• Functional status
  
• health status
  
• hospitalization and nursing home placement
  

• Patient satisfaction and quality of care
  

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:

1. greater independence in activities of daily living over 2 years of follow-up;
2. better health status scores as assessed by the HEDIS® 2000 Health Outcomes Survey
3. fewer nursing home days over 2 years of follow-up; and
4. fewer hospitalizations over the 2 years of follow-up.