Geriatric Resources for Assessment and Care of Elders

Wishard Health Services
Indianapolis, IN
293 Beds

The Problem
Geriatric Resources for Assessment and Care of Elders (GRACE) is an integrated care model targeting the senior population facing multiple chronic conditions. A partnership among Indiana University and other local facilities, the program is centered around a community-based health center, leveraging the expertise of a geriatric interdisciplinary team to design individual, patient-specific care protocols. The initiative reached close to 500 patients by 2007.

The Solution
The program was designed with an understanding that integration of medical and social care, in addition to repetition in clinical and support visits, constitutes essential care for beneficiaries with functional limitations. While patients receive comprehensive assessments, ongoing communication and evaluation aids in developing an ideal care plan. These periodic visits vary by patient but generally include: (1) Comprehensive in-home assessment by nurse practitioner and social worker; (2) Second in-home visit after development of an individualized care protocol to communicate the patient care plan and discuss logistics; (3) Patient contact by phone at least once a month with program coordinators and (4) Home visits after a hospitalization or emergency department visit.

Providers are reimbursed on the same typical fee-for-service and Diagnosis-Related Groups as other patients. Working together with Indiana University, the group secured funding from a variety of local and national organizations to cover any additional costs (approximately $105 per member per month).

The Result
A randomized control trial found a positive impact on both quality and cost. In a group with incomes 200% of the federal poverty level, high-risk patients had fewer visits to the emergency department, inpatient hospitalizations, and readmissions. Satisfaction was higher among GRACE patients and participating providers than the control groups. Finally, the improved quality and reduced number of acute hospitalizations saved approximately $1,500 per patient by the second year of program implementation.

This case study was originally featured in the HPOE guide: 'Caring for Vulnerable Populations,' published January, 2012.