Grace Primary Care

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Grace primary care is a health clinic that provides medical care on a subscription basis, without the need for insurance. The practice specializes in patient empowerment and advocacy. It is certified as a Patient-Centered Medical Home (PCMH) by the National Committee for Quality Assurance.

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The GRACE model was developed to improve outcomes for adults with complex needs and yield long-term cost savings to the health care system. It involves an interdisciplinary team of nurses and social workers who visit patients in their homes to conduct comprehensive geriatric assessments, develop care plans, and implement strategies to address their needs. The nurse practitioner and social worker dyad is central to the model because it addresses patients’ medical and non-medical needs in ways that are most meaningful for them. The teams also facilitate weekly interdisciplinary meetings with a geriatrician, pharmacist, physical therapist, and mental health social work liaison.

Carrie Ortwein, a nurse practitioner, and Olivia Dole, a social worker, worked together for several years on a caseload of seniors enrolled in the Medicare Advantage Plan sponsored by Indiana University Health. Ortwein and Dole conducted comprehensive geriatric assessments during home visits, educated the patients on their medications, and provided referrals to community-based support services. They also helped reduce inappropriate use of medications such as those that raise fall risks in older adults.

The GRACE model has been adapted in organizations under financing arrangements ranging from capitation payments to fee-for-service reimbursement supplemented by monthly care coordination fees and performance incentives. Replication sites have also used the model to complement a range of other care management programs that address a variety of high-risk populations.

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