Most older adults obtain their health care in the offices of busy primary care physicians or, in the case of those without physicians, in even busier hospital emergency departments. In either location, seniors often don't receive the recommended care for preventive services, chronic disease management and geriatric syndromes. A study published in the December 12 issue of the Journal of the American Medical Association reports on GRACE, the largest randomized clinical trial of a health system and home-based geriatrics care concept designed to improve health care for community-dwelling low-income older adults.

GRACE, developed by researchers from the Indiana University School of Medicine, the Indiana University Center for Aging Research and the Regenstrief Institute Inc., was designed to involve seniors and their primary care physicians in a program to optimize health and functional status, and decrease high-cost emergency department visits and hospital admissions. The JAMA study reports GRACE's success in both improving quality of care and health-related quality of life measures while reducing emergency department use. Hospital admissions also were reduced in the second year of the program in a group at high risk for hospital admission.

GRACE, short for Geriatric Resources for Assessment and Care of Elders, is geriatrics care specifically targeting medically vulnerable individuals. The key to GRACE is two teams. The support team, consisting of a nurse practitioner and a social worker, meet with each patient at 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, physical therapist, mental health social worker, and community-based services liaison) develops 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 health-care plan consistent with the patient's goals, for example maintaining the ability to participate in prized 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 tracking system, the GRACE support team provides ongoing comprehensive care management.

"Rather than concentrating on individual diseases, we focused on the many issues faced by aging low-income adults - access to needed services, medications, mobility, depression, transportation, diet, as well as other health issues of aging," said study leader Steven R. Counsell, M.D., Mary Elizabeth Mitchell Professor of Geriatrics at the IU School of Medicine, IU Center for Aging Research center scientist, and affiliated scientist at the Regenstrief Institute. "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 helped keep seniors from having to use the emergency department."

Dr. Counsell also is director of geriatrics for IU Medical Group which is the physician group responsible for patient care at the health centers of Wishard Health Services where the study was conducted. He also is the director of the IU Center of Excellence in Geriatric Medicine and Training, one of 22 sites supported nationally by the John A. Hartford Foundation.

The JAMA study was funded by the National Institute on Aging, the Nina Mason Pulliam Charitable Trust and Wishard Health Services. Future studies are needed to determine if the reduction in acute care utilization realized through GRACE can offset the program costs.

In addition to Dr. Counsell, coauthors of the JAMA study are Christopher M. Callahan, M.D., Daniel O. Clark, Ph.D., and Wanzhu Tu, Ph.D. of the IU School of Medicine, the Regenstrief Institute and the IU Center for Aging Research; Amna B. Buttar, formerly with the IU Center for Aging Research; Timothy E. Stump, M.S., and Gretchen D. Ricketts, BSW, of the Regenstrief Institute and the IU Center for Aging Research.

Indiana University School of Medicine

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