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Aging with grace: In-home assessments lead
to better care, lower health costs
March 9, 2011– The March 2011 issue of the
journalHeath Affairs highlights
an evidence-based model of geriatric care
management developed, implemented and tested
by researchers and clinicians from Indiana
University, the Regenstrief Institute and
Wishard Health Services.
Geriatric Resources for Assessment and Care of
Elders (GRACE) optimizes the health and
functional status of community dwelling
lower income, older adults. GRACE is now in
use by Wishard Health Services, the
third-largest safety-net health organization
in the United States; by HealthCare Partners
Medical Group, a large managed care
organization in Southern California and by a
growing number of other organizations.
A previous clinical trial found that GRACE
improves health and quality of life,
decreases emergency department visits and
lowers hospital admission rates in lower
income older adults at high risk for
The care delivery model focuses on the many
issues faced by older adults -- access to
needed services, medications, mobility,
depression, transportation, nutrition, as
well as other health issues of aging.
"Healthcare reform is calling out for ways to
improve health and lower costs. We have
found a strategy to do that for a very
vulnerable growing population in a way that
shows cost savings over time and has the
added benefit of providing services that
these seniors desperately need but can't get
elsewhere," said Steven R. Counsell, M.D.,
Mary Elizabeth Mitchell Professor of
Geriatrics at the IU School of Medicine, an
IU Center for Aging Research center
scientist, a geriatrician at Wishard, and an
affiliated scientist of the Regenstrief
Institute, the principal investigator of the
GRACE clinical trial.
He is currently leading GRACE dissemination
initiatives while working to influence
health policy to improve integration of
medical and social care for vulnerable
The key to GRACE is two teams. The support
team, consisting of a nurse practitioner and
a social worker, meet with each patient in
the 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, mental health
social worker, and community-based services
liaison) helps develop an individualized
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 healthcare 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 web-based tracking
system, the GRACE support team provides
ongoing comprehensive care management.
Because it improves health and quality of life,
GRACE is cost effective. By the second year
GRACE even saves money for the sickest
(those with three to four chronic diseases).
Results of the GRACE trial were published in
the Dec. 12, 2007, issue of theJournal of
American Medical Association (JAMA).
The cost analysis of the GRACE model was
published in the August 2009 issue of the Journal
of the American Geriatrics Society.
"The GRACE model improves health and reduces
healthcare costs by lowering hospitalization
rates in high risk seniors. The GRACE
intervention can be financed by a health
plan under managed care Medicare using the
savings from fewer hospitalizations to
offset GRACE program expenses. Most seniors,
however, are not enrolled in managed care
Medicare plans, and most services provided
by the GRACE program are not currently
reimbursed by traditional fee-for-service
Medicare. Thus, payment reform is needed for
broad dissemination of the GRACE model to
benefit seniors under traditional Medicare.
We are pleased that the newly created U.S.
government Center for Medicare and Medicaid
Innovation is looking at GRACE and other
novel ways of delivering medical care and
paying healthcare providers that can improve
health and also save money for Medicare and
Medicaid," said Dr. Counsell.
Development of GRACE was funded by the National
Institute on Aging, the Nina Mason Pulliam
Charitable Trust and Wishard Health
Services. Dissemination of GRACE to
Healthcare Partners Medical Group was
supported by a grant from The SCAN
Foundation, based in Long Beach, California.
The SCAN Foundation is dedicated to creating
a society in which seniors receive medical
treatment and human services that are
integrated in the setting most appropriate
to their needs.
The Indiana University School of Medicine, the
Regenstrief Institute and Wishard Health
Services are located on the Indiana
University-Purdue University Indianapolis