Leveraging resources improves care for seniors
Program cuts admissions, ED visits
A program that integrates care between the hospital, primary care providers and the community has reduced readmissions and emergency department visits by at-risk low-income seniors served by Wishard-Eskenazi Health, a large safety net health system with headquarters in Indianapolis.
The system includes Wishard Memorial Hospital, a 350-bed facility on the Indiana University Medical Center Campus, 10 community health centers, and a mental health division.
The hospital staff and Indiana University Center for Aging Research investigators developed the Geriatric Resources for Assessment and Care of Elders (GRACE) program because of the need for more geriatric care in the primary care setting, says Dawn Butler, MSW, JD, director of the Indiana University GRACE Training and Resource Center based at Wishard-Eskenazi Health.
"Our patient population is getting older, and there is a lack of geriatric care available in the area. We developed this program as a way to take a small geriatric work force to help primary care physicians manage the care of seniors," she says.
In a two-year study, patients who received the GRACE intervention showed significant improvement in health-related quality-of-life measures compared to patients who received the usual care. Patients who received the interventions experienced a reduction in emergency department visits over the two-year period, and those at high risk for repeat hospitalizations experienced a reduction in hospital admissions in the second year.
Older adults in general, especially the poor, often do not receive the recommended standard care for preventive services, chronic disease management, and geriatric syndromes, in part because most primary care practices do not have geriatric specialists on staff or the time and resources needed, says Steven R. Counsell, MD, chief of geriatrics and medical director for Wishard-Eskanazi Health Senior Care and director of the Indiana University Geriatrics Program at the Indiana University School of Medicine.
The GRACE program is a way to share the expertise of the hospital’s geriatric staff with primary care providers to ensure that patients get the specialized care they need, he says.
"Through close collaboration between hospital clinicians and primary care providers, the limited resources of geriatricians and geriatrics interdisciplinary team can be leveraged for the greatest impact on patient outcomes," he adds.
The senior population is growing in this country, as someone turns 65 every seven seconds, adds Kathy Frank, RN, PhD, geriatrics program administrator at Indiana University School of Medicine. "Patients are living longer, which means that many have chronic conditions and chronic problems that include falling, dementia, incontinence, and depression. This is a unique population that has medical problems and psychosocial issues as well. The people we serve may have memory loss, hearing impairment, caregiver issues, and financial problems," she says.
The GRACE model was developed around Acute Care for Elders (ACE), an inpatient program that provides care geared to the special needs of the elderly. Seniors who are hospitalized at Wishard Memorial Hospital are often seen by the ACE consult team, an interdisciplinary team of geriatric specialists that includes a geriatrician, nurse practitioners, a nurse case manager, a pharmacist, a social worker, a physical therapist, and an occupational therapist. When they are ready for discharge, the patients are referred to the GRACE team.
Once patients are discharged, the GRACE team’s nurse practitioner and social worker complete a comprehensive geriatric assessment in the home. The nurse practitioner conducts a physical examination and reconciles the patient’s medication. The social worker’s assessment includes psychosocial issues, functional abilities, caregivers, home safety, depression, and a cognitive screen. They work with the patient to set goals that may range from getting the heat or water turned back on to having a family meeting to discuss end-of-life options. Pain control is a frequent choice as a goal, Butler says.
The team goes back to the hospital and collaborates with a geriatrician to develop an individual care plan following the GRACE protocol. Other members of the interdisciplinary GRACE team, including a mental health social worker, a pharmacist, and community-based services liaison, review their findings and goals of the patient and add to the plan of care. When the final care plan has been developed, the nurse practitioner and social worker meet with the patient’s primary care physician and share information on what they found in the home, the patient’s goals, and the care plan. The physician has the opportunity to give input and to approve the plan or suggest changes.
After the primary care physician approves the plan of care, the social worker and nurse practitioner sit down with the patient and family to go over the plan and to discuss the patient’s medication. "We review the medications and confirm what they are supposed to take and explain why it’s important. Once they understand what a medication is for, it makes more sense to take it," Frank says. Many times, patients and caregivers are confused about what medication to take when. An extreme example is when one woman who was taking medication for depression and dementia reached into the chair cushions and showed the nurse practitioner and social worker a mason jar full of pills. She told the team that she just grabbed a few to take every day.
When the social worker and nurse practitioner start implementing the plan, they focus on the patient’s initial goal in order to build trust, Butler says. They continue to provide care management and caregiver support over time and work closely with the local agency on the aging to identify services that may benefit the patients.
The team contacts the patients by telephone or in person at least monthly, depending on the patient needs. "The team typically has more contact with patients in the beginning until the services they need are in place," Butler says. After patients have an emergency department visit or hospitalization, the team meets with them again in their homes, reconfirms the plan of care, and finds out the medications they are taking, and then notifies the primary care physician about the episode of care.
The nurse practitioner-social worker teams each carry a caseload of 80 to 100 patients, ranging from those who are just released from the hospital and take a lot of time to those who are stable and need only occasional follow up.
Once patients are a part of GRACE, they’re in for life unless they move out of the area or are admitted to a long-term care facility, Counsell says. The team re-evaluates them every year to determine if they still need intensive services.
"Healthcare reform is calling out for ways to improve health and lower costs. We have found a strategy to do that for a very vulnerable population. The program shows cost saving over time with the added benefit of providing services that these seniors need and can’t get anywhere else," Counsell says.