AGS: Protocol-Driven Team Care Improves Health of Low-Income Elderly

May 4, 2007

SEATTLE -- Interdisciplinary primary care using condition-specific protocols improved health and functioning of low-income seniors, researchers reported here.

SEATTLE, May 4 -- Interdisciplinary primary care using condition-specific protocols improved health and functioning of low-income seniors, researchers reported here.

After two years, 379 older patients randomized to the Geriatric Resources for Assessment and Care of Elders (GRACE) intervention scored significantly better on standardized measures of general and mental health, vitality, and social functioning compared with patients assigned to usual care.

Patients managed by the interdisciplinary team also spent fewer days in the hospital and were less likely to use emergency department services, said Steven R. Counsell, M.D., director of geriatrics at Indiana University in Indianapolis and colleagues.

But those differences did not reach statistical significance, Dr. Counsell reported at the American Geriatrics Society meeting.

Low-income seniors typically lack access to preventive services or continuity of care, and often depend on emergency departments for routine care, he said. This group is also at risk for frequent hospitalization.

The GRACE intervention was designed to reverse that trend by improving the overall quality of primary care services, Dr. Counsell said. Theoretically, better primary care would result in less frequent use of hospital services.

The mean age of patients enrolled in the study was 72, three-quarters were women, and 60% were black. Care was provided at seven community-based clinics.

Those randomized to the GRACE intervention received an initial in-home assessment by a geriatric nurse practitioner and a social worker. The interview established medical and psychosocial history and physical and cognitive functioning. The team also did a detailed medication review, preventive health and home safety evaluations, and reviewed advance directives.

The full geriatrician-led interdisciplinary team, which included a pharmacist, physical therapist, mental health case manager, and community resource expert, then reviewed results of the initial assessment.

The team selected appropriate protocols and made suggestions for implementation. Then the team worked with the patient's primary care physician to implement the protocols. Both the nurse practitioner and the social worker worked with the primary care physician to provide ongoing care and management through home visits, telephone calls, and web-based monitoring of the patient's medical record.

Following a specific set of protocols selected from a list of 12 that were targeted for specific conditions such as medication management, hearing loss, or chronic pain, the intervention team members interacted with the average patient 18 times over the 24-month study and 39% of those contacts were face-to-face.

An average of five protocols were implemented for each patient and the team came up with an average of 63 suggestions about ways to improve care for each patient.

Outcomes were assessed using SF-36 scales in physical functioning, bodily pain, general health, vitality, social functioning, emotional health, and mental health, as well as the SF-36 physical component summary and mental component summary.

Instrumental activities of daily living and basic activities of daily living were assessed with the AHEAD (Assets and Health Dynamics of the Oldest Old) survey and hospital records were used to assess emergency department visits, hospital admissions, and hospital days.

Among the findings:

  • Compared with controls, the intervention patients had significantly better mean ST-36 scores in the domains of general health (P