Geriatric Resources for Assessment and Care of Elders (GRACE)

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 to optimize health and functional status, decrease excess healthcare use, and prevent long-term nursing home placement.

• Program Goals:
• -Improve the quality and outcomes of care for low-income seniors in primary care.

 

• Target Audience:
• -Low-income seniors with multiple chronic medical conditions

 

• Program Description:
• -In the GRACE Team Care model, every patient is assigned a support team, composed of a nurse practitioner and social worker, who work closely with the patient, caregiver, and patient’s primary care physician.
• -The support team:
  • *Performs an in-home geriatric assessment of each patient.
  • *Develops an individualized care plan, with input from a larger interdisciplinary team that includes a geriatrician, pharmacist, mental health professional, and community resource expert.
  • *Implements the care plan in collaboration with the primary care physician.
  • *Provides ongoing care coordination.
  • *Delivers proactive transitional care and integrates new treatments or medications into the care plan if the patient is admitted to the hospital.

 

• Program Delivery:
• -Working together, a team of doctors, nurses, social workers, and pharmacists use geriatric knowledge and techniques to improve patient care — not just in the clinic, but in the patient’s home and community.

 

• Costs to Implement Program:
• -To learn more about the GRACE Team Care model, contact Dawn Butler, Director of the GRACE Training and Resource Center at butlerde@iu.edu or (317) 880-6577.

Contact information

• Website: http://graceteamcare.indiana.edu/home.html

Reference Material

Counsell SR, Callahan CM, Buttar AB, Clark DO, Frank KI. Geriatric Resources for Assessment and Care of Elders (GRACE): a new model of primary care for low-income seniors. Journal of the American Geriatric Society. 2006 Jul; 54(7):1136-41.

Counsell SR, Callahan CM, Tu W, Stump TE, Arling GW. Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention. Journal of the American Geriatric Society. 2009 Aug; 57(8):1420-6.

Counsell SR, Callahan CM, Clark DO, Tu W, Buttar AB, Stump TE, Ricketts GD. Geriatric care management for low-income seniors: a randomized controlled trial. JAMA. 2007 Dec 12; 298(22):2623-33.