Published in the March 2012 AAMC Reporter
By Whitney L.J. Howell
For months, Paloma Saucedo had a patient whose blood-sugar level hovered in the very high 600s. He resisted any dietary changes and did not correctly take his diabetes medication. Saucedo made weekly home visits, attended diabetes meetings with him, and discussed the importance of taking medication properly. Eventually, she said, his blood sugar dropped to 130.
She knew the light bulb had flickered on for him when, during a home visit, she saw a picture of the U.S. Department of Agriculture’s food plate on his kitchen wall. She had picked one up at an earlier diabetes meeting, mentioning to him it was a good reminder when she cooked of how her plate should look. Clearly, he was following her lead.
“I thought to myself, ‘Finally!’ It was a huge success for me,” said Saucedo, who works with the Harrisonburg Community Health Center in Harrisonburg, Va. “Even though I wasn’t telling him what he could and couldn’t eat, I was teaching by example.”
Saucedo didn’t need a medical or nursing degree to make a positive impact on her patient’s health. Instead, she made a difference as a Grand-Aide (GA)—a layperson who receives training as a certified nursing assistant (CNA) to work with patients in their homes, serving as a connection to the health care system.
GAs are the brainchild of Arthur “Tim” Garson Jr., M.D., M.P.H., director of the Center for Health Policy at the University of Virginia School of Medicine (UVA). The idea sprouted when Garson analyzed his patient population 15 years ago. “I realized 50 percent of my patients could be cared for by a good grandmother, and 80 percent of the rest could be taken care of by a good nurse,” he said. “That insight led to Grand-Aides.”
The hope, he said, was that GAs, who are supervised by nurses, would reduce emergency department visits and hospital readmissions by up to 50 percent each by working closely with patients to manage many primary and chronic care needs.
According to Carol A. Aschenbrener, M.D., the AAMC’s chief medical education officer, some patient concerns can be addressed by other caregivers, with appropriate guidance from physicians and nurses. This would free health professionals to focus on providing care at “the top of their license.” With relatively brief training, GAs can be a trusted link to the health care system and meet many day-to-day, low-level patient needs. Although GA programs are still in the pilot stage, they have shown great promise for bringing health care providers together for new collaborations, she said.
“The Grand-Aides program is testing a new, lower cost approach to follow-up for specific categories of patients,” Aschenbrener said. “What I like about this program is that it uses people in midlife who have something to give. They have a maturity and can improve communication between patients and their health care providers.”
To date, one-year pilot programs at federally qualified health centers in Harrisonburg and Houston have tested the GA model by bringing primary care services to about 15,000 Medicaid beneficiaries. The Texas Legislature even appropriated $1.25 million for the endeavor.
In addition to curbing provider visits and lightening the workload for doctors and nurses, GAs are poised to help manage the impending increase of newly insured patients after 2014, when major provisions of the health reform law are scheduled to go into effect. In fact, Garson said, GAs will soften the blow of the looming physician and nursing shortages. According to the AAMC Center for Workforce Studies, the nationwide physician shortage will be more than 90,000 by 2020. The Health Resources and Services Administration has estimated the nursing shortage will reach 1 million in the same year.
“Given the influx of newly covered patients under Medicaid, there are going to be huge medical needs throughout the country,” Garson said. “Grand-Aides can easily fill this void and provide appropriate access to the care and services most patients will need.”
What GAs do
GAs receive training to work with patients in primary or chronic care settings. They gather and relate health information but do not treat or make clinical decisions. Primary care GAs focus on general family and maternal-fetal care, while chronic care GAs focus on five conditions, including diabetes, heart failure, and pneumonia. Training lasts three or four months, depending on whether the person has previous CNA experience. Throughout classroom training, clinical preceptorship, and field work, they learn anatomy, physiology, and the specifics of certain diseases.
GAs and patients meet in either the clinic or the hospital. Primary care GAs split their time among home visits, follow-up phone calls, and preventive calls. Their training, coupled with a predesigned, 20-question protocol, helps them gather health information, relay the data to a nurse, and then explain the appropriate care plan to the patient, Garson said.
Chronic care GAs can be more hands-on. Not only do they accompany patients home from hospital stays, but they also assess living conditions and daily routines to spot habits that can negatively affect patients’ recovery and future health. These visits are “pantry sweeps,” said Donna M. Green, R.N., executive director of the Grand-Aide Foundation, a program of UVA’s Center for Health Policy.
“The Grand-Aides will find bad foods, reinforce smoking cessation, try to get the patients to do at least minimal exercise, and help them establish a day-to-day routine to manage their disease,” she said. “They’re in the patient’s home every day for the first week, and then they stay in touch through telemedicine. The patient never feels cut off from their health care provider.”
Overall, Green said, GAs are effective because patients see them as peers and mentors rather than as an authority figure.
“They often view nurses and doctors as preaching to them without a clear understanding of their life situations,” she said. “But this peer has the time to really work with them, to become their partner, and help them make the best decisions for their health.”
The challenge facing GAs
While both pilots have been successful, gaining widespread support for the GA program depends on whether the industry maintains a fee-for-service model or navigates to a bundled payment system, Garson said.
“When looking at a capitation model, GAs are perfect, because they reduce the number of visits and expenses, accruing savings for clinics,” he said. “But with fee-for-service it gets more complex. How do you pay the GA? The supervisor? And with a reduced number of visits, money earned drops as well.”
According to Garson, the financial impact from GAs has been significant. Over the past year in Houston, GAs prevented nearly 700 clinic and emergency department visits. The net savings per GA for patients and providers was nearly $101,000. In Virginia, the average savings per GA was almost $82,000.
To read the article in its original location: https://www.aamc.org/newsroom/reporter/march2012/276858/grandaide.html