Academic journal article Generations

Integrating Medical and Social Services with GRACE

Academic journal article Generations

Integrating Medical and Social Services with GRACE

Article excerpt

The GRACE program offers thorough patient assessment, care planning, and care coordination-a model that saves money in serving patients with chronic conditions.

A recent federal report validated what clinicians caring for older adults have long recognized-that the most complex and costly patient populations are those with a combination of chronic conditions and functional limitations (The Lewin Group, 2010). Not surprisingly, these patients place a high demand on medical services and social supports, and have very high healthcare costs. The majority of elders dually eligible for Medicare and Medicaid have chronic conditions and functional limitations, and annual healthcare costs for this group are in the ninety-fifth percentile.

Often, these patients have socioeconomic stressors, low health literacy, limited access to care, and fragmented healthcare, which contribute to poor care quality and excess costs. And, most medical and social service providers have limited geriatrics expertise. Thus, the potential to improve quality and lower costs for dually eligible elders is substantial. We need new delivery models that better address common geriatric conditions and integrate medical and social care.

The Concept of GRACE

To address these issues, clinicians and researchers at Indiana University Center for Aging Research designed and tested a new model of interdisciplinary team care called GRACE, or Geriatric Resources for Assessment and Care of Elders (Counsell et al., 2006). In a randomized controlled trial involving nearly 1,000 low-income elders, the GRACE model was shown to improve both quality and health outcomes compared to care as usual (Counsell et al., 2007). In a high-risk group, GRACE led to fewer hospital admissions and re-admissions, resulting in lower total healthcare costs (Counsell et al., 2009).

The GRACE model has been replicated successfully by a large managed-care medical group in Southern California, and at a VA Medical Center in Indianapolis, Indiana. Through initiatives under the Affordable Care Act (ACA), GRACE is emerging as a model of integrated and cost-effective care that may be broadly applicable to our aging population, especially for older persons with multiple chronic conditions and complex healthcare needs (Boult and Wieland, 2010).

Developing a Care Plan

The GRACE model builds on lessons learned from prior efforts to improve the care of older adults through multidimensional assessment and interdisciplinary team care (see sidebar, below, for features of the GRACE approach to care).

In the GRACE model, the first step is an in-home assessment, which serves as the basis for developing a care plan. After meeting with the patient's primary care physician to review, modify, and prioritize the plan, the GRACE social worker and nurse practitioner work in collaboration with the physician to put the plan into place. Weekly GRACE interdisciplinary team meetings with the GRACE geriatrician, pharmacist, mental health social worker, and community- based services expert provide accountability for implementing the plan and assisting with troubleshooting care barriers.

The GRACE social worker and nurse practitioner have at least monthly contact with the patient, and provide coordination and continuity of care between all healthcare professionals and sites of care. In particular, the GRACE team works closely with staff at the emergency department, hospital, or nursing facility to optimize care in transitions and link the patient back to their primary care physician. During transitions, GRACE care includes collaborating with hospital or nursing home discharge planners, supporting the older person and their family or caregivers, a post-discharge home visit where medications are reconciled, and ensuring services such as home healthcare are implemented as planned. Finally, care is coordinated with home- and community-based services as delivered by the local aging network. …

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