Care That Works: GRACE

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Innovations in how to best care for people with complex health and social needs are happening across the country. Our “Care That Works” series seeks to examine and elevate these successful programs and share the stories of the people they serve.

The latest brief in this series, “Care That Works: GRACE,” profiles the Geriatric Resources for Assessment and Care of Elders program (GRACE) developed and implemented more than a decade ago by the Indiana University School of Medicine’s Center for Aging Research. This home-based care program supports the office-based primary care physician in helping address the health care challenges faced by low-income seniors with multiple chronic conditions. The model utilizes a home support team consisting of a nurse practitioner and a social worker. They, in turn, collaborate with a larger interdisciplinary team (including a geriatrician, pharmacist and mental health liaison) to develop an individualized care plan including activation of the GRACE protocols for evaluating and managing common geriatric conditions. A particular focus of the model is on care transitions, which can cause serious issues for older adults with multiple chronic conditions. The brief shares the story of 81-year-old GRACE participant, Ms. Helen Carson.

Read the Brief