Background 

The Indiana University School of Medicine’s Center for Aging Research designed and tested the GRACE Team Care model over ten years ago as a potential solution for the health care challenges faced by low-income seniors with multiple chronic medical conditions.

The Center for Aging Research conducted a multi-year randomized controlled clinical trial of 951 adults age 65+ with incomes less than 200% of the federal poverty level. The goal of the research study was to test the effectiveness of this geriatric care management model on improving the quality and outcomes of care for low-income seniors in primary care. The trial enrolled 474 patients who received the GRACE Team Care intervention for two years, while 477 patients received usual care, all in community-based health centers.

Among high risk patients, those enrolled in GRACE had fewer emergency department visits, decreased number of hospitalizations, fewer hospital readmissions, and reduced hospital costs. By the second year GRACE saved money for high risk patients and in the third year, a year after the intervention ended, it saved even more.

GRACE received high ratings by physicians for being helpful in meeting the needs of their 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.

To date, more than 1,500 people have benefited from the GRACE model. GRACE Team Care has been adapted to a variety of patient populations and health care settings, and consistently has positive results on patient and caregiver satisfaction, quality indicators, and acute care utilization. Replications include:

  • HealthCare Partners Medical Group – Los Angeles, CA (House Calls Program)
  • Indianapolis VA Medical Center – Indianapolis, IN (Transitional Care Program)
  • Indiana ADRC Care Transitions Program – Indianapolis, IN (Community-Based Organization Partnership and Care Transitions Program)
  • Indiana University Health MA Plan and ACO – Indianapolis, IN (Medical Home Program)

Replications scheduled for 2013 include:

  • University of California, San Francisco – San Francisco, CA
  • Health Plan of San Mateo – San Mateo County, CA
  • Whittier Hospital Medical Center – Whittier, CA
  • San Francisco VA Medical Center – San Francisco, CA
  • Cleveland VA Medical Center – Cleveland, OH