Implementation of an Interdisciplinary, Team-Based Complex Care Support Health Care Model at an Academic Medical Center: Impact on Health Care Utilization and Quality of Life

Abstract

IntroductionThe Geriatric Resources for the Assessment and Care of Elders (GRACE) program has been shown to decrease acute care utilization and increase patient self-rated health in low-income seniors at community-based health centers.AimsTo describe adaptation of the GRACE model to include adults of all ages (named Care Support) and to evaluate the process and impact of Care Support implementation at an urban academic medical center.Setting152 high-risk patients (≥5 ED visits or ≥2 hospitalizations in the past 12 months) enrolled from four medical clinics from 4/29/2013 to 5/31/2014.Program DescriptionPatients received a comprehensive in-home assessment by a nurse practitioner/social worker (NP/SW) team, who then met with a larger interdisciplinary team to develop an individualized care plan. In consultation with the primary care team, standardized care protocols were activated to address relevant key issues as needed.Program EvaluationA process evaluation based on the Consolidated Framework for Implementation Research identified key adaptations of the original model, which included streamlining of standardized protocols, augmenting mental health interventions and performing some assessments in the clinic. A summative evaluation found a significant decline in the median number of ED visits (5.5 to 0, p = 0.015) and hospitalizations (5.5 to 0, p<0.001) 6 months before enrollment in Care Support compared to 6 months after enrollment. In addition, the percent of patients reporting better self-rated health increased from 31% at enrollment to 64% at 9 months (p = 0.002). Semi-structured interviews with Care Support team members identified patients with multiple, complex conditions; little community support; and mild anxiety as those who appeared to benefit the most from the program.DiscussionIt was feasible to implement GRACE/Care Support at an academic medical center by making adaptations based on local needs. Care Support patients experienced significant reductions in acute care utilization and significant improvements in self-rated health.

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“…Our findings suggest that a similar approach may be appropriate for middle-aged adults. Indeed, proven geriatric models of care have already been successfully delivered to vulnerable middle-aged adults (43, 44). Novel models of care that improve functioning in low income older adults (45) may hold similar promise for low income adults in middle age.…”

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“…Moreover, a reconstructive plan requiring multiple surgeries and prolonged treatment time may be undesirable for this patient population. To optimize outcomes, inclusion of supportive care team members (ie, including nursing, counseling, and social work) has previously been previously reported …”

“…To optimize outcomes, inclusion of supportive care team members (ie, including nursing, counseling, and social work) has previously been previously reported. [12][13][14] Prosthetic rehabilitation of a nasal defect is an alternative option for geriatric patients which does not require additional surgery, is safe, and has a shorter treatment time. Additionally, the use of craniofacial implants is desirable for this patient population to assist in prosthesis retention.…”

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