September 28th, 2009
Editor’s Note: In addition to Arthur Garson (photo and bio available above), coauthors of this post include Margaret Whitehead, Tracy Buni, Catherine Sommers, and Karen Rheuban.
Given current trends, access to health care will worsen considerably in the next 15 years. The first wave of baby boomers is now turning 65, and health care utilization for this population is anticipated to double. Health reform could add many of America’s nearly 50 million uninsured people to this already burgeoning demand for health care. When Massachusetts added 400,000 insured residents, the waiting time to see an internist increased from 33 to 52 days.
Despite current increases in the number of physicians and nurses trained, that supply will not keep pace with demand, and we face an ever greater crisis in access. The U.S. health care system is challenged to identify new models of health care delivery that do not require ever increasing numbers of physicians and nurses.
We propose to change the paradigm of care with the creation of a new model of the health care continuum by establishing teams that begin with the patient. Patients must take greater ownership of their health (for example, reducing smoking and obesity) and also need to understand when visits to physicians are necessary and whether visits with other members of a health care team are appropriate. These teams will also include community health workers, nurses, advanced practice nurses, primary care physicians, and specialists. This model of greater training and greater responsibility leveraging members of a health care team has been articulated by generalist physicians to address shortages in primary care, and in recognition that physicians do not need to provide all care.
This model would train and employ trusted members of the community to serve as the liaison between patients (or potential patients) and health professionals. The concept was based on a comments by two chairs of family medicine departments that a good percentage of their patients could be taken care of by good grandparents. Grandparents have raised families, have helped to raise children and grandchildren, and have had a wealth of challenging life experiences, many relating to the medical realm. Many grandparents are nearing retirement, or have retired, and may be searching for rewarding endeavors or additional income in challenging economic times. We believe that grandparents can become a new and valuable tool in a new paradigm in patient care: community health workers. Models for training such workers have been deployed successfully, for example, in New Jersey (improving efficiency and access) as well as in Native American populations and in Alaska, where 500 community health workers provide primary care.
Acute Care Community Health Care Workers Pilot
Primary care protocols have been developed for common acute conditions in both children and adults (e.g., pharyngitis, vomiting, sprains). We have adapted protocols from successful nurse triage manuals as well as the community health worker program in Alaska. Instructions are clear when the grandparent is to recommend that care be provided at home without a home visit; when a visit is necessary; and how to direct subsequent management whether at home, at the clinic, or in the emergency room. The protocols will be tested by physicians and nurses at the FQHC to determine if they align with their own style of practice and, if not, modified accordingly. A community health center nurse will train and supervise 4 health care workers for 3 months in the classroom and then for one month in the clinic. Training will include basic health care issues, cultural competency, patient encounter discipline to include privacy, the use of protocols, and learning under which conditions the protocols do not apply. At the end of the 4 months, each grandparent will be tested for ability with model patients.
Grandparents will be assigned to and meet with 50 families who agree to have a grandparent involved in their care, all current patients of the FQHC. Each grandparent will work 5 days per week and be on call every other night and every other weekend (grandparents work in pairs). The FQHC has estimated that with 50 families, each grandparent will take approximately 5 calls each day and 1 call every other night. For the first three months after clinic training, the grandparent will be in contact with a nurse for every patient by telephone (and video if necessary). After three months, if a review of the decisions by nurses and physicians reveals outstanding performance, then for certain conditions, the grandparent may be permitted not to call at the time and then have the case reviewed the following day. Quality assurance is an essential feature. At the end of 10 months of training, all cases will be reviewed and the grandparent tested. Those who succeed will receive a certificate. All processes and outcomes — both medical and cost — will be measured.
Beyond The Pilot
On the basis of the pilot, protocols and training will be modified. An expanded pilot will next be tested with 15 pairs of grandparents. Comparison data will be collected for a similar community with an FQHC but without the use of community health outreach workers. A similar pilot is planned for an urban underserved area in Houston, Texas. Similar pilots are under discussion in 9 foreign countries.
Pilots are also planned for the “primary prevention – social work” grandparent, with goals of improved health literacy as well as enrollment for all eligible people in public programs; and for the “chronic care” grandparent to reduce hospital readmission for congestive heart failure. Grandparents will be trained with patient guidelines for care after discharge from the hospital. Each grandparent will meet with a patient the day before planned discharge and visit the patient 3 times per week in the first month, with the goals of strict adherence to medical regimens (such as taking medication correctly, recording daily weight and transmitting this to the physician’s office, as well as making and keeping appointments with physicians). Where appropriate, home telehealth equipment will be used.
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