Living Independently with GRACE: A Care Management Model for Older Adults with Complex Needs
Doug McCarthy
Advocating for people, the planet, and prosperity for everyone in southwest Colorado
The complex needs of older adults typically involve both medical and social issues. And coordinating care for older patients, especially those living independently, can be challenging for providers.
In the latest of a series of case studies on models of care for high-need, high-cost patients published by the Commonwealth Fund, we provide an in-depth overview of the Geriatric Resources for Assessment and Care of Elders (GRACE) model and look at the experiences of four diverse sites that replicated it: HealthCare Partners in Los Angeles, UCSF Health in San Francisco, Indiana University Health Plans in Indianapolis, and Blue Cross of Blue Shield of Michigan and its affiliated provider organizations.
Developed by geriatrician Steven Counsell, M.D., at Indiana University School of Medicine, the GRACE model offers an integrated approach to engaging patients as partners in identifying and achieving their health goals at home. In a 2007 pilot, GRACE patients at higher risk for hospitalization had a 44 percent lower rate of admission by the second year. Replication sites also reported positive outcomes.
Amid a growing number of care management programs, the GRACE model stands out for its enhanced primary care, with a focus on geriatric conditions and medication management, and its integrated approach to meeting health and social needs.?
Nurse Informaticist / Clinical Advisor/ Clinical Informatics / Clinical Quality Improvement
3 年Seems like a great concept requiring much broader application.