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Aging with GRACE: New health care delivery model improves outcomes, saves money
Date:8/11/2009

951 low-income seniors (average age 72); 477 received usual care, 474 participated in GRACE. Both the usual care and the GRACE groups were comprised of lower risk for hospitalization and higher risk for hospitalization individuals, were predominately female (77 percent) and African-American and were seen at six community-based health centers.

The key to GRACE is two teams. The support team, consisting of a nurse practitioner and a social worker, meet with each patient at his home to conduct an initial comprehensive geriatric assessment from the medicine cabinet to the kitchen cabinet. Based on the support team's findings, a larger interdisciplinary team (including a geriatrician, pharmacist, physical therapist, mental health social worker, and community-based services liaison) develops an individualized care plan.

Then the ball is back in the support team's court. The nurse practitioner and the social worker meet with the patient's primary care doctor to come up with a health-care plan consistent with the patient's goals, such as maintaining the ability to participate in social and religious activities. The support team then works with the patient to implement the plan which contains strategies for medical issues of concern as well as elements related to maintaining quality of life. With the assistance of an electronic medical record and tracking system, the GRACE support team provides ongoing comprehensive care management.

"With GRACE we focused on the many issues faced by aging low-income adults -- access to needed services, medications, mobility, depression, transportation, nutrition, as well as other health issues of aging," said Dr. Counsell, who is a geriatrician. "Using a model for geriatrics care based on our prior work, we were able to deliver care which was very popular with patients and their doctors, improved health outcomes, and saved money because it helped keep seniors from having to use the emergency department or be admi
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Contact: Cindy Fox Aisen
caisen@iupui.edu
317-274-7722
Indiana University
Source:Eurekalert  

Page: 1 2 3

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