Problem Addressed

Many older adults, especially low-income and other vulnerable seniors, do not receive recommended, evidence-based care in the primary care setting, including preventive services, chronic disease management, and management of common geriatric conditions. As a result, these seniors may suffer a decline in physical and functional status and end up requiring expensive emergency department (ED) or inpatient care. Although evidence-based interventions to improve outpatient geriatric care for seniors exist, most of these models are narrowly focused (on a single disease, population, or site of care) and/or are poorly integrated with primary care.

• Failure to provide evidence-based care, especially for vulnerable populations: A review of the care provided to more than 345,000 Medicare beneficiaries between 1994 and 1996 found that they received indicated care less than two-thirds of the time for 16 of 40 indicators studied. African Americans, low-income seniors, and residents of federally defined Health Professional Shortage Areas were much less likely to receive indicated care.
• Negative impact on health and costs: The failure to receive timely, evidence-based care can have a negative impact on physical and mental health and functional status, leading to increased morbidity and mortality and the need for expensive inpatient and ED care. In fact, older adults with five or more chronic conditions account for 76 percent of Medicare expenditures, and per capita health expenditures for those with five or more chronic conditions are 17 times higher than for those with no chronic conditions.
• Limited use of existing models: Although a variety of system-level interventions to improve quality and outcomes in older adults exist (e.g., outpatient geriatric evaluation, collaborative interdisciplinary care), many of these models have been narrowly focused on a single disease, a specific subpopulation of older adults, and/or a single site of care. In addition, these interventions are often poorly integrated with primary care and mental health services and often fail to adequately manage care transitions.

Description of the Innovative Activity

The Geriatric Resources for Assessment and Care of Elders (GRACE) model uses nurse practitioners and social workers who work together as a support team for seniors and other high-risk individuals. Key elements of the program are described below:

• The support team: Trained, certified nurse practitioners and licensed clinical social workers with experience in geriatrics serve on the support team. These individuals are employed by the primary care practice. Three teams participated in the 2-year pilot program, each serving two practice sites.
• Population served: The initial program served patients aged 65 and older who have an annual household income of less than 200 percent of the Federal poverty level, have had one or more primary care visits in the past 12 months, and who live in the local community and have access to a telephone. Different replications of the program have served different populations, including adults of all ages who are high risk, Medicare beneficiaries who were 70+ with multiple comorbidities, and older veterans following an emergent hospital admission and discharge home.
• Initial assessment: The GRACE support team meets with patients (and family members if available) in the patient's home to conduct an initial, comprehensive assessment, including a medical and psychosocial history, medication review, functional assessment, and review of social support and advance directives. In addition, the team performs a home safety evaluation. In one replication of the program with adults of all ages, some assessments were performed in the clinic or by phone rather than at home based on patient preferences.
• Consultation with larger interdisciplinary team to develop protocol-based care plan: After the assessment, the support team meets with a larger interdisciplinary team to develop an individualized care plan. The team includes at a minimum a geriatrician or physician with expertise in caring for older adults, pharmacist and behavioral health liaison, all of whom work for the affiliated health system. The care plan is based on a set of program-specific protocols that have been adopted by GRACE for 12 conditions, such as medication management, difficulty walking/falls, chronic pain, and depression. The protocols for each condition spell out specific interventions to be considered for implementation. For each condition present, the corresponding protocol recommendations, along with additional recommendations from the team, are activated. In the replication of the program with adults of all ages, protocols were revised slightly to address an array of patient concerns beyond traditional geriatric syndromes, including substance abuse and severe mental illness.
• Face-to-face meeting with PCP to gain plan approval: Once the care plan is developed, the support team meets with the patient's PCP to review a computer-generated summary of the patient assessment and interdisciplinary team suggestions. Participation in these meetings is considered in the PCP's annual performance review.
• Team-led implementation, ongoing care coordination, and follow-up: Once approval has been secured, the support team collaborates with the PCP to implement the plan, including taking charge of ongoing care coordination and follow-up. Routine interventions based on the established protocols (often home and self-care interventions) can be implemented without the need for additional team review. Key steps in this process are outlined below:
  • In-home follow-up visit: The support team meets with the patient in his or her home to review the care plan and patient goals.
  • Ongoing care coordination and case management: The support team provides ongoing care management and coordination of care across conditions, providers, and sites of care, primarily using face-to-face and telephone contacts with patients, family members/caregivers, and providers. Face-to-face home visits occur automatically after any ED visit or hospitalization.
  • Communication with providers: To enhance coordination of care across settings, the support team makes contact with other providers. For example, the team facilitates consultation by a specialized geriatric inpatient team whenever a program participant is hospitalized. Providers in the primary care and specialty clinics, ED, and hospital receive automated prompts via the EMR to contact the support team for information and assistance with follow-up and coordination of care.
  • Annual reassessment and follow-up visit: Each year, the support team repeats the comprehensive assessment, which, in turn, triggers another collaboration with the larger interdisciplinary team to develop a new individualized care plan.
  • Interdisciplinary team case reviews: The interdisciplinary team reviews each case at 1, 2, 3, 6, and 9 months after the initial and annual care-planning meetings. Additional reviews are held for any patient who has a major change in status or requires ED or inpatient care.
  • EMR support: The nurse practitioners and social workers have access to the affiliated health system's EMR which serves as a critical support to the team in all of its activities, particularly with respect to facilitating communication and information transfer across team members and between the team and physicians.

Context of the Innovation

At the time of innovation design, Indiana University Medical Group—Primary Care, located in Indianapolis, IN, was a large primary care practice affiliated with an urban health care system (Wishard Health Services now called Eskenazi Health) serving many medically indigent patients. The practice had seven community-based health centers that provided primary care to approximately 6,000 mostly low-income seniors. Most of these seniors had Medicare coverage, while some also had Medicaid and/or received assistance from a county program that covers some or all out-of-pocket costs for people who earn up to 200 percent of the Federal poverty level.

The GRACE program represented a logical expansion of a number of other geriatric services that already existed at the health system, including an outpatient geriatric assessment and multispecialty clinic, an inpatient acute care for elders unit, a skilled nursing facility, a physician house calls program, and geriatric psychiatric care available through the health system's community mental health center. The program was developed as a way to integrate care for low-income seniors, as the fragmentation of the existing system led to missed opportunities to provide appropriate preventive, screening, and therapeutic services.

Results

The GRACE program improved the provision of evidence-based care; led to significant improvements in measures of general health, vitality, social functioning, and mental health; reduced ED visits, admissions, readmissions, and total bed days; and generated high levels of physician and patient satisfaction. Although in one evaluation, overall hospital admission rates were not affected by the program in two other evaluations, admission rates were significantly reduced. One analysis found that the program was cost neutral over a 2-year period and yielded cost savings in the third year for high-risk enrollees, while the most recent analysis found substantial net savings to the health system after program implementation.

• Enhanced provision of evidence-based care: Data from the EMR and patient reports were evaluated to determine what impact the program had on Assessing Care of Vulnerable Elders quality indicators, which have been tied to better survival among community-dwelling vulnerable adults. This analysis showed that program participants were more likely than usual-care patients to have their condition(s) recognized or diagnosed, receive a specialty consultation, and be provided with appropriate intervention or treatment. Participants were also more likely to receive evidence-based interventions related to preventive care, continuity of care, medication use, and end-of-life care.
• Improved health status and self-rated health: Compared with the control group, participants exhibited significant improvements in four of eight measures of functional status (which was measured using the eight Medical Outcomes 36-Item Short Form), including general health, vitality, social functioning, and mental health, and on the Mental Component Summary score. Another evaluation found that the proportion of patients who reported that their health was somewhat or much better than three months ago increased from 36% at enrollment to 64% at 9 months (p = 0.002).
• Lower hospital utilization: ED visits for program participants were substantially lower than for usual-care patients in all three evaluations, including a 7.1% reduction in the most recent evaluation. Effect on overall hospital admission rates differed between the three evaluations, with two showing a significant decrease and one showing no difference. However, in the study with the non-significant difference, analysis of a subgroup of patients deemed to be at high risk of hospitalization found that program participants had significantly fewer hospital admissions in the second year than did those receiving usual care. The most recent evaluation also showed a 14.8% reduction in 30-day readmissions and 28.5% fewer bed days.
• High levels of patient and provider satisfaction: Sixty-four percent of program participants rated their overall satisfaction with care as very good or excellent, roughly the same as those receiving usual care (62 percent). A separate survey found that physicians were much more satisfied with the resources available to treat patients under the GRACE program than under usual care.
• Cost saving are at least cost neutral: A recent analysis found that 179 participating patients at one VA medical center produced an estimated net savings of $200k per year due to lower utilization of ED and hospital services. In the cost analysis based on the original RCT with a larger sample, average (mean) total costs were not significantly different for enrollees than for those receiving usual care, both overall (i.e., for all participants) and for high-risk patients. For high-risk patients, however, costs declined in the third year due to lower ED and hospital utilization in the intervention group.

Planning and Development Process

Key steps in the planning and development process included the following:

• Adoption of target conditions: Several champion PCPs and opinion leaders within the system reviewed a set of geriatric conditions that had previously been identified by an expert panel as being optimal targets for quality improvement. These individuals came to consensus on 12 conditions to be targeted.
• Protocol development: Program-specific protocols were developed for each of the 12 conditions based on several different published practice guidelines developed by various professional and specialty organizations and agencies.
• Development of educational materials: Patient education and self-management materials were developed for seniors with limited literacy skills. Materials were written at a fifth-grade level.
• Development of Web-based tracking system: Although the practice had its own EMR, a separate, Web-based tracking system for the GRACE program was developed to provide summary sheets for team rounds and “to-do” lists. The GRACE support team shared progress toward implementation of the care plan with PCPs using printouts from this system and summary notes entered in the shared EMR.
• Training: Nurse practitioners and social workers each complete a 12-session training program (with meetings held once a week) on implementing the GRACE protocols and working as part of an interdisciplinary team.

Resources Used and Skills Needed

• Staffing: To handle a caseload of 300 patients, the following staff are needed: three full-time equivalent nurse practitioners and social workers (i.e., each support team can handle 100 cases); 1.0 full-time equivalent administrative assistant; and 0.1 full-time equivalents (i.e., 1/2 day a week) of a geriatrician, pharmacist, and behavioral health liaison.
• Costs: Including salary and benefits for these personnel, mileage reimbursement, cell phone costs, home visit bags, and office supplies, the estimated direct cost of providing the GRACE program is $1,260 per patient per year, or $105 per patient per month as calculated in a cost-analysis of the original RCT. A portion of this cost is reimbursable by Medicare for nurse practitioner home visits. This cost estimate does not include office space and administrative overhead.

Funding Sources

The National Institute on Aging and Nina Mason Pulliam Charitable Trust provided funding for the initial RCT. GRACE received federal funding from the Administration on Aging, the Office of Geriatrics and Extended Care at the VA, and the Centers for Medicare and Medicaid Services to participate in a care transitions program in conjunction with the local Area Agency on Aging.

Tools and Resources

GRACE Training and Resource Center: Director, Dawn Butler, MSW, JD, can be contacted at (317) 880-6577 and e-mail butlerde@iu.edu.

The program description, information on replication partners, and a list of training and support offered through the GRACE Training and Resource Center can be found at http://graceteamcare.indiana.edu.

Information on the Assessing Care of Vulnerable Elders measure set can be found at http://www.rand.org/health/projects/acove/about.html.

Information on the Medical Outcomes 36-Item Short Form measure set can be found at https://www.rand.org/health-care/surveys_tools/mos/36-item-short-form.html Information on the Assets and Health Dynamics of the Oldest-Old measure set can be found at http://hrsonline.isr.umich.edu/meta/sho_meta.php?hfyle=qnaires.

Getting Started with This Innovation

• Consider target population carefully if cost savings is a critical objective: In the original RCT and largest of the three evaluations, the program led to fewer hospitalizations only in the patients at high-risk of hospital admission. Given that outpatient visits for prevention and chronic care also increased, a broadly targeted program could potentially result in an increase in overall costs, while a more targeted approach focused on high-risk patients is much more likely to be cost neutral or yield overall savings. However, results from another evaluation at a VA medical center demonstrated a reduction in hospital admission rates, readmission rates, total bed days, and emergency department visit rates in all patients enrolled at hospital discharge, leading to a substantial cost savings for the health system; thus, a faster return on investment can be found when GRACE is implemented as a care transitions program to prevent hospital readmissions.
• Integrate with primary care: Although any organization, including a health plan, could adopt the GRACE model, the case management program must be integrated with the primary care practice. The team itself can be within the practice or external to it, but the focus needs to be on identifying and treating geriatric conditions and psychosocial problems, providing care coordination, and facilitating access to needed care.

Sustaining This Innovation

• Ensure multidisciplinary buy-in and support: Factors contributing to the success of GRACE have included early engagement and consistent buy-in from leadership and physicians who saw the benefits of the program.
• Align financial incentives: The savings generated under the GRACE model will typically accrue to the payer (e.g., Medicare, Medicaid, or a health plan affiliated with either or both of these programs). Under traditional reimbursement systems, providers, including both hospitals and physician practices, will have little or no incentive to implement this kind of program because they carry the expense of the program but do not share in potential savings. Medicare Advantage plans and accountable care organizations (ACOs) are payment models that provide the opportunity for a health plan or health care system to realize cost savings through the implementation of the GRACE program.
• Maintain relations with community-based resources: This is especially important for programs focusing on low-income seniors and/or those with functional limitations, who are much more dependent on public and community-based resources than more affluent or highly functional populations.
• Seek ongoing funding sources: Although Medicare provides some reimbursement for program services, and a managed care organization may be able to fund the program out of the cost savings generated, provider-sponsored programs operating under traditional reimbursement will likely need outside financial support to maintain the initiative over time. Indiana University Health has implemented GRACE as part of its Medicare Advantage plan and as a component of its ACO.

References/Related Articles

References/Related Articles

Barretto T, Bazemore A, Coffman M, Jabbarpour Y, Liaw W. Bright Spots in Care Management: In Medicare Advantage. Robert Graham Center. June 2017. https://www.graham-center.org/content/dam/rgc/documents/publications-reports/reports/BrightSpotsCareManagement%20.pdf.

Boult C, Wieland GD. Comprehensive primary care for older patients with multiple chronic conditions: “nobody rushes you through.” JAMA. 2010;304(17):1936-43. [PubMed]

Bielaszka-DuVernay C. The GRACE model: in-home assessments lead to better care for dual eligibles. Health Affairs. 2011;30(3):431-4. [PubMed]

Brown R, Mann DR. Best bets for reducing Medicare costs for dual eligible beneficiaries: assessing the evidence. Issue Brief. Kaiser Family Foundation. October 2012. https://www.kff.org/wp-content/uploads/2013/01/8353.pdf.

Center for Consumer Engagement in Health Innovation. Care That Works: Geriatric Resources for Assessment and Care of Elders (GRACE). April 2018. https://www.healthinnovation.org/resources/publications/document/Care-That-Works-GRACE_4_5_18.pdf?1522963914.   

Counsell SR, Callahan CM, Buttar AB, et al. Geriatric Resources for Assessment and Care of Elders (GRACE): a new model of primary care for low-income seniors. J Am Geriatr Soc. 2006;54(7):1136-41. [PubMed]

Counsell SR, Callahan CM, Clark DO, et al. Geriatric care management for low-income seniors: a randomized controlled trial. JAMA. 2007;298(22):2623-33. [PubMed]

Counsell SR, Callahan CM, Tu W, et al. Cost analysis of the Geriatric Resources for Assessment and Care of Elders Care management intervention. J Am Geriatr Soc. 2009;57(8):1420-6. [PubMed]

Counsell SR. Aging with GRACE: quality integrated care for low-income elders. Aging Today. September/October 2009;30(5).

Long P, Abrams M, Milstein A, et al. (eds.). 2017. Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health. Washington, DC: National Academy of Medicine.

Peterson Center on Healthcare. Learning Update: Improving Healthcare for High-Need Patients. Person Healthcare website. November 2017. https://petersonhealthcare.org/learning-update-improving-healthcare-high-need-patients.

Malone MI, Capezuti E, Palmer RM. (eds.). Geriatrics Models of Care: Bringing ‘Best Practice’ to an Aging America, 125. DOI 10.1007/978-3-319-16068-9_10.

Schubert C, Myers LJ, Allen K, Counsell SR. Implementing Geriatric Resources for Assessment and Care of Elders Team Care in a Veterans Affairs Medical Center: Lessons Learned and Effects Observed. J Am Geriatr Soc. 2016;64:1503-1509. [PubMed]

Ritchie C, Andersen R, Eng J, Garrigues SK, et al. Implementation of an Interdisciplinary, Team-Based Complex Care Support Health Care Model at an Academic Medical Center: Impact on Health Care Utilization and Quality of Life. PLOS ONE. 2016;11(2):e0148096. https://doi.org/10.1371/journal.pone.0148096. [PubMed]

Shier G, Ginsburg M, Howell J, et al. Strong social support services, such as transportation and help for caregivers, can lead to lower health care use and costs. Health Aff. 2013;32(3):544-51. [PubMed]

Quist KK, Counsell ST, Shubert CC, Weiner M. Medication management interventions in patients enrolled in GRACE Team Care. Geriatr Nurs. 2016;37(5):371-375. [PubMed]

Vaugh CP, Fowler R, Goodman RA, Graves TR, Flacker JM, Johnson TM. Identifying landmark articles for advancing the practice of geriatrics. J Am Geriatr Soc. 2014;62(1):2159-62. [PubMed]

Footnotes

Counsell SR, Callahan CM, Buttar AB, et al. Geriatric Resources for Assessment and Care of Elders (GRACE): a new model of primary care for low-income seniors. J Am Geriatr Soc. 2006;54(7):1136-41. [PubMed]

Schubert C., Myers LJ., Allen K, et al. Implementing Geriatric Resources for Assessment and Care of Elders Team Care in a Veterans Affairs Medical Center: Lessons Learned and Effects Observed. J Am Geriatr Soc. 2016;64(7):1503-509. [PubMed]

Ritchie C, Andersen R, Eng J, et al. Implementation of an Interdisciplinary, Team-Based Complex Care Support Health Care Model at an Academic Medical Center: Impact on Health Care Utilization and Quality of Life. PLOS ONE. 2016;11(2): e0148096. https://doi.org/10.1371/journal.pone.0148096. [PubMed]

Asch SM, Sloss EM, Hogan C, et al. Measuring underuse of necessary care among elderly Medicare beneficiaries using inpatient and outpatient claims. JAMA. 2000;284(18):2325-33. [PubMed]

Jencks SF, Cuerdon T, Burwen DR, et al. Quality of medical care delivered to Medicare beneficiaries: a profile at state and national levels. JAMA. 2000;284(13):1670-6. [PubMed]

Wenger NS, Solomon DH, Roth CP, et al. The quality of medical care provided to vulnerable community-dwelling older patients. Ann Intern Med. 2003;139(9):740-7. [PubMed]

Bodenheimer T, Berry-Millett R. Follow the money—controlling expenditures by improving care for patients needing costly services. N Engl J Med. 2009;361(16):1521-3. [PubMed]

Counsell SR, Callahan CM, Clark DO, et al. Geriatric care management for low-income seniors: a randomized controlled trial. JAMA. 2007;298(22):2623-33. [PubMed]

Higashi T, Shekelle PG, Adams JL, et al. Quality of care is associated with survival in vulnerable older patients. Ann Intern Med. 2005;143(4):274-81. [PubMed]

Counsell SR, Callahan CM, Tu W, et al. Cost analysis of the Geriatric Resources for Assessment and Care of Elders Care management intervention. J Am Geriatr Soc. 2009;57:1420-6. [PubMed]

Counsell SR. Integrating medical and social services with GRACE. Generations. 2011;35(1):56-9.

Original Publication

July 2, 2014

Date Verified by Innovator

June 12, 2020