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

Authors

  • Steven R. Counsell MD,

    1. From the *Indiana University Center for Aging ResearchDivision of General Internal Medicine and Geriatrics, School of Medicine, Indiana University, Indianapolis, IndianaRegenstrief Institute, Inc., Indianapolis, Indiana§Department of Medicine, Medical School, University of Wisconsin, Madison, Wisconsin.
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  • Christopher M. Callahan MD,

    1. From the *Indiana University Center for Aging ResearchDivision of General Internal Medicine and Geriatrics, School of Medicine, Indiana University, Indianapolis, IndianaRegenstrief Institute, Inc., Indianapolis, Indiana§Department of Medicine, Medical School, University of Wisconsin, Madison, Wisconsin.
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  • Amna B. Buttar MD, MS,

    1. From the *Indiana University Center for Aging ResearchDivision of General Internal Medicine and Geriatrics, School of Medicine, Indiana University, Indianapolis, IndianaRegenstrief Institute, Inc., Indianapolis, Indiana§Department of Medicine, Medical School, University of Wisconsin, Madison, Wisconsin.
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  • Daniel O. Clark PhD,

    1. From the *Indiana University Center for Aging ResearchDivision of General Internal Medicine and Geriatrics, School of Medicine, Indiana University, Indianapolis, IndianaRegenstrief Institute, Inc., Indianapolis, Indiana§Department of Medicine, Medical School, University of Wisconsin, Madison, Wisconsin.
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  • Kathryn I. Frank RN, DNS

    1. From the *Indiana University Center for Aging ResearchDivision of General Internal Medicine and Geriatrics, School of Medicine, Indiana University, Indianapolis, IndianaRegenstrief Institute, Inc., Indianapolis, Indiana§Department of Medicine, Medical School, University of Wisconsin, Madison, Wisconsin.
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  • Presented in part at the American Geriatrics Society Annual Scientific Meetings: Washington, DC, May 2002; Baltimore, Maryland, May 2003; and Orlando, Florida, May 2005.

Address correspondence to Steven R. Counsell, MD, Indiana University School of Medicine, 1001 West 10th Street, WOP-M200, Indianapolis, IN 46202. E-mail: scounsel@iupui.edu

Abstract

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.

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