Diffusion of GRACE Team Care™ Technologies to Improve Care Transitions of Older Persons with Complex Health Care Needs

9/10/12

Indiana Care Transitions Program

Summary

The Indiana CTA Tech4Impact grantee implemented GRACE Team Care™ technologies to enhance and help evaluate the GRACE (Geriatric Resources for Assessment and Care of Elders), care management program. GRACE Team Care™ is an evidence-based care management model that has demonstrated improvement in patient quality of care and reductions in hospital utilization for older persons with complex health care needs.  GRACE Team Care™ technologies include electronic tools for patient assessment and individualized care planning, tracking of care plan implementation, and communication among providers. These computer-based technologies can be used to facilitate program evaluation ensuring fidelity to the GRACE model and improvement of performance on quality of care indicators. GRACE Team Care™ technologies have been adapted to the VA electronic medical record and are thus compatible with the VA healthcare system nationally.

Surveys indicate GRACE technologies improved the quality, coordination, efficiency, and effectiveness of care management for 200 older Veterans with complex health care needs. GRACE technologies are in the process of being transferred to the Atlanta, Durham, and San Francisco VA Medical Centers for use by their geriatrics interdisciplinary teams in patient assessment, individualized care planning, and care management.

WHO WAS INVOLVED?

Primary Developers: Indiana University Center for Aging Research; Indiana University School of Medicine; Regenstrief Institute, Inc.; Wishard Health Services

Secondary Developers: Indianapolis VA Medical Center

WHAT THEY DID

Problem Addressed: Older patients with complex health care needs often receive care that is fragmented, incomplete, inefficient, and ineffective. Adoption and diffusion of technologies that support models of care shown to improve the effectiveness and efficiency of complex primary care is needed.

Patient Population: Veterans aged 65 or older with chronic conditions and functional limitations placing them at high risk for hospital readmission and institutional long-term care. The target population includes Veterans living in Indianapolis and Marion County, Indiana having a non-elective hospitalization on the medical service at the Indianapolis VA Medical Center, who are discharged home, not receiving palliative care or hospice services.

Description of the Innovative Activity: The Indiana Tech4Impact Project accelerated adoption and diffusion of GRACE Team Care™ technologies at the Indianapolis VA Medical Center in a manner that ensures compatibility with the VA healthcare system nationally. GRACE Team Care™ technologies include electronic geriatric assessment and care management tracking tools. These tools provide decision support for individualized care planning, allow tracking of care plan implementation for follow-up and accountability, and facilitate communication among health care team members for coordination of care.

For additional information on the GRACE care management model and project results, see the AHRQ Innovation Profile.

DID IT WORK?

Summary of Results:

The GRACE Team Care™ technologies were successfully implemented with over 200 older Veterans enrolled in the GRACE care management program at the Indianapolis VA Medical Center. Nurse practitioners, social workers, pharmacists, psychologists, and physicians used one or more of the electronic tools for geriatric assessment, development of an individualized care plan, tracking of care plan implementation, and communication with other members of the health care team for coordination of care. The care plan tracking tool was successfully used to facilitate program evaluation including:

  • Monitoring process of care measures that ensured fidelity to the GRACE model, and
  • Monitoring quality of care indicators that documented improved performance on targeted quality measures.

 

By supporting the GRACE model, GRACE Team Care™ technologies contributed to improved quality, efficiency, and effectiveness of care transitions and longitudinal care management for older Veterans with complex health care needs. Preliminary results of the GRACE Team Care™ program at the Indianapolis VA Medical Center demonstrate high levels of patient and caregiver satisfaction, improved quality of care for common geriatric conditions, fewer 30-day readmissions, and lower hospital utilization rates in Veterans enrolled in GRACE compared to a control group.

Key Results of GRACE Team Care™ Technologies

  • Geriatric patient assessments are standardized, more comprehensive, and documented in the electronic medical record.
  • Evidence-based care protocols for common geriatric conditions are used routinely in developing individualized patient care plans.
  • Tracking and accountability for implementation of patient care plans is enhanced.
  • Quality of care for geriatric conditions is improved.
  • Communication is increased and coordination of care is improved among interdisciplinary team members.
  • Care transitions are better and hospital readmissions reduced.

 

HOW THEY DID IT?

Context of the Innovation: The GRACE Team Care™ technologies were first developed for use in the original GRACE program at Wishard Health Services, a university-affiliated urban health care system serving medically indigent patients in Indianapolis, Indiana including approximately 6,000 older adults. Under the Tech4Impact Project, the GRACE Team Care™ technologies were adapted for use in the Indianapolis VA healthcare system serving over 15,000 older Veterans. At Wishard, the GRACE care management tracking tool was Web-based and separate from the electronic medical record. GRACE Team Care™ technologies at the Indianapolis VA were implemented as an integral component of the electronic medical record.

GRACE has been tested for low-income individuals aged 65 years or older in primary care, including a group at high risk of hospitalization (as determined by the probability of repeated admission risk screen). A randomized study indicated the total annual intervention costs for high-risk patients to be $315,040 ($1,432 per patient). The study concluded the intervention to be cost-neutral for high-risk patients due to reductions in hospital costs (Counsell SR, 2007).

The Tech4Impact Project and GRACE Team Care™ technologies innovation at the Indianapolis VA Medical Center was part of two larger initiatives. First, the Veterans Health Administration through the Office of Geriatrics and Extended Care awarded funding in 2010 to the Indianapolis VA to implement the GRACE model under a grant opportunity for “Patient-Centric Alternatives to Extended Institutional Care.” Second, under Section 2405 of the Affordable Care Act, funding was provided to expand Aging and Disability Resource Centers (ADRC). In the summer of 2010, the Administration on Aging and Centers for Medicare and Medicaid Services issued a grant opportunity for “ADRC Evidence-Based Care Transition Programs.” The GRACE model was one of four evidence-based models that states could choose to implement; the state of Indiana was awarded a two-year grant using the GRACE model at Wishard Health Services and the Indianapolis VA.

Planning and Development Process:

Implementation of the GRACE program, including the GRACE Team Care™ technologies, was achieved through the following key steps:

  • Assemble a GRACE Steering Committee to involve key stakeholders in the implementation and evaluation process.
  • Hire and train VA personnel to deliver the GRACE model.
  • Customize and load the GRACE patient assessment, protocols, and care plan technologies in the VA electronic medical record.
  • Implement GRACE in at least 200 older Veterans at risk for institutional extended care.
  • Evaluate the program for GRACE model implementation, Veteran and caregiver satisfaction, quality of care, and acute care services utilization.

 

For implementation of the GRACE Team Care™ technologies, the Indianapolis VA Systems Redesign Service provided: 1) systems engineering expertise to ensure appropriate integration of GRACE technologies within current processes, and 2) clinical informatics and human factors engineering support to develop and test novel clinical informatics tools (i.e., GRACE technologies) to enhance individualized care planning, provider to provider communication, care coordination, and continuity of care.

Resources Used and Skills Needed:

Implementation of GRACE Team Care™ technologies at the Indianapolis VA Medical Center required the following staffing and support:

 

  • VA GRACE project director and interdisciplinary team members including the geriatrician, nurse practitioners and social workers to adapt original assessment and care planning tools to the Indianapolis VA electronic medical record system.

 

 

  • VA Systems Redesign Service clinical applications coordinators to develop, pilot, implement, evaluate, and refine the GRACE computer-based technologies. The clinical applications coordinators were responsible for fully integrating the new technologies within the local VA medical center and in a manner such that GRACE technologies would be transferable to other VA healthcare systems.

 

ADOPTION CONSIDERATIONS

Sustaining This Innovation: GRACE Team Care™ technologies are in the process of being transferred to the Atlanta, Durham, and San Francisco VA Medical Centers for use by their geriatrics interdisciplinary teams in patient assessment, individualized care planning, and care management. Updated software is being developed for Web-based applications of GRACE Team Care™ technologies for organizations interested in keeping GRACE care management tools distinct from an electronic medical record system.

Care Transitions Diffusion Grants Program


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