~rrNw@ffiw,¥\iNE$iii!si!/Wfii¾ifirrWf'M¥,4'il!i&\uMt6Wi@iliii&ixiiW\W!iWilciffi1;WliVtll'ii•w~®W PRACTICE OPERATIONS ~
Grand-Aides: Lowering Healthcare
Costs and Improving Outcomes
Neil Baum, MD,* and Arthur Garson Jr., MD, MPH, MACO
The challenges facing the healthcare profession, including doctors, hospitals, 'Profossorof Clinical Urology, Tulane
, Modica! School, Now Orloans, l ouisi,
the pharmaceutical industry, and device companies, are to reduce the cost of • ann, and author of Tho Three Sr.ag es
' of• Phy.ioJn's CJroer- Navigaling
care and improve, or at least maintain, the quality of care. One area that could : From Training lo Beyond Retirement
be considered low-hanging fruit is the well over $50 billion per year spent on ' (Greonbranch Publishing , 20l?); o,mail:
• email@example.com. t Profasso, of
hospital readmissions, defined as returning to the hospital in less than 30 days , Managomcnt, Policy and Community
• Hcolth, University of Tc.u s School of
from the date of discharge. One solution to this problem is to have certified ' Pl.lblic Health, Houston, Texas.
, Copyright C 2021 by Amoric.,n
nurse aides make frequent home visits, which are supervised via telemedicine • Association for Phy,ician leadership•.
by a nurse, with the goal of reducing readmissions and emergency department •
visits, thus reducing the cost of healthcare. Importantly, the Grand-Aides nurse •
supervisor reports to the care team rather than making their own decisions. This :
approach, in which the aides are known as Grand-Aides, has been developed ·
and tested in patients with heart failure, diabetes, and other types of chronic •
d isease and has been shown to reduce readmission rates as well as the cost of :
caring for patients with a chronic medical condition. This article describes how •
Grand-Aides might fill an important need to improve care and at the same time '
reduce cost. This is of interest to any medical practice interested in improving ,
care for patients with chronic diseases or practices whose compensation is based •
on value-based payment/risk-based payment models, because the concept is •
focused on saving money while providing care for patients with chronic diseases, ,
KEY WORDS: Heart disease; congestive heart failure; cost of healthcare; outcomes;
disease management; patient satisfaction; Grand-Aides; emergency room visits,
T he United States wastes about $1 trillion peryearabout
one-third of our total healthcare dollars.
More than $50 billion of this waste takes the form of
"failure of care transitions," a category that includes
unnecessary hospitalizations, readmissions, emergency
department visits, and even clinic visits, which not only are
expensive bur also take a huge toll on patients and their families.
Even if all of this waste were eliminated, we still would be
faced with increasing demand for medical care as the population
ages, with increases in chronic disease and greater expectations
for healthcare. 1n the face of increasing demand,
ch ere is a shortage of supply: some have suggested that in the
next year, we will face shortages of 100,000 physicians and
one million nurses. 1 Only a reduction in unnecessary care
wilJ help to alieviace the impending shortages.
'Il1e U.S. Institute of Medicine has suggested that there
arc more efficient ways to meet these workforce needs than
increasing the numbers of physicians and nurses, A new
approach to work.force and healthcare delivery is needed
thatimprovcs access, improves outcomes, and reduces costs.
Grand-Aides (GA) is an innovative solution to reducing
hospital readmissions and emergency room visits, thus
significandy decreasing the cost of care. How does the GA
concept work'? GAs arc certified nurse aides who make
frequent home visits to patients with chronic diseases such
as congestive heart failure with the goal of keeping them at
home and out of the hospital and emergency department.
"Ihomas et aP demonstrated that In patients with heart faiJ.
ure being cared for by GAs, 30-day readmissions decreased
from 82% to 2.8%, and the number of emergency room
visits also was reduced, Furthermore, there was 92% medication
adherence and extremely high pat.icnt sali fa ctfon,
GAs act like a surrogate grandparent (hence the name
"Grand-Aides"). Each home visit takes approxima tely 45
186 www.physicianleaders.org I 800-562-8088
mi nut and ii. up rvl ed In reo l-1tm for r, to 10 mlnul
b ' n r gi l r d nur c u Ing ont mpornr I 1 m di In
I h nolog , During 1hc c I It s, 1h , d lop. on und
r ton d ing of th m dl cal ltuntlon of the pntl nt and
d •t •nn in "an , dang •r lgns 1h01 mn b' pre cnt during
'-Uh, q11 nt \lis lt . qu stlonnnlre thot I. unique for cnch
poti nt and h i or her medl al probl m is ompleted by
th , on o h \Ii. It and then ent tJirough the cloud for
th nur to re lew. ll1e ph I Ian and team hnve decided
whi hon 'W ~ on the questionnaire need medical attenti
n: all the a, w r arc placed In the medical record for
th ph , I Ian ro re\llew ot any tlme. Grand-Aides repons
that patl nt and families confide in the aides and hJghly
I t th nur e and physicians, so communication
b tw n patients and healthcare professionals ls a seams
p ro s.
Th 6 1'5t week after the patient is discharged from the
ho pital. a GA will visit the patient three tlmes. Then depending
on the patient's condition, the number of visits is
lowly de reascd over the first month to one visit per week.
n cit I cenain that the patient ls stable, the GA makes
onJ a "telemedidne" visit, which ls supc.rviscd by the RN.
\ h •never there ls a question about the patient's cond.ition
or th re i a n ed for a home visit, the GA will see the pati
nt within a few hours of receiving a call from the patient
or hi or hc.r family. GAs also make home visits for primary
pr ent.lon; to increase efficiency (e.g., reduce "no-shows"),
a w II a econdary prevention; and provide "intervent
ion" with intense attention to medication adherence (e.g.,
for a )'lllptomadc patients with hypencnsion).
Who ar the GAs and how arc they trained? GrandAid
U A works with JO national employment agencies to
mp Loy Local GAs, nurse supervisors, and social workers,
ho th •n lnteract with the program's nurses and with the
pall nt' phy lei an .
A ar elected ba ed on thelr communlcarlon skills.
h A musr be able to:
■ B mpath de, but also display ~,ough love" (lllce n good
■ Understand ba le principles of verbal and nonverbal
■ ommunl ate wl1h empathy ond gnthor informotlon in
a r •srwctful manner;
■ ldendf harriers to communlcotlon;
■ • p • tknnd wrll in 1h • p tlont' proforrod lnngungo; ond
■ w 11 • on if>e wri111•n do umentotlon of onch visit to
th pnri n1'i. homr.
Ea h nur supervise flvu GA . Dop ndlng 011 the rypo
of program, a GA can help to core fur I 00 d1ronl nil)' Ill or
250 primary nrc pml 111s per y nr.
, , follow rh post-di horg • proto ·ol by odhorlng to
th · following guldeUne :
Baum ind Garson I lowering Healthcare Costs 187
■ fl inror oil lc rn ent of the dlscharge plan created by
th h nhhcorc provider ( .g. method for medication
odh r n c);
■ .ondu t m dlcatlon recon lllallon with the supervisor
vlo live HIPAA-compllnnt video; and
• Administer ymplom questionnaire cu tomized by the
supervisor for each patient, ent electronically 10 the
supervisor, who has a video call with the patJent on each
GA vi It. GA do not make Independent decision ; every
visit is supervised.
GAs also arc helpful for population-based programs.
Each GA cares for the whole patient and all of their medical
conditions. This is different from home health, where
a specific skilled service (e.g., wound care) is being deUvered.
In fact, for the 20% of patients who have both home
health and a GA, the GA program work., closely with home
health to be sure they are not in the home on the same day
and communicate any observed concerns to each other
as well as the medical team. The concept has been used
with patients who have public insurance such as Mecticare,
Medicaid, and Accountable Care Organizations. as well as
those with commercial insurance.
Some programs begin caring for high-risk patfonts
referred from a clinic. Grand-Aides recently has reponed
on a group of family medicine patients with diabetes and
hypertension who achieved medication adherence greater
than 90% at l year and a 75% reduction in hypertension."
l11e United States is projected to experience a physician
shortage in the near future.• This problem will be even
greater in rural areas, because many of those areas are already
experiencing a physician shortage. The GA program
may help ameliorate that shortage in those areas. The current
program allows GAs lo meet patients in the hospital or
clinic and, ideally, make several home visits, regardless of
the distance from the GA to the patient in the rural area, 10
see the home environment, meet families. and understand
the home conditions. l11e GA makes sure the patient has a
way to do video communlcotJon-elther dedicated television
cnmern, tablet, or smartphone- nnd understands how
10 use IL 1110 patient needs only n mobile phone or a tablet.
Hit Is absolutely not practical to make even an Initial home
visit, then the Initial Mbond.ing" between the patient and
family and the GA occurs in the clinic or hospital.
The Grand-Aide provides the
personal touch, while also using
the most up-to-date technology
to enhance communication.
Th blllit way tu achieve tho desired relationship und
compllnncc is with 01. lenst three or four visit In the first
w •ck. ·1hls cnrly frequen cy is one of the bedrocks of the GA
program and i a requirement. Over the following weeks,
the vi it frequency is reduced at the discretion ofthe nurse
or nurse practitioner (NP) supervisor. ·n1e intent of the program
i to empower patients and families and have them
able ro care for themselves after one month. The GA stays
involved with the patient as long as the program desiresusually
111e GA provides the personal touch, while also using
the most up-to-date technology to enhance communication.
Every home visit that a GA makes has the supervising
nurse or NP on video (using HIPAA-compliant video from
a tablet, such a.s FaceTime or Jabber). Proprietary software
also is used for data collection (and transmission to the
supervisor), analysis, and reporting.
Patients with chronic diseases such as congestive heart
failure experience a reduction in resource utilization (e.g.,
hospital readmissions) for such conditions and also in
emergency department visits. Medicare patients with heart
failure who had GAs had a 2.8% 30-day all-cause readmission
rate, compared with the control patients who received
usual care in the same time period, who had a 15.8% 30-
day all-cause readmission rate. This represents an 82%
reduction in readmissions. For 30-day all-cause emergency
department visits, only 2.8% of those with GAs had at least
one ED visit, compared with 45.1% of control subjects.2
The GA approach makes economic sense when physicians
are "at risk." Under bw1dled care or capitation, direct
savings would be generated because the reduced expense
per visit (GA compared wid1 nurse or physician visit) would
be credited against the capiration or bundled revenue per
patient. There are several possible payment mechanisms
Jn a patient-centered medical home model, with an added
"per member per month" payment for accompli hing the
healthcare goals of the patient. In a fee-for-service plan, the
clinic could be paid for the supervisor's work, rather than
billing for the GAs directly. The payer would see a reduction
in tl1e average cost per visit, because the care provided to
patients seen by GAs and tl1e supervisor would cost less.
Bottom Line: These early reports indicate that a GA
program supplemented with a supervising nurse could
have a substantial impact on helping patients to stay at
home and out of the hospital or tl1e emergency department
by incorporating standardized protocols. ·n1e result would
be reduced congestion in emergency departments and
doctors' offices and improved access for those patients
who truly need to be seen there. 1l1is program also could
generate savings and begin to bend the cost curve, as
health reform unfolds. 1l1e Grand-Aides program is going
to work as more than a "Band-aid" to solving the current
healtl1care crisis. ::
I. The Complexities of Physician Supply and Demand: Projections
from 2017 to 2032. April 2019. Association of American Medical
Colleges. www.aamc.org/system/fi les/c/2/3 l -2019_update_ -_the_
comph!xltics_of_physiclan_su pply a nd_d cmnnd_ -_projections_
2. Thomas SC, Greevy RA Jr, Garson A Jr. Effect of grnnd-nldes nurse extenders
on readmissions and emergency department vi it in Medicare
patients with heart failure. Am I Cnrd/oL 20l8;121:1336-1342.
3. Garson T. Hcnlth workforce innovatfons to support delivery ystcm
transformation. Health \>Vorkforcc In stitute. September 12, 20 16.
www.gwhwi .org/up londs/ 4/3/ 3/ 5/,1335845 I / hea Ith_ workforce_
4. Cooper RA , Getzen TE, McKee HJ. Laud P. Economic and demographic
trends signal an impending physician shortage. Ilea/th
Affairs. 2002:21 ( I): 140- 154 .