Team-Developed Care Plan and Ongoing Care Management by Social Workers and Nurse Practitioners Result in Better Outcomes and Fewer Emergency Department Visits for Low-Income Seniors

Groups Focus On Cutting Hospital Readmission Of Medicare Patients
August 7, 2019
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):1136-1141.
August 7, 2019

Team-Developed Care Plan and Ongoing Care Management by Social Workers and Nurse Practitioners Result in Better Outcomes and Fewer Emergency Department Visits for Low-Income Seniors

Social worker/nurse practitioner teams collaborate with a larger interdisciplinary team and primary care physicians to develop and implement individualized care plans for low-income seniors. The social worker/nurse team also proactively manages and coordinates the patient’s care on an ongoing basis through regular telephone and in-person contact with both patients and providers. The program, known as Geriatric Resources for Assessment and Care of Elders (GRACE), improved the provision of evidence-based care; led to significant improvements in measures of general health, vitality, social functioning, and mental health; reduced emergency department visits and hospital admissions; and generated high levels of physician and patient satisfaction. A recent analysis found that the program was cost neutral for high-risk patients in the first 2 years, and yielded savings by year three. Strong: The evidence consists of a randomized controlled trial (RCT) of 951 patients that compared results for program participants with patients receiving usual care on a variety of metrics (including functional status, activity of daily living status, ED and hospital use, and patient and physician satisfaction).

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