In a time of medical provider shortages and anticipated rise in demand, the health care community has been searching for ways to bolster its ranks. Arthur Garson Jr., MD, MPH, Director of the Center for Health Policy at the University of Virginia School of Medicine, is addressing this issue by looking outside the traditional health care community—to grandparents as a model.
“The idea for the original program started 15 years ago when a chair of family medicine said to me that he thought 50% of his patients could be taken care of by a good grandmother,” Dr. Garson said. “I didn't give it much thought and was then chairing a large workforce meeting about five or six years ago.”
At the meeting, Dr. Garson repeated the story to another chair of family medicine, who had his own reply.
“He said, ‘I suspect most of the rest can be taken care of by a good nurse.’ That became the origin of what started as primary care Grand-Aides.”
The Grand-Aides program trains individuals, grandparents or not, to provide home care to patients and reinforce medical advice under the supervision of a nurse.
“The hallmark is the characteristics of a good grandparent—caring, experience, exuding confidence, and somebody you would take advice from, recognizing that Grand-Aides don't make decisions,” Dr. Garson said.
Ideally, these individuals would be able to comfort patients at home and perhaps cut down on expensive readmissions, but not without training.
“The Grand-Aides training is on top of certified nursing assistant (CNA)/certified medical assistant (CMA) training,” Dr. Garson said. “We have found that some knowledge of what taking care of a patient is like is needed. We will certainly take pure lay people, but they need to go to school first to become a CNA. Our training is around 200 extra hours. The transitional care/chronic care Grand-Aide learns a lot about very basic anatomy and physiology.”
The day of hospital discharge, the Grand-Aide goes home with the patient and helps set up the medication and diet regimen, reinforcing the information the physician had sent home with the patient, and teaches medication adherence.
“They go through a lot of teaching, and then they have a protocol that they go through that's specific to the basic chronic disease. That protocol is anywhere from 30 to 50 yes-no questions.
“The Grand-Aide asks the patient that and then ships it off electronically to the nurse supervisor, who then goes on television live with the patient. All the Grand-Aide is doing is teaching and being a question asker for the nurse supervisor, who then talks to the patient and makes decisions, and then the Grand-Aide reinforces these decisions.
“We want the Grand-Aide to be with the patient every day for the first week, and then it decreases according to what the medical needs are and what the decision making by the medical team is,” Dr. Garson said. “In today's world, 30-day readmission is an important thing everybody would like to avoid. The metric of success is a healthy patient at 30 days or 60 days who hasn't been readmitted.”
Pilot tests of the Grand-Aides program were conducted in two pediatric Medicaid settings: an urban-qualified health center in Houston, and a semirural emergency department in Harrisonburg, VA, with the results published in Health Affairs (2012;31:1016-1021).
Dr. Garson and his team estimated that Grand-Aides and their supervisors averted 62% of drop-in visits at the Houston clinic and would have eliminated 74% of emergency department visits at the Virginia test site. The calculated cost of the program was $16.88 per encounter, compared with the then current Medicaid payments of $200 per clinic visit in Houston and $175 per emergency department visit in Harrisonburg.
Application to Nephrology
The question of whether or not the Grand-Aides program can have a positive impact on patient care has already been answered, said Thomas Golper, MD, Professor of Medicine at Vanderbilt University Medical Center and Medical Director of Medical Specialties Patient Care Center.
“All of the experiences have shown that this kind of stuff does work,” Dr. Golper said. “We know that staff going into the field is helpful.”
As for financial effects, though, Dr. Golper thinks that such a system can only be cost-effective if there is a transfer to different models of payment.
“No doubt that this stuff can improve health care,” Dr. Golper said. “Now whether this is cost-effective, that would be learned if we go to global capitated models of health care.”
The Grand-Aide program can work in nephrology, Dr. Garson said. However, he wanted to be clear that these individuals are not social workers.
“They are trained to make social work referrals, trained to understand what programs are available for people, and trained to understand what inexpensive drugs and programs are, but that's about 20 percent of what they do,” Dr. Garson said.
“What they really are doing is teaching, being on television back with the nurse, and doing those protocols. Somebody with newly diagnosed disease, whether diabetes or chronic renal failure, who goes home from the hospital, that's probably the biggest potential use of a Grand-Aide right now, to help them get settled. The next is somebody who's having trouble with chronic disease, whether it's hypertension or even somebody who's got renal disease who's had a stroke and is at home.”
W. Kline Bolton, MD, Professor of Medicine at the University of Virginia School of Medicine, agreed that Grand-Aides can address patient compliance, which in turn can improve readmission rate and diet.
“The idea would be that there is an added level of trust between this type of individual and the patient,” Dr. Bolton said. “One of the big problems we have is compliance. A lot of patients don't really understand or feel comfortable in saying they don't understand or admitting that they are not taking their medication.
“They can help with diet. It's easy to recommend it and say it, but it's harder for the patient, so I think the better home support there is, the better for the patient.”
While the program can be beneficial, Dr. Bolton cautioned that Grand-Aides must not go beyond the bounds of their experience.
“I think you have to be really careful that these individuals don't overstep their areas of influence or expertise. They are not doctors; they are cheerleaders, and knowledgeable, so in that sense they will be good.
“That is the biggest caution that I have, is to be sure that everyone recognizes their level of knowledge or expertise and is OK with going the next step up to address the issues.
“The ideal model, and the one that is needed for the best care, utilizes a nephrologist as the team leader of an integrated health care team.”
The Grand-Aides program is also starting to take shape overseas, Dr. Garson said.
“We have trained 30 Grand-Aides in Jakarta, Indonesia, and each of the 30 is ultimately probably going to train about 200 Grand-Aides, for 6,000 Grand-Aides throughout the country,” he said. “We have delivered to the government of Bangladesh a curriculum specific to Bangladesh for 87,000 Grand-Aides. We are talking to about 10 other countries.”
As health care continues to evolve, Dr. Garson sees a Grand-Aide becoming part of the team to assist patients and busy doctors and nurses.
“Health care has turned into a team sport, and we seem to have forgotten to put the patient on the team, so the idea of making the patient take greater responsibility for their own care, whether it's chronic disease or prevention, the Grand-Aide is somebody who is the next person to really help the patient ultimately take better care of themselves,” Dr. Garson said.
“The idea of the Grand-Aide is patient empowerment. The Grand-Aide takes some of what a nurse or nurse practitioner now does but doesn't need to do, and the nurse or nurse practitioner does what the doctor now does but doesn't need to do.
“There is going to be a need to free up doctors and nurses to do what they absolutely have to do. That's what this is.”