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After a breast mass was identified by a physician assistant during a routine visit, a 60-year-old woman received a diagnostic mammogram and ultrasound. The radiology assessment was challenging due to dense breast tissue and ultimately interpreted as “probably benign” findings. When the patient returned for follow-up 5 months later, the mass had increased in size and she was referred for a biopsy.

Social worker/nurse practitioner teams collaborate with a larger interdisciplinary team and primary care physicians to develop and implement individualized care plans for seniors and other high-risk patients. The social worker/nurse practitioner team also proactively manages and coordinates the patient's care on an ongoing basis through regular telephone and in-person contact with both patients and providers. The program, known as Geriatric Resources for Assessment and Care of Elders (GRACE), improved the provision of evidence-based care; led to significant improvements in measures of general health, vitality, social functioning, and mental health; reduced emergency department visits, hospital admissions, readmissions, and total bed days; and generated high levels of physician and patient satisfaction. These successes have been across a variety of health system contexts, including: a VA medical center, primary care health centers, and as a part of a Medicare Advantage plan. A recent analysis found that the reduction in service usage saved the VA medical center $200k per year for the 179 veterans enrolled in GRACE. Another analysis in primary care health centers found that the program was cost neutral for high-risk patients in the first 2 years, and yielded savings by year 3.

The program was initially designed to serve low-income seniors, but has subsequently been replicated with different populations, including adults of all ages who are high risk, Medicare beneficiaries who are 70+ with multiple comorbidities, and older veterans following an emergent hospital admission and discharge home.