Hospital readmissions for the same condition within 30 days likely should not occur, and most often indicate system failure. Readmitted patients are either discharged too early, should be placed into palliative care or hospice, or most often are victims of a failure in transition of care from hospital to home. Most hospitals and physicians would like to eliminate such readmissions, particularly now that payers like Medicare are penalizing hospitals for high rates of readmission. Numerous approaches have been tried to reduce readmissions, with recent published improvements between a 2 percent and 26 percent reduction.
The Grand-Aides® program features rigorous training of nurse aides or community health workers to work as nurse extenders, 5 Grand-Aides to one RN or nurse practitioner (NP) supervisor, with approximately 50 patients per Grand-Aide per year. The Grand-Aides visit at home daily for the first 5 days post-discharge and then as ordered by the supervisor (e.g. 3 days the next week) for at least 30 days, extending as long as desired.
The post-discharge protocol for Grand-Aides includes the following:
1. Reinforce all elements of the discharge plan (e.g. 6 methods for medication adherence).
2. Do medication reconciliation with the supervisor via live HIPAA-compliant video.
3. Administer symptom questionnaires customized by the supervisor for each patient, sent electronically to the supervisor, who then has a video call with the patient on each Grand-Aide visit. Grand-Aides do not make independent decisions; every visit is supervised.
More research is needed, but preliminary unpeer-reviewed indications regarding the effectiveness of Grand-Aides are promising. (See Note 1) The most common issue raised in the 72 existing Grand-Aides programs under consideration has been reimbursement; however, before addressing reimbursement we must tackle two other policy issues that are crucial not just to Grand-Aides programs but across the health care system.
State certification. We believe that to be paid, at a minimum, an individual should be certified by a state. Such a credential demonstrates not only initial ability to pass a test but, with recertification, also shows continued proficiency. Grand-Aides USA certifies Grand-Aides, supervisors and programs with tests and demonstration of care of patients; there is continuing education required, and a yearly site visit. Such certification is appreciated by the programs, but carries no weight.
States should consider adopting such procedures (perhaps using ours as a model) not only for Grand-Aides but also for similar non-professionals such as community health workers. Community health workers are largely social worker extenders, but some are now entering the medical arena. There are few states that certify community health workers, and there is currently tremendous variability in training programs and the capabilities of the graduates.
Grand-Aides USA has begun training community health workers and believes that certification of community health workers would be beneficial for these individuals themselves, as well as those who employ them. States appear reluctant to add new categories to the current groups of people that they certify, but this must change as the workforce changes. States also must develop reciprocity so that there are not different criteria for certification, as the Grand-Aide or community health worker in Nevada may have significantly different training than in Florida.
Allowing everyone to practice to the fullest extent of their abilities and licensure. Grand-Aides support the burgeoning policy strategy to leverage the diverse members of the health workforce, including nonclinical care providers, within a team-based care model. Workforce trends suggest that there will be a physician and nurse shortage. However large it is (projected by some at up to 100,000 physicians and 1 million nurses in the next 10 years), it will not, cannot, and should not be conquered entirely by adding to the number of medical and nursing school graduates.
If we start with patients, we can leverage them to the best of their capabilities, educating them and incenting them to do the right thing in terms of underuse (improving medication adherence) but also overuse (not using the emergency department for colds). Even that is not easy — as we have found in our primary care Grand-Aides programs with the goal of appropriate use of the emergency department, some (more than a few) emergency department physicians and hospitals are happy to have those patients in a fee-for-service world. In a way, the special interest groups of physicians and hospitals are preventing the leveraging of patients because of the current economics of medical care.
Moving up the ladder, nurses are worried that Grand-Aides will take their jobs away (even though nurses supervise every Grand-Aides visit). There are similar, longer standing, issues between optometrists and ophthalmologists. The raging battle is being fought one level further up the ladder with advance practice nurses (APRN’s) and physicians. The Institute of Medicine produced a well-documented and exhaustive report containing unequivocal data that demonstrate the competency of nurse practitioners. Nonetheless, physician groups insist APRN’s should not be permitted to practice at the level of their licensure. The issue actually goes beyond licensure and should go to competency. We should develop tests of competency for different levels, and those who excel in these tests should be permitted to practice at an elevated level.
These are, of course, not issues of deep philosophy, but rather of money. All these groups are concerned that they will make less money if the group “beneath” them is permitted to do more for patients. Moving away from the fee-for-service payment model toward either bundling over an episode of care or capitation will at least put a dent in these objections. The more rapidly physicians and nurses are salaried (with appropriate quality bonuses) and hospitals migrate to become cost centers within accountable care organizations, rather than volume-based revenue generators, the better.
Payment will not fix it all. Those at the top of the professional organizations in states may feel they are “serving their members” and thus good patient care. This may not always be the case; as many physicians are deeply concerned for the access of their own patients and the 30 million more patients to be cared for after the influx of patients newly covered by the Affordable Care Act. There will clearly be enough patients to go around.
Now back to reimbursement, a policy issue that is much simplified after state certification and scope of practice are dispatched. If non-professionals are appropriately certified and recertified, and the professional societies will support the concept, Grand-Aides, community health workers and other similar providers should be paid at an appropriate rate by both public and private payers while we are still in a fee-for-service payment system. It is likely that in the coming world of integrated systems that will receive bundled or capitated payments, leveraging the workforce will prove in rigorous studies to improve both quality and cost, and will therefore be more widely adopted as a cost-effective improvement in coordinated patient care.
Note 1
We recently reviewed data for a group of patients involved in the Grand-Aides program in the University of Texas Health System Consortium. Since January 2013, among 62 unselected Medicare patients with Class III-IV Heart Failure (HF), there was 1 HF 30-day readmission (1.6 percent) with 1 elective Coronary Artery Bypass Grafting, resulting in a HF-related 30-day readmission rate of 3.2 percent. Compared with the historical University Health System Consortium patient-matched HF-related readmission rate of 6.8 percent, this represents a 53 percent reduction. There was an 8.1 percent all-cause readmission rate among patients in the Grand-Aides program, compared with an 18.6 percent historical rate, a 58 percent reduction. Medication adherence was 91 percent at 30 days in the Grand-Aides program. While the small numbers and historical controls make firm, statistically significant conclusions impossible, these results suggest that, the use of Grand-Aides may have helped reduce hospital readmissions, and that Grand-Aides could be a promising way to improve quality and health outcomes.