking medications appropriately), and recognize and act on any warning signs or symptoms that suggest a potential exacerbation. To assist them, Grand-Aides use protocols specific to the patient's chronic disease, along with portable telemedicine technology to communicate with the nurse supervisor about patient signs and symptoms.

Context of the Innovation

The Grand-Aides Foundation is a not-for-profit, 501(c)3 organization that assists health care organizations in training Grand-Aides and in implementing Grand-Aide programs. The organization was founded in 2008 by Arthur "Tim" Garson, MD, a pediatric cardiologist who also serves as director of the University of Virginia's Institute for Health Policy and formerly served as dean for academic operations at the Baylor College of Medicine in Houston. The impetus for the Grand-Aide program and the creation of the foundation came earlier in 2008, when one of Dr. Garson's colleagues mentioned at a conference that many patients visiting health clinics could effectively be taken care of by a "good grandmother." Intrigued by the concept and aware that many visitors to both health clinics and EDs do not need to see a physician, Dr. Garson began exploring whether grandparents could be trained to extend the reach of nurses and physicians in various health care settings.

As noted earlier, use of Grand-Aides has been tested in two primary care organizations. The first is a pediatric clinic within Legacy Community Health Services in Houston, Texas, a federally qualified health center with five locations. This clinic handles roughly 52,000 visits per year, primarily from Medicaid beneficiaries (who represent 98 percent of patients), a significant proportion of whom are African American or Hispanic. The second site is the Harrisonburg Community Health Center in Harrisonburg, Virginia, a primary care clinic with an emphasis on pediatrics that handles approximately 10,000 visits a year.

Did It Work?

Back to Top

Results

Data on hospital readmissions show significant reductions for the first 8 months of implementation with Grand-Aides at one site. In year-long pilot tests in two pediatric primary care clinics, the program reduced unnecessary physician visits and demonstrated the potential to generate significant cost savings. Data on the program's impact with postdischarge transitions are not yet available, as pilot testing of this application of Grand-Aides is just getting under way.

  • Reduction in hospital readmissions: Early data on the program's impact with postdischarge transitions in congestive heart failure at the University of Virginia show no readmissions specifically for this condition in the first 8 months of the program and a 54-percent reduction in all-cause readmissions. (Updated October 2013.)
  • Fewer unnecessary primary care visits: In the Houston clinic, 62 percent of the 457 children seen by a Grand-Aide in June 2011 returned home without seeing a physician. (Updated October 2013.)
  • Significant cost savings potential: Separate analyses on cost savings were performed at each of the two primary care sites. One focused on the potential savings from reducing unnecessary physician visits and the other focused on the potential savings from avoiding ED visits.
    • Potential savings from fewer primary care visits: At the Houston site, each averted physician visit saves the clinic roughly $183 (the $200 cost of a regular physician visit, less the roughly $17 cost for each consultation with a Grand-Aide). Each Grand-Aide can handle about 2,400 calls or visits per year. Assuming that the data from June 2011 hold true and that roughly 62 percent of consultations do not require a physician visit, each Grand-Aide can reduce costs by about $272,000 a year.
    • Potential savings from fewer ED visits: Over a 15-month period at the Harrisonburg primary care site (July 2010 through September 2011), 402 clinic patients made 779 visits to the Rockingham Memorial Hospital ED. A theoretical analysis found that in 73.7 percent of these cases (574 cases), a primary care–based Grand-Aide could have handled the case without the need for an ED visit. Since each averted ED visit saves the hospital roughly $158 (the $175 cost of the ED visit less the $17 cost of a Grand-Aide consultation), the potential cost savings from avoiding all 574 cases would be just over $90,000.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the proportion of patients at the Houston primary care clinic screened by Grand-Aides who did not need to see a physician, along with estimates of the potential cost savings that could be generated by Grand-Aides at the primary care clinic and an ED.

How They Did It

Back to Top

Planning and Development Process

Key steps included the following:
  • Refining concept beyond grandparents: Dr. Garson's initial research led him to realize that focusing exclusively on using grandparents as Grand-Aides limited the potential of the program (and discriminated against nongrandparents), since many other lay members of the community had excellent caregiving skills. Consequently, he changed the scope of the program to focus on identifying and training lay community members who were wise and nurturing, had experience caring for others, and had the ability to generate the respect and trust of patients. To accommodate the change in focus, he named these workers "Grand-Aides" (replacing the original name "Grandparents Corps").
  • Selecting initial pilot site: In 2009, Dr. Garson began searching for a setting in which to test the concept. Believing a federally qualified health center would make an ideal site (because of its established infrastructure and large base of underserved patients), Dr. Garson contacted administrators at Legacy. Legacy leaders liked the idea and successfully applied for a grant from the Houston Endowment to fund the pilot program.
  • Protocol development and training: In 2009 and 2010, Dr. Garson worked with Legacy's medical director to develop the protocols related to the program and introduce the Grand-Aide concept to the clinic's physicians and nurses. Over a period of several months, Dr. Garson trained the nurse who would supervise the Grand-Aides and then worked with her and several physicians to recruit and train five Grand-Aides. The site launched the pilot program in June 2010. The test ended at the end of the year (when funding ended), meaning that the Grand-Aides were not recertified.
  • Selecting second site: In 2009, Dr. Garson contacted leaders of the Harrisonburg Community Health Center about being a pilot site, and they too expressed interest. The center successfully applied for a grant from the Ronald and Deborah Harris Charitable Foundation. After going through a similar protocol development, recruitment, and training process, the Harrisonburg site launched a 1-year pilot test of the concept in July 2010. As with the initial pilot, the test ended after a year, when funding ran out.
  • Expansion to additional sites: Harris County Hospital District in Harris County, Texas, began using Grand-Aides at several primary care clinics in 2012. Additional hospitals in Texas, as well as hospitals in Virginia, California, and Pennsylvania, are currently training individuals to serve as Grand-Aides and began using them to help with patient transitions from the hospital to home in 2012 and 2013. Several of these sites use a "train-the-trainer" model, with nurse supervisors receiving training at the Grand-Aides Foundation and then returning to their place of employment to train other prospective Grand-Aides. (Updated October 2013.)

Resources Used and Skills Needed

  • Staffing: The Harrisonburg site used four Grand-Aides during the pilot test, whereas the Houston site used five. The Grand-Aides varied in age but most were in their 50s and 60s. The typical site will use 5 to 10 Grand-Aides, with a nurse supervisor handling oversight responsibilities for up to 5 Grand-Aides.
  • Costs: As noted earlier, each consultation with a Grand-Aide costs roughly $17. An analysis of the Houston pilot test found that the total costs to train and employ a Grand-Aide averaged $40,500 a year. This figure includes $25,000 for salary and benefits, $2,500 for training, and about $13,000 to cover the costs of nurse supervision, technology, and transportation.
begin fs

Funding Sources

Houston Endowment; Ronald and Deborah Harris Charitable Foundation
end fs

Tools and Other Resources

An example of a protocol for Grand-Aides (focused on the common cold/congestion) is available at: http://www.grand-aides.org/images/uploads/US_PROTOCOL_-_Common_cold-Congestion.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

Adoption Considerations

Back to Top

Getting Started with This Innovation

  • Assess need: Before implementing this type of initiative, facilities should evaluate whether Grand-Aides are likely to have an impact on the overall treatment process. In primary care, areas to assess include the extent of overcrowding in waiting rooms, wait times, and the percentage of patients with basic health problems such as colds and sore throats.
  • Evaluate financial implications: Clinics considering implementing a Grand-Aide program should assess the long-term financial implications. Those in a fee-for-service environment should consider whether payers will reimburse for the service and whether they have enough demand to fill "averted" physician visits with new visits that will generate new revenues. (Many practices will be able to do this, given the primary care shortage.) For those operating under capitation or other shared-risk models, the program will likely be financially beneficial, since per-patient revenues will be unaffected, costs will be reduced, and physician and nurse capacity will be freed up to see more patients.
  • Consider local workforce: Facilities considering a Grand-Aide program should conduct a preliminary assessment of whether there is likely to be sufficient interest among community members in becoming Grand-Aides. Factors to consider include the area's unemployment rate, the percentage of unemployed people in the age range most likely to be interested and qualified in the position (those in their 40s, 50s, and 60s), and whether a high percentage of entry-level health care slots remain unfilled.
  • Seek buy-in from physicians and nurses: Before introducing a Grand-Aide program, clinic and hospital administrators should take time to explain a Grand-Aide's role to physicians and nurses and address any concerns, since some feel threatened by the new position or have concerns about quality or liability issues. Key points to emphasize are that Grand-Aides do not provide actual treatment, are closely supervised by nurses, and free nurses and doctors to treat patients who need them most.

Sustaining This Innovation

  • Require ongoing training: Annual training and recertification play a vital role in ensuring that all Grand-Aides keep up with changes in medical protocols and remain committed to their jobs.
  • Take advantage of technology: Recent technological advances, such as improvements in wireless networks and handheld devices with video capability, can help Grand-Aides quickly transmit vital information from patients' homes to nurses at clinics and hospitals.
  • Track and report data: If time and resources are available, programs should analyze Grand-Aides' effects in areas such as waiting time, readmissions, and physician and ED visits averted. Such data can help maintain support for the program among administrators and frontline staff.

More Information

Back to Top

Contact the Innovator

Arthur Garson, Jr., MD, MPH
University Professor and Professor of Public Health Sciences
University of Virginia
Chairman
Grand-Aides Foundation
602 Sawyer Suite 140B
Houston, TX 77007
(434) 924-8416
E-mail: garson@virginia.edu

Innovator Disclosures

Dr. Garson serves as Board Chair of the Grand-Aides Foundation, a nonprofit organization that receives funding for supporting health care sites in implementing the Grand-Aides program; in addition, information on funders is available in the Funding Sources section.

References/Related Articles

Garson A Jr, Green DM, Rodriguez L, et al. A new corps of trained Grand-Aides has the potential to extend reach of primary care workforce and save money. Health Aff (Millwood). 2012 May;31(5):1016-21. [PubMed]

Howell WLJ. Grand-aide model offers new solution to disease management. AAMC Reporter. March 2012. Available at: https://www.aamc.org/newsroom/reporter/march2012/276858/grandaide.html.

Footnotes

1 Physician shortages to worsen without increases in residency training. Association of American Medical Colleges Web site. Available at: https://www.aamc.org/download/150584/data/physician_shortages_factsheet.pdf.
2 Buerhaus PI, Staiger DO, Auerbach DI. The future of the nursing workforce in the United States: data, trends, and implications. Burlington: Jones and Bartlett; 2008.
3 Garson A Jr, Green DM, Rodriguez L, et al. A new corps of trained Grand-Aides has the potential to extend reach of primary care workforce and save money. Health Aff (Millwood). 2012 May;31(5):1016-21. [PubMed]
4 Coleman EA, Parry C, Chalmers S, et al. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822-8. [PubMed]
5 Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009; 360:1418-28. [PubMed]
6 Lowrey A, Pear R. Doctor shortage likely to worsen with health law. The New York Times. 2012 July 29:1. Available at: http://www.nytimes.com/2012/07/29/health/policy/too-few-doctors-in-many-us-communities.html.
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: September 12, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: November 20, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: October 21, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.