Geriatric Resources for Assessment and Care of Elders (GRACE): A New Model of Primary Care for Low-Income Seniors

Steven R. Counsell, MD; Christopher M. Callahan, MD; Amna B. Buttar, MD, MS; Daniel O. Clark, PhD; Kathryn I. Frank, RN, DNS

Disclosures

J Am Geriatr Soc. 2006;54(7):1136-1141. 

In This Article

Abstract and Introduction

The majority of older adults receive health care in primary care settings, yet many fail to receive the recommended standard of care for preventive services, chronic disease management, and geriatric syndromes. The Geriatric Resources for Assessment and Care of Elders (GRACE) model of primary care for low-income seniors and their primary care physicians (PCPs) was developed to improve the quality of geriatric care so as to optimize health and functional status, decrease excess healthcare use, and prevent long-term nursing home placement. The catalyst for the GRACE intervention is the GRACE support team, consisting of a nurse practitioner and a social worker. Upon enrollment, the GRACE support team meets with the patient in the home to conduct an initial comprehensive geriatric assessment. The support team then meets with the larger GRACE interdisciplinary team (including a geriatrician, pharmacist, physical therapist, mental health social worker, and community-based services liaison) to develop an individualized care plan including activation of GRACE protocols for evaluating and managing common geriatric conditions. The GRACE support team then meets with the patient's PCP to discuss and modify the plan. Collaborating with the PCP, and consistent with the patient's goals, the support team then implements the plan. With the support of an electronic medical record and longitudinal tracking system, the GRACE support team provides ongoing care management and coordination of care across multiple geriatric syndromes, providers, and sites of care. The effectiveness of the GRACE intervention is being evaluated in a randomized, controlled trial.

Most older adults receive care in primary care settings, and many fail to receive the recommended standard of care for preventive services, chronic disease management, and geriatric syndromes.[1,2,3] Multiple previous studies have investigated a variety of system-level interventions to improve the quality and outcomes of care for older adults and thereby reduce utilization and costs.[4,5] Examples of these interventions include outpatient geriatric evaluation and management, collaborative interdisciplinary care, disease management, case management, changes in reimbursement schemes, and changes in the hospital or primary care environment.[6,7,8,9,10,11,12] Many of the early models of care focused on a single disease, a narrow population of older adults, or a single site of care. Other limitations included poor integration with primary care and mental health and poorly executed care transitions.[6,13,14]

Building from the findings of earlier studies, more-successful models have recognized the importance of facilitating adherence to recommendations and longitudinal tracking, among other innovations.[15] For example, outpatient comprehensive geriatric assessment coupled with an intervention to ensure adherence to recommendations or interdisciplinary primary care has been shown to prevent functional decline.[16,17] The Acute Care for Elders (ACE) inpatient model of geriatric assessment and interdisciplinary team care, which also facilitates adherence to recommendations, has been demonstrated to prevent functional decline and decrease nursing home placement.[9,10] Preventive home visits and social and medical care integrated with case management have been shown to delay the onset of disability and reduce nursing home placement.[18,19,20] An interdisciplinary, collaborative practice intervention involving a primary care physician (PCP), a nurse, and a social worker decreased hospitalizations in community-dwelling seniors with chronic illnesses.[21] Nevertheless, each of these examples also demonstrates a continued need to investigate more-powerful interventions to achieve adherence to recommendations, to improve coordination and integration of care, and to increasingly engage the patient and family in self-management. Prior research also demonstrates a continued need to better understand how to target these interventions and how to individualize the intensity of the intervention.[4,5]

The Geriatric Resources for Assessment and Care of Elders (GRACE) model of primary care was developed to improve the quality of care for low-income seniors. Low-income seniors represent a particularly complex and high-cost group of older adults who frequently suffer from socioeconomic stressors and low health literacy in addition to chronic medical conditions.[22] The goal of the GRACE model is to optimize health and functional status, decrease excess healthcare use, and prevent long-term nursing home placement. Building on the lessons learned from prior efforts to improve the care of older adults through multidimensional assessment, the GRACE intervention targets low-income seniors and adds several new features: integration of the geriatrics team within the primary care environment; in-home assessment and care management provided by a social worker and nurse practitioner team; extensive use of specific care protocols; utilization of an integrated electronic medical record and a Web-based care management tracking tool; and integration with affiliated pharmacy, mental health, home health, community-based, and inpatient geriatric care services. The purpose of this article is to describe the GRACE clinical intervention that is currently being tested in a randomized clinical trial. Results of that trial will be reported in a future article.

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