Geriatric Resources for Assessment and Care of Elders (GRACE)

Multistate

GRACE is a team-based care management model targeting low-income seniors. Eligible patients are connected with a social worker or nurse practitioner who conducts comprehensive in-home assessments of patients' needs and collaborates with larger interdisciplinary geriatric care teams to develop individualized care plans. Once a care plan is developed, the care team meets with the patient's primary care physician to gain approval and implement the plan, which includes protocols for care coordination and follow up. Communication and information transfer across team members is facilitated by electronic medical records and a web-based care management tracking tool developed specifically for the program. Program evaluations have linked GRACE with increased provision of evidence-based care; significant improvements in general health, vitality, social functioning and mental health; and high levels of physician and patient satisfaction.

Partner Organizations

• Indiana University School of Medicine
• Indiana University Center for Aging Research
• Regenstrief Institute, Inc.
• Wishard Health Services

Participants include:

• HealthCare Partners Medical Group in Southern California/University of California-San Francisco/Health Plan of San Mateo/Whittier Hospital Medical Center (funded by The SCAN Foundation)
• Indianapolis VA Medical Center/San Francisco VA/Cleveland VA (funded by the VA Office of Geriatrics and Extended Care)
• CICOA Aging and In-Home Solutions/Wishard Health Services/Indianapolis VA
• Indiana University Health Physicians at IU Health

Target Population

Low-income seniors ages 65 and older

Care Team

Social worker or nurse practitioner, primary care physician, geriatrician, pharmacist, physical therapist, mental health social worker, community-based services liaison

Timeframe

2006 - present

Results/ Studies

Assorted studies

Funding

Various

Resources

Program website

Profile by the Agency for Healthcare Research and Quality