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Case for Grace

The GRACE Team Care model is already helping hundreds of older adults in communities across the United States. While GRACE has been adapted to a variety of patient populations and health care settings, it has consistently improved patient and caregiver satisfaction, quality indicators, and acute care utilization. GRACE uses a dashboard to monitor quality indicators and help partners reach targeted quality goals. Organizations using GRACE Team Care have reduced emergency department visits, hospital admissions, 30-day readmission rates, and admissions to skilled nursing facilities. Learn more about how GRACE Team Care is working in a wide range of care sites by clicking on any of the stories below:

HealthCare Partners Medical Group in Southern California implemented GRACE Team Care for homebound managed care Medicare beneficiaries age 70+ having multiple chronic illnesses. The model received high satisfaction ratings from physicians and professional staff, who indicated that GRACE increased overall patient satisfaction, improved quality of life, and led to better follow-up and coordination of care. Compared to the year before, patients receiving GRACE Team Care had a 22 percent reduction in emergency department visits, 34 percent reduction in hospital admissions, and 29 percent reduction in hospital-bed days. Substantial reductions in skilled nursing facility (SNF) use also occurred among patients receiving GRACE Team Care.

The Indianapolis VA Medical Center is using GRACE Team Care as a care transition program and intensive medical home model for older Veterans. Veterans are eligible for GRACE Team Care following an emergent hospital admission and discharge home. Veterans first receive a transitional home visit by the GRACE Support Team that focuses on ensuring the hospital transition plan is implemented, providing medication reconciliation, and reconnecting the patient with their primary care physician. Subsequently, the GRACE Support Team completes the in-home geriatric assessment, develops an individualized care plan, and provides the traditional model of GRACE Team Care. The VA model has led to a 46 percent reduction in the 30-day hospital readmission rate and a 45 percent reduction in the hospitalization rate.

GRACE Team Care featured as a new Veterans Administration home based care option.

Under the Affordable Care Act, funding was provided to expand Aging and Disability Resource Centers (ADRCs). The Administration on Aging and Center for Medicare and Medicaid Services issued a grant opportunity for ADRC Evidence-Based Care Transition Programs. The GRACE model was one of four evidence-based models states could choose to implement through this grant. Indiana received a two-year grant using the GRACE model to provide care transitions to patients admitted to Wishard Health Services, a public safety net hospital in Indianapolis. The social worker from the ADRC served as the GRACE social worker and in some cases also assumed the role of Medicaid Home and Community-Based Services waiver case manager. Working in collaboration with the nurse practitioner from the medical group, this care transition model has helped integrate medical and social services more fully in older patients with complex needs and reduced by their hospital 30-day readmission rate to less than 10 percent.

Indiana University (IU) Health has recently implemented GRACE Team Care as a part of their Medicare Advantage (MA) Plan and Accountable Care Organization (ACO) to improve quality of care and outcomes in older primary care patients. Modeled after the VA program, GRACE at IU Health targets older patients who have been hospitalized on the medicine service at IU Health Methodist Hospital in Indianapolis. GRACE provides transitional care followed by longitudinal care management in collaboration with the patient’s primary care physician and medical home. Although relatively early in the start-up, physician acceptance of the program is high and hospital readmission rates are trending downward which has prompted plans to expand the program.