Transitional/Chronic Disease Care = Population Health

Patients with chronic disease can either be enrolled in the Grand-Aides program on hospital discharge (“Transitional program”) or at any other time not immediately related to hospitalization (“Chronic disease program”). The immediate goal of the Transitional program is to reduce hospital readmissions, whereas the longer-term goals of both programs are to keep patients healthy, reduce unnecessary: admissions to the hospital, visits to the emergency department and clinic visits, thereby reducing the overall cost of care.


  • Conditions
    • Manuals and teaching can be created for any chronic condition / procedure in children or adults
      • Adults such as those with Cardiac (Heart failure, Acute Myocardial Infarction, Post Percutaneous Coronary Intervention, Coronary Artery Bypass Graft), Chronic Obstructive Pulmonary Disease, End Stage Renal Disease - on dialysis, Diabetes, Pneumonia, Joint replacement, Severe mental illness, Delirium/Dementia
      • Children such as those with complex medical conditions (in partnership with the Children's Hospital Association), and single diseases such as asthma
  • Populations
    • Examples: Medicare Advantage, Medicaid Dual Eligibles, General Pediatrics (e.g. Medicaid Children), Medicaid expansion adults, Emergency Department Hyper-utilizers (adults and children)


Goals - Keep healthy at home; reduce readmissions

Grand-Aides leverage the supervisor with 5 Grand-Aides per supervisor, and approximately 100 patients per Grand-Aide

During Hospitalization

  • The supervisor identifies eligible patients as early as possible after admission; then visits the patient and family, explains the program and has a permit signed if part of a research study.

First week

  • Grand-Aide conducts first visit within 24-36 hours of discharge.  Preference is for in-person visits but in the COVID era, some localities may require telemedicine. 
    • Total of 3 visits the first week – begins relationship.
    • The first day, the supervisor conducts medication reconciliation via video (Grand-Aide uses the tablet’s video)
    • All visits: detailed questionnaire, video with supervisor, reinforcement of teaching on diet, medication adherence

Weeks 2-4

  • Visits conducted as recommended by supervisor
    • Standard is decreasing number (ie 2-3 week 2 -> 1 week 4)
    • Grand-Aides monitor medication adherence, symptoms
    • Increasing empowerment of patient and family
    • Rapid access to medical team if patient / family calls


  • Visits and phone / video calls bi-weekly as often as need out to to 6 months.
  • Can increase intensity of visits and visit home with decrease in adherence / increase in symptoms


Goals: Keep healthy at home; reduce unnecessary: admissions, emergency department and clinic visits


As some patients with chronic disease near end of life, the Grand-Aide serves as a trusted connection to the care team.

  • Provide support connecting the patient / family and the medical care team.
    • Use protocols specifically developed for palliative and hospice care.
  • Examples of Palliative Care Protocols
    • Increased pain
    • Constipation
    • Shortness of breath; difficulty breathing
    • Nausea
    • Depression
    • Family support


  • Commercial Insurers and Medicaid are covering Grand-Aides programs on a state-by-state basis.
  • A spreadsheet with calculated savings using a program’s own data is available from Grand-Aides USA.