Implementation of an Interdisciplinary, Team-Based Complex Care Support Health Care Model at an Academic Medical Center: Impact on Health Care Utilization and Quality of Life

PLoS One. 2016 Feb 12;11(2):e0148096. doi: 10.1371/journal.pone.0148096. eCollection 2016.


Introduction: The Geriatric Resources for the Assessment and Care of Elders (GRACE) program has been shown to decrease acute care utilization and increase patient self-rated health in low-income seniors at community-based health centers.

Aims: To describe adaptation of the GRACE model to include adults of all ages (named Care Support) and to evaluate the process and impact of Care Support implementation at an urban academic medical center.

Setting: 152 high-risk patients (≥5 ED visits or ≥2 hospitalizations in the past 12 months) enrolled from four medical clinics from 4/29/2013 to 5/31/2014.

Program description: Patients received a comprehensive in-home assessment by a nurse practitioner/social worker (NP/SW) team, who then met with a larger interdisciplinary team to develop an individualized care plan. In consultation with the primary care team, standardized care protocols were activated to address relevant key issues as needed.

Program evaluation: A process evaluation based on the Consolidated Framework for Implementation Research identified key adaptations of the original model, which included streamlining of standardized protocols, augmenting mental health interventions and performing some assessments in the clinic. A summative evaluation found a significant decline in the median number of ED visits (5.5 to 0, p = 0.015) and hospitalizations (5.5 to 0, p<0.001) 6 months before enrollment in Care Support compared to 6 months after enrollment. In addition, the percent of patients reporting better self-rated health increased from 31% at enrollment to 64% at 9 months (p = 0.002). Semi-structured interviews with Care Support team members identified patients with multiple, complex conditions; little community support; and mild anxiety as those who appeared to benefit the most from the program.

Discussion: It was feasible to implement GRACE/Care Support at an academic medical center by making adaptations based on local needs. Care Support patients experienced significant reductions in acute care utilization and significant improvements in self-rated health.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Academic Medical Centers
  • Adult
  • Aged
  • Aged, 80 and over
  • Female
  • Geriatric Assessment / methods*
  • Humans
  • Interdisciplinary Studies
  • Male
  • Middle Aged
  • Nurse Practitioners
  • Patient Acceptance of Health Care*
  • Patient Care Team
  • Poverty
  • Precision Medicine
  • Program Evaluation
  • Quality of Life*
  • Social Workers

Grant support

Evaluation of Care Support was supported by a grant to TideswellTM at UCSF from the S.D. Bechtel, Jr. Foundation. The SCAN Foundation provided support for the training and implementation assistance provided by the Indiana University Geriatrics GRACE Training and Resource Center to the UCSF Care Support program. The SCAN Foundation – advancing a coordinated and easily navigated system of high-quality services for older adults that preserve dignity and independence. For more information, please visit The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.