Geriatric Resources for Assessment and Care of Elders (GRACE)

A new model of primary care for low-income seniors

Steven Counsell, Christopher Callahan, Amna B. Buttar, Daniel Clark, Kathryn I. Frank

Research output: Contribution to journalArticle

117 Citations (Scopus)

Abstract

The majority of older adults receive health care in primary care settings, yet many fail to receive the recommended standard of care for preventive services, chronic disease management, and geriatric syndromes. 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 so as to optimize health and functional status, decrease excess healthcare use, and prevent long-term nursing home placement. The catalyst for the GRACE intervention is the GRACE support team, consisting of a nurse practitioner and a social worker. Upon enrollment, the GRACE support team meets with the patient in the home to conduct an initial comprehensive geriatric assessment. The support team then meets with the larger GRACE interdisciplinary team (including a geriatrician, pharmacist, physical therapist, mental health social worker, and community-based services liaison) to develop an individualized care plan including activation of GRACE protocols for evaluating and managing common geriatric conditions. The GRACE support team then meets with the patient's PCP to discuss and modify the plan. Collaborating with the PCP, and consistent with the patient's goals, the support team then implements the plan. With the support of an electronic medical record and longitudinal tracking system, the GRACE support team provides ongoing care management and coordination of care across multiple geriatric syndromes, providers, and sites of care. The effectiveness of the GRACE intervention is being evaluated in a randomized, controlled trial.

Original languageEnglish
Pages (from-to)1136-1141
Number of pages6
JournalJournal of the American Geriatrics Society
Volume54
Issue number7
DOIs
StatePublished - Jul 2006

Fingerprint

Geriatric Assessment
Primary Health Care
Geriatrics
Primary Care Physicians
Delivery of Health Care
Nurse Practitioners
Social Welfare
Electronic Health Records
Quality of Health Care
Physical Therapists
Standard of Care
Disease Management
Nursing Homes
Pharmacists
Health Status
Patient Care
Mental Health
Chronic Disease
Randomized Controlled Trials

Keywords

  • Care management
  • Geriatric assessment
  • Interdisciplinary team
  • Low-income seniors
  • Systems of care

ASJC Scopus subject areas

  • Geriatrics and Gerontology

Cite this

@article{fa8960b7cd944695bb8eefb4539cbd70,
title = "Geriatric Resources for Assessment and Care of Elders (GRACE): A new model of primary care for low-income seniors",
abstract = "The majority of older adults receive health care in primary care settings, yet many fail to receive the recommended standard of care for preventive services, chronic disease management, and geriatric syndromes. 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 so as to optimize health and functional status, decrease excess healthcare use, and prevent long-term nursing home placement. The catalyst for the GRACE intervention is the GRACE support team, consisting of a nurse practitioner and a social worker. Upon enrollment, the GRACE support team meets with the patient in the home to conduct an initial comprehensive geriatric assessment. The support team then meets with the larger GRACE interdisciplinary team (including a geriatrician, pharmacist, physical therapist, mental health social worker, and community-based services liaison) to develop an individualized care plan including activation of GRACE protocols for evaluating and managing common geriatric conditions. The GRACE support team then meets with the patient's PCP to discuss and modify the plan. Collaborating with the PCP, and consistent with the patient's goals, the support team then implements the plan. With the support of an electronic medical record and longitudinal tracking system, the GRACE support team provides ongoing care management and coordination of care across multiple geriatric syndromes, providers, and sites of care. The effectiveness of the GRACE intervention is being evaluated in a randomized, controlled trial.",
keywords = "Care management, Geriatric assessment, Interdisciplinary team, Low-income seniors, Systems of care",
author = "Steven Counsell and Christopher Callahan and Buttar, {Amna B.} and Daniel Clark and Frank, {Kathryn I.}",
year = "2006",
month = "7",
doi = "10.1111/j.1532-5415.2006.00791.x",
language = "English",
volume = "54",
pages = "1136--1141",
journal = "Journal of the American Geriatrics Society",
issn = "0002-8614",
publisher = "Wiley-Blackwell",
number = "7",

}

TY - JOUR

T1 - Geriatric Resources for Assessment and Care of Elders (GRACE)

T2 - A new model of primary care for low-income seniors

AU - Counsell, Steven

AU - Callahan, Christopher

AU - Buttar, Amna B.

AU - Clark, Daniel

AU - Frank, Kathryn I.

PY - 2006/7

Y1 - 2006/7

N2 - The majority of older adults receive health care in primary care settings, yet many fail to receive the recommended standard of care for preventive services, chronic disease management, and geriatric syndromes. 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 so as to optimize health and functional status, decrease excess healthcare use, and prevent long-term nursing home placement. The catalyst for the GRACE intervention is the GRACE support team, consisting of a nurse practitioner and a social worker. Upon enrollment, the GRACE support team meets with the patient in the home to conduct an initial comprehensive geriatric assessment. The support team then meets with the larger GRACE interdisciplinary team (including a geriatrician, pharmacist, physical therapist, mental health social worker, and community-based services liaison) to develop an individualized care plan including activation of GRACE protocols for evaluating and managing common geriatric conditions. The GRACE support team then meets with the patient's PCP to discuss and modify the plan. Collaborating with the PCP, and consistent with the patient's goals, the support team then implements the plan. With the support of an electronic medical record and longitudinal tracking system, the GRACE support team provides ongoing care management and coordination of care across multiple geriatric syndromes, providers, and sites of care. The effectiveness of the GRACE intervention is being evaluated in a randomized, controlled trial.

AB - The majority of older adults receive health care in primary care settings, yet many fail to receive the recommended standard of care for preventive services, chronic disease management, and geriatric syndromes. 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 so as to optimize health and functional status, decrease excess healthcare use, and prevent long-term nursing home placement. The catalyst for the GRACE intervention is the GRACE support team, consisting of a nurse practitioner and a social worker. Upon enrollment, the GRACE support team meets with the patient in the home to conduct an initial comprehensive geriatric assessment. The support team then meets with the larger GRACE interdisciplinary team (including a geriatrician, pharmacist, physical therapist, mental health social worker, and community-based services liaison) to develop an individualized care plan including activation of GRACE protocols for evaluating and managing common geriatric conditions. The GRACE support team then meets with the patient's PCP to discuss and modify the plan. Collaborating with the PCP, and consistent with the patient's goals, the support team then implements the plan. With the support of an electronic medical record and longitudinal tracking system, the GRACE support team provides ongoing care management and coordination of care across multiple geriatric syndromes, providers, and sites of care. The effectiveness of the GRACE intervention is being evaluated in a randomized, controlled trial.

KW - Care management

KW - Geriatric assessment

KW - Interdisciplinary team

KW - Low-income seniors

KW - Systems of care

UR - http://www.scopus.com/inward/record.url?scp=33745597072&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=33745597072&partnerID=8YFLogxK

U2 - 10.1111/j.1532-5415.2006.00791.x

DO - 10.1111/j.1532-5415.2006.00791.x

M3 - Article

VL - 54

SP - 1136

EP - 1141

JO - Journal of the American Geriatrics Society

JF - Journal of the American Geriatrics Society

SN - 0002-8614

IS - 7

ER -