Grand-Aides: Transitional/ Chronic Care Management S 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

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. Primary Care 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 24- 48 hours All visits supervised on video 3 visits for first week Decreases over first month Continued contact 6

Grand- Aides Program NP organized and led. 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 Patients are enrolled while hospitalized or referred to program from Cardiology Clinic based on the criteria: Have HF 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. Live within 60 miles of Medical Center Agree to participate in the program 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 At home, assist the patient in developing regimens for medication adherence as well as other parts of the treatment plan. 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 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 Medication related

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

Patient Self-management Representation

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  

30-DAY ALL-CAUSE READMISSIONS 6-MONTH ALL-CAUSE READMISSIONS 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% 12.0% CONTROL (856) 15.8% 45.0% 45.1% 51.5% p 0.0003 <0.0001

Patients with Grand-Aides 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.  

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  

Outcomes “This, I submit, presents a much more complete, personalized description of our relationship.” “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. “ Letter from patient, 2016

Grand-Aides programs in U.S. 14 current or completed Including Cleveland Clinic, Temple, Aetna, Humana 9 in 2016 51 in negotiation

S. Craig Thomas, MSN, ACNP-BC 434-243-9320 sct2z@virginia.edu Thank you S. Craig Thomas, MSN, ACNP-BC 434-243-9320 sct2z@virginia.edu