September 2016

1. Grand-Aides: Transitional/ Chronic Care ManagementS. Craig Thomas, MSN, ACNP-BCUniversity of VirginiaAdvanced 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. • Usuallya 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 Address chronic disease • Single diagnosis or population (e.g. Medicaid, Dual-eligible, Medicare Advantage) • Behavioral health • Social issues 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-AidesNO decisions 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

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 Clinicbased 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 1stwk, 2-3 times 2ndwk, 1-2 times 3rdwk, etc. Trending with fewer visits over time

9. Virginia Population Density/ Readmission

10. DuringHomeVisit • 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, 4400+ 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 12/31 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

16. Heart failure patients with Grand-Aides have significantly fewer all-cause readmissions and E.D. visits.

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