Integrating Services for Low-Income Seniors Shows Health Care Benefit

By Claire Sowerbutt
INDIANAPOLIS, Dec. 11 -- For low-income seniors, the likelihood of providing the recommended standard of health care services could be enhanced by integrating home-based and institutional services, found researchers here. The results of the two-year Geriatric Resources for Assessment and Care of Elders (GRACE) study, a randomized trial of community-dwelling older patients with low incomes, found that the model improved quality of life and reduced utilization of acute-care resources, reported Steven R. Counsell, M.D., of Indiana University, and colleagues, in the Dec. 12 issue of the Journal of the American Medical Association.
The GRACE intervention included in-home assessment and care management provided by a nurse practitioner and social worker team; extensive use of specific care protocols for common geriatric conditions; use of an integrated electronic medical record and a Web-based care management tracking tool; and integration with affiliated pharmacy, mental health, home-health, and community-based and inpatient geriatric care services.
The investigators sought to see whether, compared with usual care, patients enrolled in the intervention would receive superior quality of care for common geriatric conditions, resulting in better health status, greater independence in activities of daily living, and lower acute care services utilization over the two years of follow-up.
In total, 951 patients, 65 or older, who had had at least one visit to a primary care physician at the same site within the previous 12 months, took part. Patients living in nursing homes or living with a patient already enrolled in the study were ineligible.
The protocol involved randomizing the participants' primary care physicians rather than the patients themselves, "to minimize the potential for contamination across groups," the researchers reported. Recruitment took place from January 2002 through August 2004 from six health care centers affiliated with the Wishard Health Services urban health care system here.
There were 474 patients who received home-based medical care from a nurse practitioner and social worker and 477 patients given usual care. The mean patient age was 71, and the study population was predominantly female.
The primary study measures were the Medical Outcomes 36-Item Short Form (SF-36), including summary measures, emergency department visits that did not result in hospitalization, hospitalization, and activities of daily living. Participants completed assessments, by phone, at baseline and months six, 12, 18, and 24.
Results at 24 months, from the intent-to-treat analysis, showed significant improvements, compared with usual care, for four of the eight SF-36 outcomes, specifically: general health (P=0.045), mental health (P=0.001), social functioning (P=0.008), and vitality (P<0.001). p="0.03)." n="106)" n="105)," p="0.03" n="106)" n="105)," p="0.03" href="http://jama.ama-assn.org/cgi/content/full/298/22/2623" target="blank">"Geriatric care management for low-income seniors: a randomized controlled trialJAMA 2007; 298: 2623-33. Additional source: Journal of the American Medical AssociationSource reference: Reuben D, "Better care for older people with chronic diseases: an emerging vision" JAMA 2007; 298: 2673-74.