GRACE’s high-intensity care-team model is nationally recognized as offering a fresh approach for effectively managing the health and well-being of high-risk Medicare populations outside of the hospital setting. For the Atlanta VA, GRACE was engaged to apply its model to a broader population and to manage high-risk veterans in the outpatient setting utilizing an interdisciplinary, team-based approach to augment resources already available within the medical center.
Doing so included creating individualized care plans for each veteran’s personal needs as identified through home visits, increased social worker support, broad telehealth support, and direct communication with emergency department and inpatient teams. Of particular focus were patients considered to be at high risk for transitions within the healthcare system from outpatient to ED/urgent care to inpatient to nursing home care (both within VA and outside VA).
GRACE’s involvement over the past year has included intensive on-site training, hosting of webinars for Atlanta VA leadership, assisting the Atlanta VA in developing a GRACE dashboard for monitoring program implementation and quality measures, and a sustainability session in Atlanta for evaluation and strategic planning. The Atlanta VA team reported finding the training provided by the IU Geriatrics GRACE Training and Resource Center to be practical, direct and easy to implement.
“Our work with GRACE perfectly aligns with our commitment to ensure that every veteran achieves the highest quality outcome and is personally satisfied with the care that they receive,” said Neha Pathak, M.D., PIM project team lead, Atlanta VA Medical Center. “We strive to be the benchmark of excellence and value in healthcare and benefits, and robustly applying the GRACE model of care will help us reach that goal. In fact, early results show that the new program is extremely well received by both veterans and their caregivers; and our team has reported many stories of how the program is effectively meeting the needs of veterans with complex health issues.”
The Atlanta VA Medical Center in Decatur, Georgia, is a Level 1A tertiary care facility providing patient-centered healthcare via an array of comprehensive medical, surgical and geriatric specialty services as well as state-of-the-art diagnostic testing. With 445 inpatient beds, including a 120-bed Community Living Center, a 40-bed domiciliary, and a 12-bed residential treatment program, the Atlanta VAMC is uniquely positioned to serve the healthcare needs of more than 130,000 enrolled veterans living in 50 counties across northeast Georgia. The medical center, also a teaching hospital, provides hands-on and state-of-the-art technology, education and research to residents in collaboration with Emory University School of Medicine and Morehouse School of Medicine.
First launched at Eskenazi Health, a public hospital and healthcare system, GRACE (Geriatric Resources for Assessment and Care of Elders) is being successfully applied at several leading health plans, medical groups and VA hospitals around the country. Going well beyond traditional care coordination, GRACE’s high-intensity care-team approach has been shown to enhance quality of care in ways that optimize health and functional status and decrease excess healthcare use, including avoidance of hospitalization and visits to the emergency department. GRACE may also prevent or delay the need for long-term nursing home placement by allowing seniors to stay in their homes with better support. Through experience GRACE has also been shown to deliver proven value as it relates to higher quality of life, better quality of care, and lower overall healthcare cost.