AHRQ Innovations Exchange | 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

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

Snapshot
Summary
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 inperson 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.

See the the Results section for updated evaluation data and cost effectiveness analysis results (updated August 2009).
Evidence Rating
Strong: The evidence consists of a randomized controlled trial 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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AHRQ Innovations Exchange | 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