GRACE: Geriatric Resources for Assessment and Care of Elders

National Institutes of Health (NIH)

Status: Completed

Conditions: Aging; Functional Decline

Treatments: Behavioral: Geriatric Resources for Assessment & Care of Elders (GRACE)

Study type: Interventional

Funder types: Other; NIH

Identifiers

NCT00182962

R01AG020175 (U.S. NIH Grant/Contract)

AG0042

Details and patient eligibility

About

The purpose of this study is to test the effectiveness of a collaborative model of team care as compared to usual care in improving functional outcomes among community-dwelling low-income older adults.

Full description

This collaborative model of care, Geriatric Resources for Assessment and Care of Elders (GRACE), involves a geriatric nurse practitioner and a geriatric social worker caring for the vulnerable older adult in collaboration with the patient's primary care physician to improve coordination and quality of care. The specific components of GRACE mirror those recommended in recent reviews: a) specific targeting of elders at risk; b) availability of collaborative expertise in geriatrics; c) integration of the program into primary care; d) coordination of care across all sites of care; e) integration of data systems that support physician's practice and facilitate monitoring of pertinent clinical parameters; and f) institutionally endorsed clinical practice guidelines. To our knowledge, there are no prior studies investigating the effectiveness of such a comprehensive approach among vulnerable older adults.

We are hypothesizing that, compared to usual care, patients enrolled in the intervention will have:

1. greater independence in activities of daily living over 2 years of follow-up;
2. better health status scores as assessed by the HEDIS® 2000 Health Outcomes Survey
3. fewer nursing home days over 2 years of follow-up; and
4. fewer hospitalizations over the 2 years of follow-up.

Sex: All

Ages: 65+ years old

Volunteers: Accepts Healthy Volunteers

Inclusion criteria

• 65 years old or older
• Annual income less than 200% of the federal poverty level
• Have had one or more primary care visits in the past 12 months
• Reside in the community (non-institutionalized)

Exclusion criteria

• Non-English speaking
• No regular access to a telephone
• Currently undergoing kidney dialysis treatments
• Residing with a patient already participating in the GRACE clinical trial

Trial design

Primary purpose: Treatment

Allocation: Randomized

Interventional model: Single Group Assignment

Masking: Single Blind