Geriatric Resources for Assessment and Care of Elders.

GRACE is not designed to assume the role of the primary care provider. The GRACE nurse practitioner and social worker (GRACE Support Team) works closely with the patient’s primary care physician to complement and support the physician and their office staff.

Caseload projections vary depending on a number of factors including patient complexity, time of enrollment (e.g., care transition vs. physician referral), new vs. established, etc. In general, a combined caseload of approximately 100 patients is anticipated for each nurse practitioner and social worker support team.

The GRACE program was originally developed as a longitudinal model. However, GRACE has been replicated in a number of settings as a care management program with an average length of stay of 12 months (range of 6-18 months depending upon individual patient needs and progress towards achieving care goals).

The GRACE Support Team is made up of a nurse practitioner and social worker. The support team meets weekly with the expanded GRACE Interdisciplinary Team to review patient care plans and progress towards meeting patient goals. The GRACE Interdisciplinary Team, in addition to including the GRACE Support Team(s), is composed of a geriatrician/physician medical director, pharmacist, mental health liaison, and community resource expert.

No, a physician with experience and expertise in geriatric care principles and interdisciplinary team care can serve in the role of the GRACE Medical Director on the GRACE Interdisciplinary Team.

Yes, the issues presented by complex older patients are optimally addressed with input from health professionals representing these disciplines and integration of these components of the health care system with primary care.

No, the GRACE Training and Resource Center offers training and support tailored to your organization’s needs.

Keys to the success of GRACE Team Care in improving the quality and outcomes of care include: 1) Each GRACE Support Team is assigned to specific primary care physicians to develop strong collaborative relationships with the physicians and their office staff; 2) The GRACE care protocols and work of the GRACE team are focused on geriatric conditions and psychosocial issues and thus complement and support the care provided by the primary care physician; and 3) The weekly team conference provides a forum for interdisciplinary patient care planning, care coordination, and accountability for care plan implementation and follow-up.

To learn more about the GRACE Team Care model, contact Dawn Butler, Director of the GRACE Training and Resource Center at butlerde@iu.edu or (317) 880-6577.