Fragmentation of care is common among Medicare beneficiaries, half of whom receive treatment for five or more chronic conditions each year. Comprehensive, coordinated care—particularly during transitions in care—has the potential to improve health outcomes and lower the cost of care.
Geriatric Resources for Assessment and Care of Elders (GRACE) conducts in-home assessments using a team with nurse practitioner and a social worker to develop individualized care plans for low-income seniors, many of whom are eligible for Medicare and Medicaid and most of whom have multiple chronic conditions. The team, which is responsible for coordinating patient care on an ongoing basis, collaborates with a broader group of providers including a geriatrician, a pharmacist, a physical therapist, and a mental health worker. A Web-based care management tracking system supports coordination and continuity of care among the health care professionals and sites of care.
The two-year intervention—developed by Wishard Health Services in Indiana—saved $1,500 per enrolled high-risk patient by the second year. For patients at the highest risk of hospitalization, GRACE reduced hospital admission rates by 12 percent and 44 percent in the first and second years of the program. GRACE patients also reported higher quality of life compared with the control group.