GRACE: Geriatric Resources for Assessment and Care of Elders

Study Overview
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Brief Summary
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The purpose of this study is to test the effectiveness of a collaborative model of team care as compared to usual care in improving functional outcomes among community-dwelling low-income older adults.

Detailed Description
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This collaborative model of care, Geriatric Resources for Assessment and Care of Elders (GRACE), involves a geriatric nurse practitioner and a geriatric social worker caring for the vulnerable older adult in collaboration with the patient's primary care physician to improve coordination and quality of care. The specific components of GRACE mirror those recommended in recent reviews: a) specific targeting of elders at risk; b) availability of collaborative expertise in geriatrics; c) integration of the program into primary care; d) coordination of care across all sites of care; e) integration of data systems that support physician's practice and facilitate monitoring of pertinent clinical parameters; and f) institutionally endorsed clinical practice guidelines. To our knowledge, there are no prior studies investigating the effectiveness of such a comprehensive approach among vulnerable older adults. We are hypothesizing that, compared to usual care, patients enrolled in the intervention will have: greater independence in activities of daily living over 2 years of follow-up; better health status scores as assessed by the HEDIS® 2000 Health Outcomes Survey fewer nursing home days over 2 years of follow-up; and fewer hospitalizations over the 2 years of follow-up.

Official Title
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Geriatric Resources for Assessment and Care of Elders

Conditions
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Functional Decline, Aging

Intervention / Treatment
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* Behavioral: Geriatric Resources for Assessment & Care of Elders (GRACE)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: 65 years old or older Annual income less than 200% of the federal poverty level Have had one or more primary care visits in the past 12 months Reside in the community (non-institutionalized) Exclusion Criteria: Non-English speaking No regular access to a telephone Currently undergoing kidney dialysis treatments Residing with a patient already participating in the GRACE clinical trial

Ages Eligible for Study
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Minimum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Single Group Assignment
Masking: Single


Arms and Interventions

| Intervention/Treatment |
| --- |
|Behavioral: Geriatric Resources for Assessment & Care of Elders (GRACE)|nan|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Functional status |  |  | 
| health status |  |  | 
| hospitalization and nursing home placement |  |  | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Patient satisfaction and quality of care |  |  | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Activities of Daily Living, Low-income, geriatric medicine, computer assisted patient care