~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 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:

• 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 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

grandpar nt);

■ Understand ba le principles of verbal and nonverbal

ommunl ation;

■ 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" 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

six months.

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. 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 .