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 team provides ongoing management & care coordination
• GRACE model improves quality of care & reduces emergency department visits, hospitalizations & 30-day hospital readmissions