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Grand-Aides: Transitional/ Chronic
Care Management
S. Craig Thomas, MSN, ACNP-BC
University of Virginia
Advanced Heart Failure Center
The “people + technology”
answer to improve population
health by decreasing admissions,
readmissions and costs
One person at a time
September 2016
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A GRAND-AIDE
• A Grand-Aide is a lay-person who has been trained
with a specified curriculum in medical care to be
an extender for a nurse, nurse practitioner or
physician.
– Usually a Certified Nurse Aide or Certified Medical Assistant or
Certified Community Health Worker.
• A Grand-Aide is paid. (national median $12.40/hr)
WHAT DOES A GRAND-AIDE DO?
• Grand-Aides have two functions usually, but
not always, performed by different people.
1. Primary Care
2. Transitional/Chronic care (This presentation)
• Each addresses appropriate preventive and
social issues.
THE TRANSITION - CHRONIC CARE
GRAND-AIDE
• Grand-Aides have protocols specific to the chronic
disease.
– Portable telemedicine to
• complete medication reconciliation
• communicate with the supervisor regarding patient signs and
symptoms.
– Aid in the transition to palliative care as directed by
supervisor.
Grand-Aides nurse extenders work with chronic disease patients
to improve adherence and catch major problems early
Leverage
Grand-Aides
as nurse extenders
•
CNA, MA, CHW
•
1 nurse supervises
5 Grand-Aides
•
1 Grand-Aides
cares for 100
patients per year
•
Grand-Aides
NO decisions
Address chronic
disease
•
Single
diagnosis or
population
(e.g.
Medicaid,
Dual-eligible,
Medicare
Advantage)
•
Behavioral
health
•
Social issues
Attack readmission, ED and
unnecessary admission
•
Supervisor visits in hospital
•
First Grand-Aide visit within 2448 hours
•
All visits supervised on
video
•
3 visits for first week
•
Decreases over first month
•
Continued contact
6
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Grand- Aides Program
o NP organized and led.
o Program description: Patients receive home visits by specialty
trained nurses aides (aka GA), supervised by a heart failure
Nurse Practitioner, to ensure patients are well informed
about their healthcare plan following a hospital discharge or
recent clinic visit. Program was designed to provide at-home
support to help people adjust to the lifestyle
recommendation through early identification of barriers,
symptoms or deviations from the care plan.
Grand-Aides Program
o Patients are enrolled while hospitalized or referred to
program from Cardiology Clinic based on the criteria:
o Have HF
o Those felt to be higher risk for readmission or require more support: 2
or more admissions in the last year, demonstrated non-adherence
with medications/ follow up appointments, lives alone.
o Live within 60 miles of Medical Center
o Agree to participate in the program
o Grand-Aides (GA) visit the discharged patients with Heart
Failure in their homes, usually within 24-48 hrs of enrollment,
then 3-4 times 1st wk, 2-3 times 2nd wk, 1-2 times 3rd wk, etc.
Trending with fewer visits over time
Virginia Population Density/
Readmission
During Home Visit
o At home, assist the patient in developing regimens for
medication adherence as well as other parts of the treatment
plan.
o
o
o
o
Ask Protocol questions
Obtain VS, daily weights
Have patient self report current diet, perform “Cabinet Raid”
Communicate with healthcare team, via phone, video chat and
documentation in the medical record
o Reinforce teaching as needed to highlight areas for change
Observations
•
•
•
•
•
•
Abnormal VS
New symptoms
Out of medications
Medication dose incorrect on discharge papers
Taking incorrect medications
Taking proper medication, just incorrect dose
Observations
• Difficultly navigating healthcare
– Getting refills vs needing additional refills
– Awareness of symptoms
– Who to call with symptoms
– Unaware of future appointments
Outcomes
• Totals
– 190 patients, 4400+ visits made
• Self-management
Symptoms (weight gain, edema, dyspnea)
Patient Self-management
14
Visit Frequency
12
Symptom Burden
Hospitalization
10
8
6
4
2
0
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64
Time in weeks
University of Virginia Medicare Patients with
heart failure
• All Medicare patients with heart failure admitted to UVA between 1/1/2013 and
12/31 2014
– Exclusion: LVAD, hospice
– Preference for those with demonstrated adherence issues, frequent hospitalizations
• There were 108 patients who agreed to have a Grand-Aide out of approximately
130. (turn-down rate 17%)
• 856 controls- proximity matched pairs with Charlson comorbidity score
• Measures were taken at 1 month and 6 months
– All patients were followed for 6 months (or shorter if died)
– Grand-Aides median “Intensive management program duration” was 6 months
15
Heart failure patients with Grand-Aides have
significantly fewer all-cause readmissions and E.D. visits.
30-DAY
ALL-CAUSE
READMISSIONS
6-MONTH
ALL-CAUSE
READMISSIONS
30-DAY
E.D. VISITS
6-MONTH
E.D. VISITS
GRAND-AIDES (108)
2.8%
13.0%
2.8%
12.0%
CONTROL (856)
15.8%
45.0%
45.1%
51.5%
p
0.0003
<0.0001
<0.0001
<0.0001
Significantly more previous admissions for heart
failure and higher severity,
in those with Grand-Aides
• Patients with Grand-Aides
– UHC severity “major” or “extreme:” 56.2% Controls 35.6% , p<0.0001
– Prior Admissions for heart failure: 49.1% Controls 26.6%, p<0.0001
– Death within 6 months: 2.75% Controls 7.7%, p=0.058
– No difference in age, gender, race.
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Medication adherence was 92%
• Scores were given to the patient at 1 month post enrollment
–
–
–
–
95+ = High adherence: All the time - Seldom miss a dose 83 patients
80 = Substantial adherence: Most the time- Miss 1-3 doses per week 16 patients
50 = Not adherent: Some of the time- Miss multiple doses each week 7 patients
30= Daily miss multiple doses: None of the time – Not adherent 2 patients
• 92% of patients scored “substantial adherence” or
better
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Outcomes
“This, I submit,
presents a much
more complete,
personalized
description of
our relationship.”
Letter from patient, 2016
“Representatives from your department have been
visiting me about once a week for the last several
weeks.. . All have been well qualified and have the
best questions. This provides them an extended
opportunity to experience the actual conditions within
which I am living. I submit that a visit like these may
be a more complete, accurate and unbiased
description than could be obtained via an office visit. .
. . I greatly appreciate the help she has given to me,
and her personal reports back to the office. “
Grand-Aides programs in U.S.
• 14 current or completed
– Including Cleveland Clinic, Temple, Aetna, Humana
• 9 in 2016
• 51 in negotiation
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Thank you
S. Craig Thomas, MSN, ACNP-BC
434-243-9320 [email protected]