Problem Addressed

• Manpower shortages as root cause of multiple problems: A shortage of primary care 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: 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 and/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 emergency department (ED) visits and/or hospital readmissions.⁴
• Particularly for 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.⁵
• Unrealized potential of trained lay workers: Many community members have years of experience taking care of the health needs of their spouse, children, and/or grandchildren. Due to current demographic and economic trends, many of these individuals are seeking employment opportunities, making them ideal candidates to play a frontline role in ensuring that patients receive proper care.⁶ With appropriate training, these individuals can potentially address the problems facing many primary care and transitioning patients. For example, under a nurse's supervision, they can help handle all or part of the many primary care visits for common conditions such as colds, fever, and rashes. They can also help to educate and monitor patients during the critical period after discharge from the hospital. Yet few patients have access to such support today.

Description of the Innovative Activity

• Rigorous certification and training: Grand-Aides complete a rigorous certification and training process before they can work directly with patients, as outlined below:
  • Preliminary State certification: Prospective Grand-Aides generally become certified by the state, either as 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), while 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' certification 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 and/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's questions and presents the results to a nurse supervisor, who determines if they need to see a provider or if the Grande-Aide needs to make a home visit and connect the patient to the supervisor with portable telemedicine. Grand-Aides also provide followup support. To date, the concept has been pilot tested for a year at two pediatric primary care clinics, with the test having been completed. (See the Context section for more information on these 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, so 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) and/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: Later in 2012 and 2013, Grand-Aides who have completed the transitional care training track will help patients transition home after discharge. In this capacity, they will meet and familiarize themselves with patients while still in the hospital, accompany patients on their trip home, visit them every day during the first week, and followup 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 with their work, 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.

References/Related Articles

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Innovator Disclosures

Results

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 underway.

• 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.
• 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 a second 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 holds 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?)

Context of the Innovation

Planning and Development Process

• 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 (due to 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, will begin 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 plan to begin 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.

Resources Used and Skills Needed

• Staffing: The Harrisonburg site used four Grand-Aides during the pilot test, while the Houston site used five. The Grand-Aides ranged 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.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Assess need: Before implementing this type of initiative, 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: 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 healthcare 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, 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.