The purpose of this study is to test the effectiveness of a collaborative model of team care as compared to usual care in improving functional outcomes among community-dwelling low-income older adults.

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.

Inclusion Criteria:

• 65 years old or older
• Annual income less than 200% of the federal poverty level
• Have had one or more primary care visits in the past 12 months
• Reside in the community (non-institutionalized)

Exclusion Criteria:

• Non-English speaking
• No regular access to a telephone
• Currently undergoing kidney dialysis treatments
• Residing with a patient already participating in the GRACE clinical trial