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Because the Affordable Care Act will expand health insurance to cover an estimated thirty-two million additional people, new approaches are needed to expand the primary care workforce. One possible solution is Grand-Aides®, who are health care professionals operating under the direct supervision of nurses, and who are trained and equipped to conduct telephone consultations or make primary care home visits to patients who might otherwise be seen in emergency departments and clinics. We conducted pilot tests with Grand-Aides in two pediatric Medicaid settings: an urban federally qualified health center in Houston, Texas, and a semi-rural emergency department in Harrisonburg, Virginia. We estimated that Grand-Aides and their supervisors averted 62 percent of drop-in visits at the Houston clinic and would have eliminated 74 percent of emergency department visits at the
Virginia test site. We calculated the cost of the Grand-Aides program to be $16.88 per encounter. That compares with current Medicaid payments of $200 per clinic visit in Houston and $175 per emergency department visit in Harrisonburg. In addition to reducing health care costs, Grand-Aides have the potential to make a substantial impact in reducing congestion in primary care practices and emergency department
The full implementation of the Affordable Care Act in 2014 is estimated to extend health insurance coverage to thirty-two million more people. But the existing physicianand nurse workforce is not likely to be adequate to provide timely access to care.1 Shortages of approximately 100,000 physicians and as many as one million nurses are projected in the next ten years.2,3 Access to primary care is at a crisis point and is worsening. New approaches are needed to expand the primary care workforce and improve health care delivery, making maxi- mum use of the capabilities of each member of the care team.
Four years ago, in response to the idea that “grandparents have been doing simple primary care for centuries,” Arthur Garson Jr., this article’s lead author, created the “Grandparent Corps.” The concept of the corps was to supply a new workforce to extend the reach of nurses and physicians. However, it quickly became ap- parent that not only was it discriminatory to require a person to be a grandparent to partici- pate in the corps, but such a requirement was also not necessary. Nonetheless, corps members are typically local community members who are wise and nurturing, have cared for others, and generate respect and trust in patients. Thus, corps members were renamed Grand-Aides®.4
The Grand-Aides program has five goals. These are to provide access to appropriate health care for primary and chronic care while freeing pro- fessionals to do what only they can do; to reduce congestion in emergency departments, clinics, and hospitals by caring for people at home, re- sulting in improved access for those who need to be seen elsewhere; to educate patients in preven- tive and self-care; to “bend the cost curve” with more affordable care; and, finally, to create pay- ing jobs and a career ladder for, and enhance the lives of, mature adults who want to give back to their community.
Although similar to community health workers, Grand-Aides are distinct in several ways. Community health workers, sometimes known by other names such as “promotores” and “nav- igators,” are typically involved in health advis- ing, information, referrals, translation services, and advocacy for their communities with some work in chronic disease counseling.5 Their ori- entation is mainly toward social services and is described in a recent article about how commu- nity health workers in Arkansas matched people in three disadvantaged counties to Medicaid home and community-based services.6 In contrast, Grand-Aides operate under the supervision of nursing personnel to provide im- mediate care or medical advice. They function as nurse extenders, working under protocols to visit patients at home and helping treat conditions usually associated with primary care. A wide variation in the length and content of community health worker training was documented by Matthew O’Brien and coauthors.7 However, training for aides is much more specific and medically oriented. In anticipation of various government and private payment mech- anisms that may become available, all Grand- Aides obtain a state certification. Such certifica- tion can be as a nursing assistant, a medical assistant, or a community health worker. Cur- rently, only Texas has state certification of community health workers. Those wanting to become Grand-Aides then take an additional 180 hours of a tailored curriculum, which covers a 200-page manual, classroom work, protocols, simulation, and field training. Prospective Grand-Aides must pass weekly written tests, participate in weekly one-on-one meetings with the instructor, and undergo for- mal evaluation of their field training. The cur- riculum is standardized across all locations of training, whether in community colleges or health care institutions. Ultimately, the instruc- tor awards the Grand-Aides certification after determining that the trainee has met all perfor- mance standards. Each aide participates in the care of 200–250 families, is employed by a primary care clinic, and may be part of a patient-centered medical home. Under supervisory nurse personnel, Grand-Aides initially conduct triage over the telephone using protocols for twenty-six simple primary care conditions, including the common cold and vomiting, in children and adults.
A protocol consists of three parts: a questionnaire that the Grand-Aide completes with the patient or patient’s caregiver; decision making by the nurse supervisor (for example, whether to recommend that the patient go to an emergency department or clinic; the supervisor may also recommend that the patient stay home and may give home care instructions such as “take acetaminophen” or recommend that the Grand- Aide make a home visit); and instructions for treating the patient, including home care in- structions. These protocols are available to the aide electronically via a netbook computer, tab- let, or mobile phone and also to nurse super- visors for assistance in decision making. In standard practice, one nurse supervises six Grand-Aides. As directed by the supervisor, the aide transmits advice over the telephone and may make a home visit. From the home, an aide may use a mobile phone to send photos or video back to the supervisor, in a form of low-tech telemedicine. A typical salary for a Grand-Aide is $25,000 per year.
Study Data And Methods
Our pilot program consisted of evaluating Grand-Aides at two sites, a clinic in Texas and a hospital emergency department in Virginia.
Clinic Legacy Community Health Services is a federally qualified health center in Houston, Texas, with five locations, one of which treats children only. At this urban site where the data were collected, 98 percent of the children were Medicaid enrollees, and the clinic received ap- proximately 52,000 visits per year. At the site, Grand-Aides approached parents of all patients under age nineteen who were there for a walk-in visit during a one-month period (June 2011). The aide explained the Grand-Aides program and invited the parent to participate. Before a nurse or physician saw the patient, the Grand-Aide completed the appropriate ques- tionnaire based on the presenting condition or complaint.
All questionnaires were in the form of approx- imately twenty to thirty “yes or no” questions dealing with seriousness of symptoms. The Grand-Aide presented the patient to the nurse supervisor and the nurse decided, on the basis of the answers to the protocol, whether the patient needed to see a nurse or doctor. Each protocol begins with “urgent questions.” For example, for the headache protocol, urgent questions in- clude: “Does the patient have a stiff neck on bending the head forward?” and “Does the pa- tient have blurred or double vision?” The protocol proceeds to other questions such as, “Has the pain lasted longer than twelve hours?” If the answer was “no” to every question, the nurse confirmed that the patient did not need to be seen in the clinic.
Emergency Department The Harrisonburg Community Health Center in Virginia handles approximately 10,000 yearly visits. Harrison- burg is located near the West Virginia border and has a population of about 45,000. Patients at the center use the emergency department of Rockingham Memorial Hospital, a 238-bed facility that handles 59,000 emergency depart- ment visits a year.
We analyzed the records of the 402 Harrison- burg Community Health Center Medicaid pa- tients younger than age nineteen who were seen in the Rockingham Memorial Hospital emer- gency department in a fifteen-month period— July 1, 2010, to September 30, 2011—but not admitted to the hospital. These patients were insured by Virginia Premier, one of two Medicaid managed care organizations that insured the Medicaid patients seen at the center. The demographics of patients in the two man- aged care organizations were similar, indicating that the Premier patients were a representative sample. Each primary diagnosis was analyzed for whether it was covered by one of the twenty-six Grand-Aide protocols.
Limitations Further data will be required to demonstrate the effectiveness of telephone triage using Grand-Aides. We tested the protocols and the ability of the Grand-Aide and nurse supervisor pairs to determine theoretically who could have remained home. For the emer- gency department analysis, we tested the hy- pothesis that a large proportion of patients had diagnoses that could have been addressed through an initial telephone call to the aide. However, although this analysis suggested who did not need to visit the emergency depart- ment, it did not determine whether those pa- tients would have been cared for appropriately at home or should have been sent to the clinic. Depending upon the experience of the families
in future studies, the number of unnecessary visits to clinics and emergency departments could be reduced. Similarly, we estimated the savings, which will require validation in actual practice.
Many of these issues will be addressed in a Texas pilot project that will begin in June 2012 with $1.25 million in funding from the State of Texas Appropriations Act for Medicaid.8 The project will reach ten thousand adults and chil- dren, five thousand with Grand-Aides and five thousand without. The project will track and publish data on visits and expenses and will com- pare outcomes with current practice, including nurse telephone consultation lines. The Grand- Aides curriculum will also be evaluated. Payment mechanisms applicable to public and private payers (such as how to pay for supervisors and Grand-Aides in a fee-for-service or capitated set- ting) will be developed during this work.
Clinic Of 471 walk-in patients to the Houston clinic who were contacted by Grand-Aides, the parents of 457—97 percent—agreed to partici- pate. Each of those 457 children were seen by a Grand-Aide and a nurse supervisor. The chief diagnoses for all but two fell under one of the twenty-six Grand-Aides protocols. The two exceptions were one case of staring spells and one of excess drooling (Exhibit 1).
The median age of the children was nineteen months but ranged from two weeks to fourteen years. After completion of the protocol specific to their chief complaint, 289—61.8 percent— were judged by the supervisory nurse and physician not to need a clinic visit and could have been cared for at home. In follow-up re- views of charts that were conducted seven days later, only 11 out of the 457 patients reported that a return visit for the same illness had been nec- essary; 9 of those 11 were judged by the nurse supervisor and physician not to have required a revisit to the clinic. None of these patients visited the emergency department.
The total cost of the program at the Houston clinic was $40,503 per year per Grand-Aide. The cost per call or visit was $16.88. The per visit cost was calculated by dividing the total cost of $40,503 by an estimated 2,400 Grand-Aide calls or visits per year. For the clinic visit, the federally qualified health center payment to the Houston clinic was $200 per visit, according to coauthor Richard Beech of Legacy Community Health. Thus, the Grand-Aides program produced an estimated savings of $183 per clinic visit avoided. Emergenc y Department The 402 patients in Harrisonburg in our study made 779 visits to the Rockingham Memorial Hospital emergency de- partment (a mean of 1.94 visits per patient). Fifty-four percent of the patients had one visit in the fifteen-month period examined. Forty-six percent of patients had between two and eleven visits. Of the 779 visits, the primary diagnosis for 574 (73.7 percent) was covered by one of the Grand-Aides protocols. Among the 402 patients,
85 percent had at least one emergency depart- ment visit covered by one of the protocols. Sixty percent of the patients had all of their visits covered by one of the protocols.
Of the 779 pediatric Medicaid visits in fifteen months, the primary diagnosis of 73.7 percent was covered by one of the protocols for Grand- Aides. In those cases, the visit to the emergency department was judged not to have been nec- essary. The payment for each visit to the Harrisonburg hospital emergency department was $175, according to coauthor Christopher Nye of the Harrisonburg Community Health Center. Thus, the savings that the Grand-Aides program could have produced for each avoided emergency de- partment visit was an estimated $158 ($175 less $17, using the Houston data).
In a fee-for-service environment, every reduction in clinic visits reduces the income to physicians
and the clinic. Assuming that clinics will be able to be paid for the supervisor’s work, rather than billing for the Grand-Aides directly. The super- visor would generate a billing code that was worth approximately the cost of the call or visit, such as $17. The payer would then see a reduction in the average cost per visit because the care provided to patients seen by Grand-Aides and the supervisor would cost less.
Under bundled care or capitation, direct savings would be generated because the reduced expense per visit (Grand-Aide compared with nurse or physician visit) would be credited against the capitation or bundled revenue per patient. In a patient-centered medical home model, with an added per member per month payment for accomplishing the goals of the patient. There are several possible payment mecha- nisms. In a fee-for-service plan, the clinic could be paid for the supervisor’s work, rather than billing for the Grand-Aides directly. The supervisor would generate a billing code that was worth approximately the cost of the call or visit, such as $17. The payer would then see a reduction in the average cost per visit because the care provided to patients seen by Grand-Aides and the supervisor would cost less.
Under bundled care or capitation, direct savings would be generated because the reduced expense per visit (Grand-Aide compared with nurse or physician visit) would be credited against the capitation or bundled revenue per patient. In a patient-centered medical home model, with an added per member per month payment for accomplishing the goals of the patient-centered medical home, the payment for the Grand-Aides program could be included in that payment. In all three of these scenarios, the clinic could share in the savings with the payer. Savings would vary depending upon current payment schedules. For example, in both Texas and Virginia, the payment for Medicaid clinic patients not in a federally qualified health center averages $56. Whether practitioners are paid by volume or salaried, their individual payment could be increased with an allocation from the shared savings.
These early data indicate that Grand-Aides and the supervising nurse personnel, by using stand- ardized protocols, could have a substantial im- pact on helping patients to stay at home when appropriate. The result would be to reduce con- gestion in emergency departments and primary care clinics and improve access for those patients who truly need to be seen there. This program could also generate savings and begin to bend the cost curve, as health reform unfolds and the number of outpatient visits by Medicaid-covered children tops 100 million per year.9,10
1 Suchetka D. Health care reform will move millions more to Medicaid. Cleveland Plain Dealer. 2011 Jun 21.
2 Association of American Medical Colleges. Statement on the physician workforce [Internet]. Washington (DC): AAMC; 2006 Jun [cited 2011
Nov 27]. Available from: https:// www.aamc.org/download/55458/ data/workforceposition.pdf
3 Council on Physician and Nurse Supply [Internet]. Philadelphia (PA): The Council. Press release, Council calls on White House to convene conference on physician and nurse supply: 30 percent increase in physician and nurse training needed, experts say; 2008 [cited 2011 Nov 27]. Available from: http:// www.physiciannursesupply.com/ Articles/council-release-feb-08.pdf
4 Grand-Aides is a registered trade- mark of the Grand-Aides Founda- tion, a nonprofit foundation inHouston, Texas.
5 Christian S, Dower C. Comparative snapshot of four allied health occu- pations in California: community health workers, medical assistants, certified medical assistants, and home health aides [Internet]. San Francisco (CA): Center for the Health Professions; 2009 Nov [cited 2012 Apr 16]. Available from: http://
6 Felix HC, Mays GP, Stewart MK, Olson M. Medicaid savings resulted when community health workers matched those with needs to home and community care. Health Aff (Millwood). 2011;30(7):1366–74.
7 O’Brien MJ, Squires AP, Bixby RA, Larson SC. Role development of community health workers: an examination of selection and training processes in the intervention literature. Am J Prev Med. 2009; 37(Suppl 1):S262–9.
8 State of Texas, 82nd Legislative Session, Fiscal Year 2012–2013 Ap- propriations Act, Article II, Health and Human Service Commission, Bill pattern rider No. 69.
9 Rhode Island Department of Human Services, Center for Child and Family Health. RIte Stats [Internet]. Cran- ston (RI): RIDHS; 2001 Jun [cited
2011 Nov 27]. (Volume 1, Issue 1). Available from: http://www.dhs.ri.gov/Portals/0/Uploads/ Documents/Public/Reports/RIte Stats_outpt_vol1_iss1.pdf
10 American Academy of Pediatrics.Medicaid and children [Internet]. Elk Grove Village (IL): AAP; 2011 Jul 10 [cited 2011 Nov 27]. (Fact Sheet). Available from: http://www.aap.org/ research/factsheet.pdf
A few years ago, a well-known Texas family physician said, "You know, 50 percent of my patients could be taken care of by a good grandmother!" Think about it, grandparents are who their children call for minor illnesses such as colds, fever or sore throats. We told you last month that there was a third idea for addressing the physician and nurse shortages in Texas (in addition to including patients as part of the work force and paying physicians differently). This "secret weapon" is grandparents.
We have created a program called Grand-Aides. We originally called it the "Grandparent Corps" (in the Houston Chronicle) until we were told at a White House meeting that requiring someone to be a grandparent was illegal and discriminatory against people who don't have grandchildren! Therefore, being a grandparent is not required, but having "the right stuff" is, including the wisdom and respect we often associate with being a grandparent. A grand-aide is a member of the local community who is an extender for a nurse, nurse practitioner or physician. Grand-aides help to provide care for adults and children using telephone protocols and home visits with Skype portable telemedicine. A grand-aide is trained to be certified by the state either as a certified nurse aide, certified medical assistant or certified community health worker, and then is taught the well-defined Grand-Aides curriculum for an additional 180 hours. Grand-aides do not make decisions on care, but are the "eyes and ears" of their supervisors, carrying out their instructions.
The purposes of the Grand-Aides program are: 1. to "decongest" emergency departments, clinics and hospitals of people who could be cared for at home, leading to a 25 percent to 50 percent reduction in unneeded emergency-department and primary-care visits, and a 25 percent to 50 percent reduction in hospital readmissions for those with chronic conditions; 2. to achieve access to appropriate health care, freeing up professionals to do what only they can do; 3. to educate patients in preventive and self-care; 4. to "bend the cost curve" with more affordable care; and, 5. to create paying jobs and enhance the lives of mature adults who want to give back to their communities.
In pilot studies: a) in the Legacy pediatric clinic in Houston, 62 percent of visits and b) in an emergency department in rural Virginia, 74 percent of visits by Medicaid patients could have been initially cared for with a primary care grand-aide and nurse supervisor, potentially saving hundreds of dollars per visit. Thanks to a great deal of work by Texas state Reps. John Zerwas and Jim Pitts and the office of Lt. Gov. David Dewhurst, Texas has placed grand-aides into the Medicaid program by law and has appropriated $1.25 million for an initial pilot that is starting at the Harris County Hospital District with more than 10,000 patients.
Transitional/Chronic Care grand-aides accompany the patient home the day of discharge and make daily visits as needed for those with chronic diseases, like congestive heart failure. Grand-aides help patients remember their medications using Skype to communicate with their supervisory nurse on every visit. The expected outcome is a 25 percent to 50 percent reduction in 30-day readmission. Public and private hospitals around the country have adopted the Grand-Aides program.
As the country struggles to get it right with health care reform, it is clear that we must do things differently. Maybe some of "doing things differently" is remembering "to do some things the same" and using respected members of the community, whether grandparents or not, to do what they have been doing for centuries.
Grandparents changing the health care system in Texas? You betcha.
Can you get in to see your doctor now? Whether you answered yes or no, Obamacare is about to add 32 million people with insurance coverage - a good thing, but when the uninsured rate dropped with universal health care in Massachusetts, the wait to see a primary care physician increased from 33 days to 44 days. Add to this the 77 million Baby Boomers who are living longer and will use more physicians as they age (70-year-olds make seven times more doctors' visits than 7-year-olds). No wonder the Association of American Medical Colleges projects a national shortage of 100,000 physicians in 10 years. Texas is now close to the bottom at 42nd in doctors per population and its share of the projected shortage is 10,000.
So how do we address this projected shortage? Texas has some great approaches and some terrible ones.
Great: Medical educators are questioning assumptions of what it takes to train a doctor. The University of Texas has a program to train doctors more efficiently and Texas Tech has decreased medical school to three years for family physicians; in an article in this month's journal Academic Medicine, one of the authors of this op-ed, Arthur Garson Jr., proposed a complete revamp of curriculum based on education data, and outlined a combined four-year undergraduate and medical school (not the current eight years).
Good: Medical malpractice caps on what patients (and attorneys) can collect on "pain and suffering" in Texas courts are credited with increasing the number of physicians.
Terrible: Cuts in funding to academic health centers for training physicians at a time when they are trying to add physicians.
Really terrible: Limiting what nurse practitioners (NP) can do. NPs have as good or better primary-care outcomes than physicians and cost at least 10 percent less. Given the Texas requirement for NP supervision, rural Texas can't be served by NPs unless a physician is there. This is a waste.
Let's take the best parts of these ideas and build on them. Here are three more:
Include patients as part of the work force and pay them - or don't; 33 percent of adults and children are obese, and one in five people still smoke; let's use insurance premiums or higher prices to provide incentives. This is not an example of the nanny state; this is about decreasing waste and improving health.
Pay physicians differently. The percent of people who have coronary bypass surgery in some parts of the country is four times as high as other parts - with the same percent alive five years later. At least part of the reason is that physicians are paid "fee-for-service," which means every operation is paid for separately and the fees increase doctors' incomes. McAllen was recently singled out in a national article for being one of the most expensive places. Why? The article said the doctors do too much. If doctors were paid a salary rather than fee-for-service, experts say physicians might do 20 percent less, possibly freeing up their time to see more patients. The projection of 100,000 physicians is a 17 percent increase. Do the math. We could surely put some dent in the projected shortage if even the relatively few physicians who do too much did only what was needed and saw more patients.
At least 25 percent of people overuse emergency rooms and primary care clinics for simple conditions that could be cared for at home. We will suggest a solution to this next month.
Does Texas need more physicians, especially in rural areas? Probably.
Does Texas need 10,000 more physicians in the next 10 years? Probably not.