The multidisciplinary home care program aims to improve health outcomes and functioning by reducing the use of health care and preventing long-term placement in a nursing home.
A retrospective cohort study evaluated the results of a multidisciplinary model of care developed to meet the primary care needs of low-income seniors that was adopted by the Department of Veterans Affairs (VA) in 1 facility.
Compared to younger veterans, older veterans are more likely to use more health services, have more impairments that hinder daily functioning, have comorbidities, and have a greater risk of adverse health outcomes. This trend will accelerate as a third of the veteran population is expected to be at least 75 by 2028.
The Geriatric Resources for Assessment and Care of Elders (GRACE) Team Care was initially developed and implemented more than a decade ago by the Indiana University School of Medicine’s Center for Aging Research. The program aims to improve health outcomes and functioning while reducing the use of health care and preventing long-term placement in a nursing home. In a randomized controlled trial, GRACE improved the quality and reduced use of health care compared to usual care.
A 1999 Veterans Healthcare Act required access to geriatric assessments. The authors said the VA-GRACE program pairs professional nurses with social workers who conduct home assessments with veterans to screen for common geriatric syndromes and conduct a physical exam as well as comprehensive medication reconciliation. The visit includes a psychosocial assessment and involves the family and health professionals.
A registered nurse and social worker present their findings to the VA-GRACE multidisciplinary team during weekly shifts, including a geriatrician, psychologist and pharmacist. A care plan is established and shared via the electronic medical record with the patient’s primary care provider.
Once enrolled, patients remain on VA-GRACE until discharge, which means placement in long-term care; request for discharge from the patient or caregiver; non-compliance with VA-GRACE recommendations; functional and clinical improvement that disqualifies them from the program; or death.
A previous VA-GRACE study found it reduced emergency room visits by 7.1%, reduced readmissions by almost 15% at 30 days, and reduced hospital admissions by nearly 40%. That study, which also found that it saved about $ 200,000 annually after program costs in the first 14 months, was limited to a 16-month period.
This retrospective cohort study aimed to evaluate the program from the outset. It included patients admitted to Richard L. Roudebush VA Hospital (2010–2019) who received VA-GRACE services after discharge. Veterans who were potentially eligible for VA-GRACE but did not receive services served as controls and received routine care.
Primary study outcomes included readmissions and 90-day and 1-year all-cause mortality and patient, caregiver, and provider satisfaction. To adjust for differences in characteristics between groups, the researchers used overweighted propensity score modeling.
VA-GRACE patients (n = 683) were older than controls (n = 4313) (mean age, 78.3 [8.2] vs 72.2[6.9]years; P. <.001). Their comorbidity score was higher (median Charlson comorbidity index, 3 vs 0; P. <.001).
The results showed that patients in the program:
- He had a lower 90-day mortality: adjusted odds ratio (aOR), 0.31; 95% CI, 0.11-0.92
- Had no statistically significant differences in 1-year mortality: aOR, 0.88; 95% CI, 0.55-1.41
- Had higher readmissions at 90 days, aOR, 1.55; 95% CI, 1.01-2.38
- Had readmissions over 1 year, aOR, 1.74; 95% CI, 1.22-2.48
As part of the study, the researchers interviewed patients, healthcare professionals and primary care providers, and high satisfaction with the program was reported.
VA-GRACE home visits have reduced travel worries and connected veterans and healthcare professionals to resources. And the primary care model has reduced providers ‘workload, improved medication management, and provided insight into patients’ daily lives, the providers said.
The study had some limitations, including the fact that the interviews were conducted with a limited number of interested parties; the VA-GRACE program exists in only 1 location and results may vary in other locations; and differences in results may reflect unmeasured confounding.
“Broad deployment of programs such as VA-GRACE will be needed to support aging veterans on the spot,” the authors noted.
Schubert CS, Perkins AJ, Myers LJ, et al. Effectiveness of the VA-Geriatric Resources for Assessment and Care of Elders (VA-GRACE) Program: An Observational Cohort Study. J Am Geriatr Soc. Published online August 29, 2022. doi: 10.1111 / jgs.18013