Priorities in Action: The Lourie Center for Children's Social and Emotional Wellness

Priorities in Action: The Lourie Center for Children's Social and Emotional Wellness

GRACE Team Care

Issue Background

Patients receiving medical care in today's complex health system often interact with many physicians, nurses, medical assistants, and other trained professionals across multiple care settings—a situation especially true for the sickest populations. The Centers for Disease Control and Prevention recently estimated that 25 percent of the U.S. population has multiple chronic conditions—a number that rises to 75 percent of adults over age 65.¹ Treatment costs for Americans with multiple chronic conditions account for nearly 70 percent of the Nation's annual health care costs.²

Successful delivery of coordinated care among health care providers has been shown to improve health care quality and outcomes and to decrease health care costs. Early studies of new care delivery models prominently featured in the Patient Protection and Affordable Care Act, including patient-centered medical homes and accountable care organizations, show promise for rapidly advancing the quality of coordinated health care delivered to Americans with multiple chronic conditions by restructuring patients' relationships with their primary care physicians.³

About the GRACE Team Care Model

Geriatric Resources for Assessment and Care of Elders (GRACE) Team Care, was initially developed and implemented more than a decade ago by the Indiana University School of Medicine's Center for Aging Research.

Designed as a promising solution to the health and health care challenges faced by low-income seniors with multiple chronic conditions, researchers at Indiana University developed the GRACE Team Care model  to assist primary care physicians (PCPs) working with low-income seniors to optimize health and functional status, decrease excess usage of health care services, and prevent unnecessary long-term nursing home placement.

Overview of Activities

The GRACE Team Care enrollment process begins when an elderly individual receives a comprehensive in-home assessment performed by a nurse practitioner and social worker (the GRACE Support Team). This two-person team is responsible for coordinating ongoing care for the person. This team brings information learned at the in-home assessment back to an expanded GRACE team, which is led by a geriatrician and includes a pharmacist and mental health liaison who is typically a licensed clinical social worker. This larger interdisciplinary team puts together a carefully tailored care plan based on evidence-based care protocols for 12 common geriatric conditions ranging from proper medication management to vision and mobility issues to depression.  A person who has experienced many falls in the past, for example, will receive recommendations about stopping medications that might contribute to falls, checking their vision, and obtaining a physical therapy referral for strength and balance exercises.  This person will also receive lessons on how to avoid falls, if possible, and recover from them when and if they occur.⁴

After the expanded team develops a care plan for the GRACE Team enrollee, the GRACE Support Team meets with the patient's PCP to review and discuss the plan. Once the plan is finalized, the support team performs a second in-home visit to align the care plan with the person's individual goals and preferences and to determine logistics with the person and any appropriate caregivers.

GRACE enrollees are seen by their GRACE Support Team as needed to implement the care plan and provide ongoing care management.  At a minimum, enrollees are contacted by phone by their care team at least once a month. After any hospitalizations or emergency department visits, the GRACE Support Team will do additional home visits, and the larger interdisciplinary team will review the individual's care plan to assess whether any changes need to be made and if the team could have prevented the patient's hospitalization.  Prearranged reviews of the care plan are built into the model at 3 and 6 weeks as well as 3, 6, 9, and 12 months.

A particular focus of the model is on care transitions, which can cause serious issues for senior citizens with multiple chronic conditions. The GRACE Team nurse practitioner and social worker together serve as advocates for the person receiving care, wherever it may happen. If a GRACE enrollee is admitted to the hospital, the GRACE Support Team communicates the person's baseline status, health care goals, and care plan to the hospital staff and informs the patient's PCP of their hospital admission. The support team continually collaborates with hospital staff to develop an effective care transition plan before the patient's discharge. The Support Team then ensures that the plan is fully implemented—for example, that home-based physical therapy or other recommended home care takes place. The nurse practitioner also reconciles medications and provides the patient with easy-to-understand medication instructions. For patients admitted to a nursing home, the GRACE team communicates relevant health information and care with the nursing home physician. A long-term goal of the GRACE model is to have the patient return home from hospitalization of any sort with adequate support, both to promote the patient's happiness and well-being and to save on high-cost nursing home and acute care services.

Results

A randomized controlled clinical trial published in the Journal of the American Medical Association demonstrates that the GRACE Team Care model delivers better, more affordable care to senior citizens with multiple chronic conditions. The Indiana University Center for Aging Research conducted a multi-year randomized controlled clinical trial of the care model, which aimed to test whether or not the model delivered improved quality and outcomes of care for low-income seniors in primary care. A total of 951 adults ages 65 and older, whose incomes were less than 200 percent of the Federal poverty level, were enrolled in the 2-year study with 474 patients receiving the GRACE Team Care intervention and 477 patients receiving usual care in community-based health centers.⁵

The trial demonstrated that high-risk senior citizens enrolled in GRACE had fewer hospitalizations, hospital readmissions, and emergency department visits, as well as reduced hospital costs.⁶In the first and second years, respectively, GRACE enrollees at highest risk of hospitalization had sustained a 12 percent and 44 percent lower risk of hospitalization compared to the control group. A cost analysis of the intervention found that, for high-risk patients, increases in chronic and preventive care costs were offset by reductions in acute care costs.⁷ In the following year after the intervention ended, the model continued to reduce costs for those enrolled.⁸ The GRACE model also received high ratings by physicians for effectively meeting the needs of older patients, and better ratings on quality indicators for both general health and geriatric conditions. Quality–of-life ratings were also higher for GRACE patients.⁹

The model's successes, demonstrated in peer-reviewed journal articles and clinical trials, has led to implementation of the model in organizations across the country. A study published in February 2016 in PLoS One took key facets of the GRACE Team Care model and expanded the patient pool to also include younger patients down to age 18 with multiple chronic conditions in a major urban academic medical center. Evaluation of the adapted care model found significant declines in the median number of emergency department visits and hospitalizations, as well as increases in the number of enrollees reporting better self-health.¹⁰  Since its initial implementation at Indiana University, GRACE Team Care has been adapted to fit a wide variety of patient populations with multiple chronic conditions, across diverse health care settings, while maintaining positive results with regard to patient and caregiver satisfaction, health care quality indicators, and health care service utilization. The Indiana University team behind GRACE Team Care currently offers a variety of technical assistance tools and support options for organizations and health care systems looking to implement the model.¹¹

Alignment to the National Quality Strategy

These efforts promote effective communication and care coordination through both the Innovation and Diffusion lever and the Learning and Technical Assistance lever.

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¹ Centers for Disease Control and Prevention. Multiple Chronic Conditions Fact Sheet. http://www.cdc.gov/chronicdisease/about/multiple-chronic.htm
² Agency for Healthcare Research and Quality. Multiple Chronic Conditions. http://www.ahrq.gov/professionals/systems/long-term-care/resources/multichronic/mcc.html
³ National Committee for Quality Assurance. Latest Evidence: Benefits of the Patient-Centered Medical Home.https://www.ncqa.org/Portals/0/Programs/Recognition/NCQA%20PCMH%20Evidence%20Report,%20June%202015.pdf
⁴ Counsell SR, Callahan CM, Buttar AB, et al. Geriatric Resources for Assessment and Care of Elders (GRACE): A New Model of Primary Care for Low-Income Seniors. Journal of the American Geriatrics Society. 2006; 54(7):1136-41.
⁵ Counsell SR, Callahan CM, Clark DO, et al. Geriatric care management for low-income seniors: a randomized controlled trial. JAMA. 2007 Dec 12;298(22):2623-33.
⁶ See footnote 5.
⁷ Counsell SR, Callahan CM, Tu W, et al. Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention. J Am Geriatr Soc. 2009; 57(8):1420-6.
⁸ See footnote 7.
⁹ See footnote 5.
¹⁰ Ritchie C, Andersen R, Eng J, et al. 2016; Implementation of an Interdisciplinary, Team-Based Complex Care Support Health Care Model at an Academic MedicalCenter: Impact on Health Care Utilization and Quality of Life. PLoS ONE 11(2):e0148096. doi:10.1371/journal.pone.0148096

¹¹ Indiana University. GRACE Team Care Training and Technical Assistance Tools. http://graceteamcare.indiana.edu/tools-support.htmlWorking for Quality