IU and Regenstrief GRACE study selected as landmark article in care of older adults

  • Dec. 15, 2014

INDIANAPOLIS -- The seminal 2007 GRACE study from the Indiana University Center for Aging Research and the Regenstrief Institute has been identified as one of 27 studies conducted over the past quarter century that have helped shape the practice of geriatric medicine. The GRACE study involved community-dwelling seniors and their primary-care physicians in a team approach to optimize health and decrease cost of care.

"Identifying Landmark Articles for Advancing the Practice of Geriatrics," which highlighted the GRACE study as groundbreaking and influential work, appears in the November 2014 issue of the Journal of the American Geriatrics Society (J Am Geriatr Soc. 2014; 62:2159-2162).

GRACE, the unique home-based geriatric care program designed by IU Center for Aging Research, Regenstrief and Eskenazi Health (then known as Wishard Health Services) researchers to keep older adults in their homes, resulted in higher-quality medical care, improvement in quality of life and fewer emergency department visits for a medically and economically vulnerable population. In GRACE's second year, hospital admissions were reduced for the sickest group of patients enrolled in the program. 

The core elements of GRACE, short for Geriatric Resources for Assessment and Care of Elders, can be effectively used by various types of health care systems. To date, the IU Geriatrics GRACE Training and Resource Center has engaged over 300 physicians nationwide to use the home-based care model now officially known as GRACE Team Care. In addition to Indiana, GRACE Team Care is offered at a growing number of medical centers from California to Georgia, including at several hospitals in the Veterans Affairs health care system. Blue Cross Blue Shield of Michigan has made GRACE Team Care training the foundation of its High Intensity Care Management program.

"The original GRACE study focused on low-income seniors and found that it decreased their need to go to the emergency department and hospital -- good for vulnerable frail elders and good for the health care system. Now GRACE Team Care is offered to adults of all income levels," said Steven Counsell, M.D., who developed GRACE and was the lead author on the landmark GRACE study.

"The problems of older adults with complex health care needs are universal: multiple chronic conditions predicted to have high health care utilization. And regardless of income level, many older adults need help managing complex medication regimes, dealing with the tasks of daily living like bathing and dressing and facing multiple health issues," said Dr. Counsell, who is an IU Center for Aging Research scientist, a Regenstrief Institute affiliated scientist and the Mary Elizabeth Mitchell Professor and director of geriatrics at the IU School of Medicine.

GRACE focuses on the many issues faced by older adults: access to needed services, transportation, mobility, diet, medications and depression, as well as the chronic health issues of aging. The key to GRACE is its two-team approach.

The support team, consisting of a nurse practitioner and a social worker, meets with patients in their home to conduct an initial comprehensive geriatric assessment “from the medicine cabinet to the kitchen cabinet.” Based on the support team's findings, a larger interdisciplinary team -- including a geriatrician, pharmacist and mental health expert -- develops an individualized care plan.

Then the ball is back in the support team's court. The nurse practitioner and the social worker meet with the patient's primary care doctor to review the care plan consistent with the patient's goals -- for example, maintaining the ability to participate in prized social and religious activities. The support team then works with the patient to implement the plan that contains strategies for medical issues of concern as well as elements related to maintaining quality of life. With the assistance of an electronic medical record and tracking system, the GRACE support team provides ongoing comprehensive care management in collaboration with the primary-care doctor. 

According to Dr. Counsell, GRACE Team Care is constantly evolving to meet the needs of what he notes is the most rapidly growing segment of the U.S. population. According to U.S. Census Bureau projections, the population of those age 65 and older is expected to more than double between 2012 and 2060, from 43.1 million to 92.0 million.

Those 65 and older will account for about one in five U.S. residents by the end of the period, up from one in seven in 2012. The increase in the number of the “oldest old” will be even more dramatic: those age 85 and older are projected to more than triple, from 5.9 million to 18.2 million, reaching 4.3 percent of the U.S. total population.

The original GRACE study was conducted at health centers of Eskenazi Health in Indianapolis. The randomized controlled trial enrolled 951 low-income seniors with an average age of 72; 477 received usual care, and 474 participated in GRACE. Both groups were predominately female and African-American.

The GRACE study was published in the Journal of the American Medical Association in December 2007. In addition to Dr. Counsell, co-authors of the JAMA paper were Christopher M. Callahan, M.D., Daniel O. Clark, Ph.D., and Wanzhu Tu, Ph.D. of the IU Center for Aging Research, the Regenstrief Institute and the IU School of Medicine; Amna B. Buttar, MBBS, formerly with the IU Center for Aging Research; and Timothy E. Stump, M.S., and Gretchen D. Ricketts, BSW, formerly with the Regenstrief Institute and the IU Center for Aging Research. Dr. Callahan is the founding director of the IU Center for Aging Research.  

A July 2009 follow-up analysis published in the Journal of the American Geriatrics Society reported that GRACE is cost effective. By the second year, GRACE started to save money for the sickest group of patients because of the marked reduction in the need for hospital care.

The GRACE study was funded by the National Institute on Aging, the Nina Mason Pulliam Charitable Trust and Eskenazi Health.

Steven Counsell, M.D.

Steven Counsell, M.D.

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Cindy Fox Aisen