Table 2. Process Measures and Fidelity to GRACE Model.
| GRACE Process Target Achieved | Value /Sub-Group | Overall (n = 148) | Age < 65 (n = 67) | Age ≥ 65 (n = 81) | p-value |
|---|---|---|---|---|---|
| In-home assessment ≤ 15 days after enrollment | Number (%) | 146 (98.6) | 66 (98.5) | 80 (98.8) | -- |
| Team conference ≤ 15 days after in-home assessment | Number (%) | 144 (97.3) | 66 (98.5) | 78 (96.3) | 0.196 |
| Team conference included: | Number (%) | ||||
| Geriatrician | 144 (97.3) | 64 (95.5) | 80 (98.8) | 0.117 | |
| Mental health | 134 (90.5) | 60 (89.6) | 74 (91.4) | 0.728 | |
| Pharmacist | 123 (83.1) | 55 (82.1) | 68 (84.0) | 0.783 | |
| Care plan reviewed with PCP ≤ 15 days | Number (%) | 139 (93.9) | 63 (94.0) | 76 (93.8) | 0.463 |
| Care plan reviewed with patient ≤ 1 month | Number (%) | 142 (95.9) | 65 (97.0) | 77 (95.1) | -- |
| Patient contacted ≤ 5 days after ED visit or discharge * | Number (%) | 38 (79.2) | 30 (93.8) | 8 (50.0) | <0.001 |
| Other Process Measures | |||||
| Protocols activated | Mean ± SD | 5.6 ± 1.7 | 5.4 ± 1.7 | 5.7 ± 1.6 | 0.283 |
| Protocol types activated | Number (%) | ||||
| Chronic condition | 141 (95.3) | 64 (95.5) | 77 (95.1) | 0.895 | |
| Social service | 131 (88.5) | 61 (91.0) | 70 (86.4) | 0.380 | |
| Advanced care planning | 124 (83.8) | 62 (92.5) | 62 (76.5) | 0.009 | |
| Mental health | 86 (58.1) | 47 (70.1) | 39 (48.1) | 0.007 | |
| Medication management | 59 (39.9) | 21 (31.3) | 38 (46.9) | 0.054 | |
| Mobility/falls | 58 (39.2) | 14 (20.9) | 44 (54.3) | <0.001 | |
| Caregiver support | 56 (37.8) | 19 (28.4) | 37 (45.7) | 0.031 | |
| Face-to-face contacts, first 30 days | Mean ± SD | 1.0 ± 1.1 | 1.0 ± 1.1 | 1.0 ± 1.1 | 0.837 |
| Telephone contacts, first 30 days | Mean ± SD | 2.6 ± 2.2 | 2.7 ± 1.8 | 2.6 ± 2.5 | 0.742 |
Abbreviations: ED, emergency department; PCP, primary care physician. Missing data included in denominator for percentages. Data missing as follows: team conference (n = 2), care plan reviewed (n = 6), patient contacted ≤ 5 days after ED visit (n = 6), face-to-face contacts (n = 6), telephone contact (n = 6).
*Restricted to patients with at least one ED visit or discharge during the first 30 days.