Hospitals in pursuit of excellence

Better Care for Seniors

Teamwork benefits seniors, too. A partnership between Wishard Health Services?a large safety net health system in central Indiana?Indiana University and local organizations is integrating care for low-income seniors with multiple chronic conditions. Geriatric Resources for Assessment and Care of Elders, or GRACE, provides comprehensive patient assessments by a nurse practitioner and social worker working in collaboration with the primary care physician. They report back to a larger multidisciplinary team led by a geriatrician and including a pharmacist and mental health care manager. Using evidence-based protocols, the team designs individualized care plans. Patients also receive monthly phone calls and home visits after hospitalization or ED visit. A web-based tracking system helps coordinate care among GRACE team members and ensures implementation of planned interventions. Physicians are reimbursed on a fee-for-service schedule, and GRACE team costs are covered by the Medicare Advantage plan, ACO and/or hospital. A randomized controlled trial showed fewer ED visits, inpatient hospitalizations and readmissions for GRACE participants at high risk of hospitalization. By its second year, GRACE saved about $1,500 per patient. Quality of life also was ranked higher by participants, and they and their primary care physicians were highly receptive to this model of team-based care. For more information, contact Steven Counsell, M.D., at scounsel@iupui.edu. To access the AHA Committee on Research report Caring for Vulnerable Populations, go to www.aha.org/research/cor/.