1. 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

2. The “people + technology” answer to improve population health by decreasing admissions, readmissions and costs
One person at a time
September 2016

3. 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)

4. 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.

5. 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.

6. 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 hours
All visits supervised on video
3 visits for first week
Decreases over first month
Continued contact 6

7. 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.

8. 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 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

9. Virginia Population Density/ Readmission

10. 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

11. 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

12. Observations Difficultly navigating healthcare
Getting refills vs needing additional refills
Awareness of symptoms
Who to call with symptoms
Unaware of future appointments

13. Outcomes
Totals
190 patients, visits made
Self-management

14. Patient Self-management
Representation

15. University of Virginia Medicare Patients with heart failure
All Medicare patients with heart failure admitted to UVA between 1/1/2013 and 12/
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

16. 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

17. 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.

18. 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

19. 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

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

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