Wishard Health Services

GRACE (Geriatric Resources for Assessment and Care of Elders):
A New Model of Primary Care for Low-Income Seniors

Founded in 2002, the Geriatric Resources for Assessment and Care of Elders (GRACE) was designed as a practical, innovative model of primary care where vulnerable seniors today benefit from a comprehensive team approach to health care and care coordination.

Specifically intended to improve the quality of care for low-income seniors in Indianapolis, this primary care practice serves a diverse population of older adults who are poor, have multiple conditions, and whose care is often fragmented across providers and sites of care.
GRACE includes eight community-based health centers and provides primary care to approximately 6,000 adults aged 65 and older. Faculty from the Indiana University School of Medicine staffs each of these health centers. GRACE utilizes a more focused disease management approach that addresses the entirety of the older patient’s health status.

Unique features of the GRACE intervention include: in-home assessment and care management provided by a nurse practitioner and social worker team; extensive use of evidence-based 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 pharmacy, mental health, home health, and community-based and inpatient geriatric care services.

The GRACE model builds on lessons learned from prior efforts to improve the care of older adults through multidimensional assessment.