A colleague’s comment some 15 years ago sparked Dr. Tim Garson’s grand idea for a way to expand access to affordable healthcare while lowering costs to the system.
“He came up to me and said, you know, 50 percent of my patients could be taken care of by a good grandmother,” recalled Garson, now the director of the Center for Health Policy at University of Virginia.
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Over the next decade, as technology advanced, the Affordble Care Act was passed and concern mounted that the U.S. would experience a shortage of doctors and nurses, his colleague’s idea began to seem quite intriguing.
Garson is the founder and chairman of the Grand-Aides Foundation, a not-for-profit that trains staff at healthcare systems to hire and supervise a new group of workers called grand-aides.
Grand-aides are certified nurses, community health workers or experienced laypeople who work with patients in their homes after they’re discharged from the hospital, or when they have an illness that doesn’t require a visit to the emergency room. The idea, Garson said, is to extend the reach of a nurse into a community but to do it at a per-patient level and at a lower cost by utilizing a less expensive, mobile team of people “with the temperaments and personalities of a good grandparent.”
By that, he means someone who’s nurturing, reliable and compassionate and can serve as a connector between patients and families and their care team. “It is a clear-headed person whose job it is to be helpful but who’s also trained to be edgy enough to say, ‘you didn’t take your medicine yesterday, so don’t tell me you did,” he explained.
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The training that grand-aides receive depends on their level of experience and certification. Generally, it’s a few-month-long process that begins in the classroom learning about basic medical care and protocols. That’s followed by lessons on fieldwork procedures. Once they become state-certified grand-aides, these people work under the direct supervision of a nurse.
But – and this is very important – Garson said grand-aides don’t make any care decisions. Rather, they observe the patient’s living conditions and daily routines, report back to the nurse and reinforce her teaching to patients.
With grant funding, Grand-Aides has been able to conduct several pilot studies covering different use cases. In one study at the University of Virginia, grand-aides visited the homes of 115 patients who had been hospitalized for heart failure. They visited each of the first five days following the patient’s discharge from the hospital – a crucial time for developing habits that support recovery. In addition to going through medications and observing their status and habits, grand-aids also connected patients with their nurse via HIPAA-compliant video chat.
In the study, all-cause readmissions dropped more than 50 percent from the average rate, Garson said, and patients demonstrated 91 percent medication adherence in the first month.
Grand-aides can also work with nurses and physicians at a clinic, meeting with patients and taking follow-up phone calls following a 20-question protocol and presenting their observations to the supervisor. In a primary care pilot study at an acute care clinic in Houston, 62 percent of patients seen by a Grand-Aide were able to return home without seeing a physician.
Garson said there are programs running in India and Bangledash, and he’s talking to institutions in at least a dozen other countries. There are also several programs running at academic medical centers in the U.S., and another set to launch at University of Virginia with family medicine and secondary prevention of diabetes and obesity.
For now, these institutions fund the hiring, training and employment of grand-aides and supervisors themselves, which is admittedly a challenge to the model. But Garson sees opportunities for grand-aides as part of home health companies, who have the infrastructure to support these kinds of workers.
“Eighty percent of discharged patients aren’t covered by Medicare-certified home health,” Garson explained. “With telemedicine, as long as you’ve got an NP as a supervisor, those visits can get paid for by commercials and Medicaid in most states.”
He also thinks Grand-Aides’ proposal will become more compelling as the ACO movement pushes forward.
“From a payment perspective, this makes the most sense in systems that are either capitated or bundled where all of the incentives are to keep people healthy and out of hospitals and reduce costs,” he said. “Hospitals and ERs like those people because they pay. The idea is to get this firmly ensconced into accountable care organizations, payers, Medicaid, and ultimately Medicare and commercial insurers.”
Grand-Aides is part of the International Partnership for Innovative Healthcare Delivery. Krishna Udayakumar, executive director of the International Partnership for Innovative Healthcare Delivery, said: “Grand-Aides is a great example of a healthcare innovation that could be transformative when scaled.”
