A Saving Grace For Seniors

The healthcare needs of a senior citizen are not the same as those of a 3-year old, or even a 43-year old. Older patients are likely to have several chronic conditions. In fact, more than half of Medicare beneficiaries are treated for five or more chronic conditions, and the average Medicare patient has two primary care doctors and five specialists! It takes a particular blend of training and insight to provide the best care to elderly patients. And it takes an even more focused effort to care for those whose income level is such that they may avoid routine doctor visits or may not be able to afford the assistance they need.

An innovative program to improve the health care of low-income seniors was developed in Indiana and is being replicated across the country. It’s called GRACE — Geriatric Resources for Assessment and Care of Elders, and it has been a saving grace for thousands of older Hoosiers and their caregivers.

GRACE is a team-care model designed by the Indiana University School of Medicine’s Center for Aging Research. It began with a pilot study at Wishard Health Services in 1999. The National Institutes of Health funded a randomized controlled trial at Wishard in 2002, and the clinical trial results were featured in the Journal of the American Medical Association (JAMA) in 2007. Since then, GRACE programs have been started at Indianapolis VA Medical Center, the Indiana ADRC Care Transitions Program, and Indiana University Health, as well as in other states.

How does the GRACE program work? It typically starts with a comprehensive in-home assessment by a nurse practitioner and a social worker. They relay the information to a larger team, led by a geriatrician (specialist in health care for the elderly), a pharmacist, physical therapist, mental health professional and expert in community resources. This group puts together a comprehensive care plan for the individual, covering medication management, depression, mobility issues, vision troubles, and other conditions common to older people. This plan is communicated to the patient’s primary care physician and to family members. It may include practical advice on health and safety and assistance with transportation.

GRACE patients are contacted by phone at least once per month. If the patient has to go to the emergency room or be admitted to the hospital, the team follows up with home visits and reassesses the care plan. If the patient is admitted to a nursing home, the GRACE team coordinates care with staff at the facility, with the ultimate goal of returning the individual to their home.

Patients receiving this type of team care have better general health and fewer geriatric conditions such as falls and depression. Among high risk patients, those enrolled in GRACE have fewer emergency department visits, decreased number of hospitalizations, fewer hospital readmissions, and reduced hospital costs.

Read more about the GRACE team-care model.

At McNeely Stephenson, we have our own team-care approach to helping Indiana senior citizens. If you or your elderly loved one has been harmed by a healthcare provider, has been the victim of abuse or neglect in a nursing home, or has suffered a fall due to the negligence of a property owner, call us at 1-317-825-5200. Hand the worry over to us; we won’t let you down.