Grand-Aides International Summary
Throughout the world, the health workforce is short at least 2.3 million physicians, nurses and midwives. Virtually every country has urban areas with overcrowded emergency departments and public hospitals (many with too many readmissions), as well as rural areas that are economically and/or geographically isolated with shortages of practitioners. The need for health care is growing as the population ages with increases in chronic disease and greater expectations for health. As the mismatch of supply and demand worsens, access to care will deteriorate further. A new approach to workforce and health care delivery is needed that improves access, reduces cost and improves quality.
Please see a short video on Grand-Aides.
- The goal of Grand-Aides International ® is to improve population health and provide appropriate access to care while reducing unnecessary emergency, clinic and hospital visits, thus reducing costs: one person at a time. Grand-Aides USA provides an innovative health care delivery program with caring, experienced nurse extenders making home visits to develop a trusting relationship, connecting the patient and care team quickly and cost-effectively. (www.Grand-Aides.com).
- Grand-Aides, regardless of age, have the temperaments and personalities of a good grandparent. Grand-Aides have had prior training in medical care, such as a Nurse Aide or community health worker, but may be lay people, ideally with some experience in care delivery such as an ill parent. All then take an added Grand-Aides curriculum. They are generally paid. Under close supervision by a nurse or physician, Grand-Aides use telephone protocols and home visits with portable telemedicine; they provide transitional – hospital discharge – and chronic disease management, as well as primary and preventive intervention to improve access to needed care and reduce unnecessary emergency, clinic and hospital visits, reducing costs. Grand-Aides are known by patients and families as trusted partners that assist in improving their health one step closer to home. Grand-Aides programs are in operation or under discussion in over 50 US sites and 14 international locations.
- Grand-Aides International trains local supervisors who then train the local Grand-Aides. Grand-Aides International does not employ Grand-Aides or supervisors, who may be employed by government, NGO, or private enterprise.
- Grand-Aides address the following issues in both adults and children: 1. Overcrowding in busy clinics and emergency departments; 2. Improved management of chronic disease, to keep patients as healthy as possible and out of the hospital both readmissions and admissions; 3. Improved access to care in rural areas for those who have little or none.
There are a number of Grand-Aides programs.
- Transitional/Chronic Disease care aimed at improvement in health and reduction in hospital readmissions for such conditions in adults as cardiac disease (congestive heart failure, acute myocardial infarction, post coronary bypass and post percutaneous coronary intervention), Chronic Obstructive Pulmonary Disease, Diabetes and others; in children, asthma, special needs children and premature infants. Grand-Aides visit every day for the first 5 days after hospitalization, less the next week and then according to the needs as determined by the supervisor. They complete personalized symptom questionnaires, send the answers electronically to the supervisor and then the supervisor then goes on video with the patient. The Grand-Aides teach extensively specifically about discharge instructions with numerous approaches to medication adherence and prevention. Recently published in Health Affairs on readmissions, at the University of Virginia, those with Grand-Aides had a 58% reduction in all-cause readmissions in patients with heart failure; 91% of their patients were taking medication appropriately at 1 month after discharge. This represents the best published data in 5 years. At the Cleveland clinic, Grand-Aides are helping to care for their 300 most severely ill patients with heart failure; with Grand-Aides there have been no admissions for heart failure in the first 60 patients followed for 90 days.
- Palliative care. Grand-Aides provide support similar to that of the primary care Grand-Aides, especially involving the family. Grand-Aides use protocols specifically developed for palliative and hospice care. The goals of the Palliative Care Grand-Aide: Increased access to and use of palliative care, improved symptom control; improved quality of life, depending upon the wishes of the patient, family and care team; decreased in ER visits in the last days of life; reduction in ICU admission in the last days of life
- Primary care. Grand-Aides function as a part of a primary care team to help care for adults and children. Grand-Aides first meet the patient / family in the clinic. When a member of one of these families calls, the Grand-Aide asks a series of questions in a "protocol" (or questionnaire) for one or more of 20 conditions (e.g. cold, fever). The Grand-Aide receives instructions from the supervisor, and may involve a home visit by the Grand-Aide. They also make home visits for primary prevention – and efficiency (e.g. reduce "no-shows") as well as secondary prevention – and “intervention” with intense attention to medication adherence (e.g. for asymptomatic patients with hypertension). In the article in Health Affairs on primary care: 62% of drop-in acute care clinic visits could have been potentially cared for by a Grand-Aide and Nurse Supervisor and 74% of Emergency Department visits fit one of the 20+ Grand-Aides protocols. A population-based Grand-Aide is being deployed in a large integrated health care system in the US to reduce visits to the emergency department (A&E) among hyper-utilizers.
- Maternal-Infant. Grand-Aides meet high-risk pregnant women and their families as soon as possible after the woman learns she is pregnant. Goals: Reduced complications of pregnancy, improved adherence with medical regimen (e.g. medication, diet, smoking cessation), improvement in other issues as possible (working with the supervisor to reinforce drug addiction programs [including alcohol] and referral to appropriate social programs), reduced ED visits and admissions, improved outcomes of pregnancy, healthier babies (e.g. less fetal alcohol), improved neonatal outcomes, mothers as well equipped as possible to care for newborns, reduced ED visits and readmissions for infants.
Each Grand-Aide may be trained to do more than one of these programs and approach entire populations rather than by disease. There are also programs for entire populations: We have delivered to the government of Bangladesh a plan for 87,000 Grand-Aides, one per visit. We have programs in rural Indonesia where >100 Grand-Aides will be trained, and is being applied in the US to the Navajo Indian population. We also have programs aimed at sub-populations such as the frail elderly with chronic disease, as well as secondary prevention to improve adherence with the medical regimen and diet in hypertension, diabetes and obesity.
- Rural Care Delivery
The Rural care Grand-Aide will help to improve the health of those with little or no access to care in a way that fits with local practice. Specific goals for medical and health outcomes will be developed with each location.
There are 2 approaches to the Rural Grand-Aide depending upon the distances from villages.
- In areas where there are villages, Grand-Aides will help to provide care at the most local level in villages – “the last mile” -- using public health (e.g. sanitation) and medical care protocols, leveraging supervisors who are located in clinics miles away, connecting to them with telephone or, if Internet is available, video. Grand-Aides are recruited from among those already providing medical care. For example, virtually every village has a grandmother who has provided medical advice and treatment – some delivering babies. These people can be trained in: 1. appropriate prenatal care, recognizing danger signs, and if no facilities or transportation are available, performing deliveries (if Internet is available, working with a clinic doctor, midwife or nurse); 2. Infant care – prevention: such as appropriate feeding, immunization, and treatment using protocols (e.g. for diarrhea or fever) that are approved by local physicians; 3. Adult care – prevention, such as medication adherence for hypertensives, as well as acute care protocols (e.g. for abdominal pain), as well as chronic disease protocols (e.g. diabetes or congestive heart failure). They need to be trained to work within established guidelines (modified by professionals for local practice) rather than the way they had previously been “treating” people. For larger villages, more than one Grand-Aide is needed – approximately 500-1000 people per Grand-Aide. Grand-Aides know every person in the village, their preventive needs and are available for acute illness. The protocols will take the Grand-Aide just as far as the local physicians and nurses in regional clinics are comfortable (e.g. they will all say when to contact the home base.)
- In areas distant from villages, Grand-Aides meet patients in the hospital or clinic and ideally make at least one or two home visits, regardless of the distance to see the home environment, meet families and understand the home conditions. The Grand-Aide then makes sure the patient has a method to do video and understands the use – either dedicated television camera, tablet or smart phone. If the family does not have this, it will be an expense to the program. If it is absolutely not practical to make even an initial home visit, then the “bonding” of the patient and family with the Grand-Aide must occur in the clinic or hospital.
Grand-Aides International has visited 29 countries, and in more than 15, presented to the Minister of Health. A current listing of the locations and types of Grand-Aides programs is available from Grand-Aides International.