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 hospital admission.

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 elders.

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 care plan.

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.

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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 campus.