Geriatric Resources for Assessment and Care of Elders (GRACE) Model

The Geriatric Resources for Assessment and Care of Elders (GRACE) Model aims to provide personalized primary health care for low-income seniors. The GRACE model involves a GRACE support team, consisting of an advanced practice nurse and social worker, as well as the patient’s primary care physician and a geriatrics interdisciplinary team.The program includes components such as initial and annual in-home comprehensive geriatric assessments; individualized care plan developed by a geriatrician and including a team of a pharmacist, physical therapist, mental health social worker, and community-based services liaison; weekly GRACE team meetings to review patients care plan; and ongoing GRACE support team care management and coordination of care supported by an electronic medical record and Web-based tracking system.

The goal of the GRACE model is to increase quality of care for low-income seniors.

The GRACE model has been shown to improve quality of care and health outcomes in low-income seniors.

The GRACE model has been shown to improve quality of care and health outcomes in low-income seniors. It has also recently been shown to be cost neutral from the health care delivery system perspective.