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Elder Care News
Home Intervention Program Makes Life Better for
Low-Income Elderly
GRACE program developed to improve quality of care
for low-income seniors
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link below news story. |
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Dec. 12, 2007 - A home-based geriatric care program
for low-income seniors resulted in higher-quality medical care,
improvement in quality of life and fewer emergency department visits,
but did not appear to prevent decline in physical functioning, according
to a study in the December 12 issue of the Journal of the American
Medical Association (JAMA).
Low-income seniors frequently have chronic medical
conditions and limited access to health care. Older adults in general,
and especially the poor, often do not receive the recommended standard
of care for preventive services and management of chronic diseases.
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These patient groups have been understudied in
previous trials and represent a complex and high-cost population that
might especially benefit from improved coordination and integration of
their health care, according to the article.
The Geriatric Resources for Assessment and Care of
Elders (GRACE) model of primary care was developed specifically to
improve the quality of care for low-income seniors.
Features of the
GRACE intervention include in-home assessment and care management
provided by a nurse practitioner and social worker team; extensive use
of specific care protocols for evaluation and management of common
geriatric conditions; utilization of an integrated electronic medical
record and a Web-based care management tracking tool; and integration
with affiliated pharmacy, mental health, home health, community-based
and inpatient geriatric care services.
Steven R. Counsell, M.D., of the Indiana University
School of Medicine, Indianapolis, and colleagues conducted a study to
test the effectiveness of the GRACE intervention on health outcomes for
951 low-income adults 65 years or older.
The participants primary care physicians were
randomized from January 2002 through August 2004 to participate in the
intervention (474 patients) or usual care (477 patients) in
community-based health centers. Patients received two years of
home-based care management by a nurse practitioner and social worker who
collaborated with the primary care physician and a geriatrics
interdisciplinary team and were guided by 12 care protocols for common
geriatric conditions.
Analysis of the results indicated significant
improvements for intervention patients compared with usual care at 24
months in several measurements, including general health, vitality,
social functioning and mental health. No group differences were found
for physical function outcomes or death.
The two-year emergency department visit rate was
lower in the intervention group, but hospital admission rates were not
significantly different between groups.
In a pre-defined group at high risk of
hospitalization (consisting of 112 intervention and 114 usual-care
patients), emergency department visit and hospital admission rates were
lower for intervention patients in the second year.
Future studies should compare potential cost
savings from less acute care utilization with program costs to determine
feasibility. Under current fee-for-service Medicare, most of the
services provided by the GRACE intervention are not reimbursed. Medicare
managed care, however, presents a financial vehicle under which the
GRACE intervention could currently be supported, the researchers write.
We hope the GRACE model will prove to be a
practical health system innovation that will contribute to improved
geriatric care and outcomes while reducing high-cost acute care
utilization in low-income seniors.
Editorial: Better care for older people with
chronic diseases an emerging vision
In an accompanying editorial, David B. Reuben,
M.D., of the University of California, Los Angeles, writes that research
has indicated what is important to deliver optimal health care for older
persons with chronic diseases.
First, care must be personalized to meet each
patients goals, values, and resources.
Second, care should be
provided in accordance with best practices.
Third, physicians cannot
do the job alone. Team care, which has been a hallmark of geriatrics, is
essential for providing high-quality care for patients of all ages who
have chronic diseases.
Dr. Reuben adds that other important points include
coordinating care among those caring for patients; care must consider
the resources and environment of the person; and older persons must be
included as active partners in their care except when they are too
frail, mentally or physically.
These principles fit well within the chronic care
model, a construct that espouses better health care linked to
community-based services. If the chronic care model is followed,
patients become more informed and activated and practice teams are more
prepared to be proactive, which should result in improved clinical and
functional outcomes. Implementing this type of care requires staff,
support systems, and a payment mechanism.
GRACE, short for Geriatric Resources for Assessment
and Care of Elders, was developed by researchers from IU Geriatrics of
the Indiana University School of Medicine, the Indiana University Center
for Aging Research and the Regenstrief Institute, Inc.
>> More about
the research at Indiana University
>>
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