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Geriatric Resources for Assessment and Care of Elders (GRACE) Model

An Effective Practice

Description

The Geriatric Resources for Assessment and Care of Elders (GRACE) Model aims to provide personalized primary health care for low-income seniors. The GRACE model involves a GRACE support team, consisting of an advanced practice nurse and social worker, as well as the patient’s primary care physician and a geriatrics interdisciplinary team.The program includes components such as initial and annual in-home comprehensive geriatric assessments; individualized care plan developed by a geriatrician and including a team of a pharmacist, physical therapist, mental health social worker, and community-based services liaison; weekly GRACE team meetings to review patients care plan; and ongoing GRACE support team care management and coordination of care supported by an electronic medical record and Web-based tracking system.

Goal / Mission

The goal of the GRACE model is to increase quality of care for low-income seniors.

Impact

The GRACE model has been shown to improve quality of care and health outcomes in low-income seniors.

Results / Accomplishments

The GRACE model has been shown to improve quality of care and health outcomes in low-income seniors. It has also recently been shown to be cost neutral from the health care delivery system perspective.

About this Promising Practice

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Topics
Health / Older Adults
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Target Audience
Older Adults