"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," says geriatrician Steven R. Counsell, MD, Mary Elizabeth Mitchell Professor of Geriatrics at the IU School of Medicine, IU Center for Aging Research center scientist and affiliated scientist of the Regenstrief Institute. Dr. Counsell and his fellow researchers’ approach is called GRACE, or Geriatric Resources for Assessment and Care of Elders, and is designed to involve seniors and their primary care physicians in a program to optimize health and functional status, and to decrease high-cost emergency department visits and hospital admissions. The key to GRACE is two teams. The support team, consisting of a nurse practitioner and a social worker, meet with each patient at his home to conduct an initial geriatric assessment from medicine cabinet to kitchen cabinet. Based on the support team’s findings, a larger interdisciplinary team—a geriatrician, pharmacist, physical therapist, mental health social worker, and community-based services liaison—develops an individualized care plan. The nurse practitioner and the social worker meet with the patient’s primary care doctor to come up with a health-care plan consistent with the patient’s goals, such as maintaining the ability to participate in social activities. The support team then works with the patient to implement the plan that 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 tracking system, the GRACE support team provides ongoing comprehensive care management. Says Dr. Counsell, "Using a model for geriatrics care based on our prior work, we were able to deliver care which was very popular with patients and their doctors, improved health outcomes, and saved money."
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