How it Works?

In the GRACE Team Care model, every patient is assigned a support team, composed of a nurse practitioner and social worker, who work closely with the patient, caregiver, and patient’s primary care physician. The support team:

  • Performs an in-home geriatric assessment of each patient.
  • Develops an individualized care plan, with input from a larger interdisciplinary team that includes a geriatrician, pharmacist, mental health professional, and community resource expert.
  • Implements the care plan in collaboration with the primary care physician.
  • Provides ongoing care coordination.
  • Delivers proactive transitional care and integrates new treatments or medications into the care plan if the patient is admitted to the hospital.

GRACE patients also benefit from program elements including:

  • Evidence-based care protocols for evaluation and management of geriatric conditions.
  • An integrated EMR for documentation and communication with physicians.
  • A web-based care management tracking tool for ensuring care plan implementation.
  • Home-based and proactive care management with regular patient contacts.
  • Integration with pharmacy, mental health, and community-based social services.