OBJECTIVES To provide, from the healthcare delivery system perspective, a cost analysis of the Geriatric Resources for Assessment and Care of Elders (GRACE) intervention, which is effective in improving quality of care and outcomes. DESIGN Randomized controlled trial with physicians as the unit of randomization. SETTING Community-based primary care health centers. PARTICIPANTS Nine hundred fifty-one low-income seniors aged 65 and older; 474 participated in the intervention and 477 in usual care. INTERVENTION Home-based care management for 2 years by a nurse practitioner and social worker who collaborated with the primary care physician and a geriatrics interdisciplinary team and were guided by 12 care protocols for common geriatric conditions. MEASUREMENTS Chronic and preventive care costs, acute care costs, and total costs in the full sample (n =951) and predefined high-risk (n =226) and low-risk (n =725) groups. RESULTS Mean 2-year total costs for intervention patients were not significantly different from those for usual care patients in the full sample ($14,348 vs $11,834; P =.20) and high-risk group ($17,713 vs $18,776; P =.38). In the high-risk group, increases in chronic and preventive care costs were offset by reductions in acute care costs, and the intervention was cost saving during the postintervention, or third, year ($5,088 vs $6,575; P < .001). Mean 2-year total costs were higher in the low-risk group ($13,307 vs $9,654; P =.01). CONCLUSION In patients at high risk of hospitalization, the GRACE intervention is cost neutral from the healthcare delivery system perspective. A cost-effectiveness analysis is needed to guide decisions about implementation in low-risk patients.

Our findings point to QOL domains that show significant variation by CI and thus may be of greatest interest to consumers, providers, advocacy groups, and other stakeholders committed to improving dementia care. Findings are particularly applicable to the development of NH quality indicators that more accurately represent the QOL of NH residents with CI.

In order to facilitate program planning for the chronically ill, it is essential to understand their propensity to use health and social services. This study has systematically examined the use of ambulatory services among the noninstitutionalized elderly (N = 772) who reported with one or more activity-limiting chronic conditions in a statewide survey of older Virginians in 1979. The determinants of differential use of physician services are investigated. The independent variables included in the analysis are: (1) personal attributes that may predispose individuals to seek care; (2) need for care factors as evidenced by the number of health disorders, physical functioning limitations, and perceived health; and (3) enabling factors such as income, insurance status, regular source of care, perceived service needs, and transportation barriers. Findings show that a significantly large number of physician visits may be generated in response to the psychological needs of disabled elderly. The eighteen predictors accounted for a relatively larger amount of variance (39%o) in use of social services than in physican visits (14%o). Furthermore, there is a strong complementary relationship between physician visits and use of social services.

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