Geriatric Resources for Assessment & Care of Elders (GRACE)

Notes

• provides home-based care by working with the patient's primary care physician
• GRACE team consists of a nurse practitioner & a social worker
• comprehensive geriatric assessment by GRACE team on enrollment
• GRACE team works with larger mulitdisciplinary team (including geriatrician, pharmacist, physical therapist, & mental health social worker) to formulate individualized care plan
• GRACE described as enhanced primary care
• GRACE team provides ongoing management & care coordination
• focus of GRACE is assisting in care transitions
• GRACE provides additional home visits after any hospitalization or emergency department visit.
• GRACE model improves quality of care & reduces emergency department visits, hospitalizations & 30-day hospital readmissions
• GRACE may be appropriate vs PACE when patient cannot leave home
• elderly may remain at risk when the GRACE team leaves