A home-based geriatric care program for low-income seniors resulted in higher-quality medical care, improvement in quality of life and fewer emergency department visits, but did not appear to prevent decline in physical functioning, according to a study in the December 12 issue of JAMA.
Low-income seniors frequently have chronic medical conditions and limited access to health care. Older adults in general, and especially the poor, often do not receive the recommended standard of care for preventive services and management of chronic diseases. "These patient groups have been understudied in previous trials and represent a complex and high-cost population that might especially benefit from improved coordination and integration of their health care," the authors write.
The Geriatric Resources for Assessment and Care of Elders (GRACE) model of primary care was developed specifically to improve the quality of care for low-income seniors. Features of the GRACE intervention include in-home assessment and care management provided by a nurse practitioner and social worker team; extensive use of specific care protocols for evaluation and management of common geriatric conditions; utilization of an integrated electronic medical record and a Web-based care management tracking tool; and integration with affiliated pharmacy, mental health, home health, community-based and inpatient geriatric care services.
Steven R. Counsell, M.D., of the Indiana University School of Medicine, Indianapolis, and colleagues conducted a study to test the effectiveness of the GRACE intervention on health outcomes for 951 low-income adults 65 years or older. The participants' primary care physicians were randomized from January 2002 through August 2004 to participate in the intervention (474 patients) or usual care (477 patients) in community-based health centers. Patients received two years of home-based care management by a nurse practitioner and social worker who collaborated with the primary care physician and a geriatrics interdisciplinary team and were guided by 12 care protocols for common geriatric conditions.
Analysis of the results indicated significant improvements for intervention patients compared with usual care at 24 months in several measurements, including general health, vitality, social functioning and mental health. No group differences were found for physical function outcomes or death. The two-year emergency department visit rate was lower in the intervention group, but hospital admission rates were not significantly different between groups.
In a pre-defined group at high risk of hospitalization (consisting of 112 intervention and 114 usual-care patients), emergency department visit and hospital admission rates were lower for intervention patients in the second year.
"Future studies should compare potential cost savings from less acute care utilization with program costs to determine feasibility. Under current fee-for-service Medicare, most of the services provided by the GRACE intervention are not reimbursed. Medicare managed care, however, presents a financial vehicle under which the GRACE intervention could currently be supported," the researchers write.
"We hope the GRACE model will prove to be a practical health system innovation that will contribute to improved geriatric care and outcomes while reducing high-cost acute care utilization in low-income seniors."
(JAMA. 2007;298(22):2623-2633. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
Editorial: Better Care for Older People With Chronic Diseases - An Emerging Vision
In an accompanying editorial, David B. Reuben, M.D., of the University of California, Los Angeles, writes that research has indicated what is important to deliver optimal health care for older persons with chronic diseases.
"First, care must be personalized to meet each patient's goals, values, and resources. ... Second, care should be provided in accordance with best practices. ... Third, physicians cannot do the job alone. Team care, which has been a hallmark of geriatrics, is essential for providing high-quality care for patients of all ages who have chronic diseases."
Dr. Reuben adds that other important points include coordinating care among those caring for patients; care must consider the resources and environment of the person; and older persons must be included as active partners in their care except when they are too frail, mentally or physically.
"These principles fit well within the chronic care model, a construct that espouses better health care linked to community-based services. If the chronic care model is followed, patients become more informed and activated and practice teams are more prepared to be proactive, which should result in improved clinical and functional outcomes. Implementing this type of care requires staff, support systems, and a payment mechanism."
(JAMA. 2007;298(22):2673-2674. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Please see the article for additional information, including financial disclosures, funding and support, etc.
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