Home-based Geriatric Care Management Decreases Rate of VA Healthcare Utilization for Older Veterans following Hospitalization

BACKGROUND:
Older Veterans who use VA resources have higher rates of functional and cognitive impairment, as well as higher levels of multi-morbidity than non-Veterans of the same age. GRACE (Geriatric Resources for Assessment and Care of Elders) Team Care works in collaboration with primary care and the patient-centered medical home model to provide home-based geriatric care management that focuses on geriatric syndromes and psychological issues commonly found in older adults. This practical clinical trial assessed Veterans aged 65 years and older with primary care providers (PCPs) from 4 VAMCs and 29 PCPs, located in Indianapolis, IN, who were enrolled in GRACE following hospital discharge to home (n=179) compared to Veterans who were not enrolled after hospital discharge(n=77). During the study period, the GRACE team performed 227 in-home post-hospitalization transition visits, 210 in-home comprehensive geriatric assessment visits, and 347 face-to-face follow-up visits. The index hospitalization for both the GRACE and comparison groups occurred between April 1, 2010 and July 31, 2011. Using VA data, investigators examined patient demographics, multi-morbidity, and acute care utilization in the one year prior to and following the index hospitalization. To estimate mean acute care costs, hospitalization data from a convenience sample of 199 Veterans who were enrolled in GRACE between October 2011 and July 2012 were used to calculate the average cost of a GRACE Veteran hospitalization. In addition to these outcomes, study investigators also discuss lessons learned during program implementation.

FINDINGS:

• Enrollment in GRACE was associated with a 7% reduction in emergency department visits, 15% fewer 30-day readmissions, a 38% reduction in hospital admissions, and 29% decreased total bed days of care. The 179 Veterans enrolled in GRACE avoided 15 hospital admissions and 53 readmissions in the year after program enrollment. This saved VA more than $200,000 in the first year – over and above GRACE program costs.
• Veterans enrolled in GRACE and Veterans in the comparison group were similar in age, sex, and burden of comorbidity, though predicted risk for one-year mortality was higher in GRACE Veterans.
• Regarding lessons learned, factors that contributed to the success of GRACE included: 1) early engagement of invested, supportive leadership who were provided with regular updates on the program's progress and positive impact; 2) recruitment of energetic GRACE team staff with experience in Geriatrics and interdisciplinary team care; and 3) the natural alignment of the concepts behind GRACE and VA's Patient-Aligned Care Team (PACT).

LIMITATIONS:

• The study used a non-randomized design, so Veterans in the GRACE and comparison groups had some differences that may have impacted the results, e.g., Veterans enrolled in GRACE appeared to be more chronically ill.
• This study only considered one year of follow-up data, and focused only on acute care use, which did not account for all costs of care for the two groups of Veterans in this study.

AUTHOR/FUNDING INFORMATION:
Dr. Myer is part of HSR&D's Center for Health Information and Communication (CHIC) in Indianapolis, IN. Dr. Schubert is a geriatrician at the R.L. Roudebush VAMC in Indianapolis, IN.

Schubert C, Myers L, Allen K, and Counsell S. Implementing GRACE Team Care in a Veterans Affairs Medical Center: Lessons Learned and Impacts Observed. Journal of the American Geriatrics Society. July 2016;64(7):1503-09.