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GRACE Interdisciplinary Team Suggestions


The GRACE (Geriatric Resources for Assessment and Care of Elders) Interdisciplinary Team Suggestions guide health care providers as they develop and implement individualized care plans for low-income seniors to improve quality of care.

The tools are based on the GRACE model, which uses nurse practitioners and social workers who work together as a support team, first meeting with low-income seniors to conduct a comprehensive geriatric assessment, and then with a larger interdisciplinary team to develop an individualized, integrated care plan based on this set of protocols for evaluating and managing common geriatric conditions. The support team works with the patient's primary care physician (PCP) to modify, finalize, and implement the plan.

Each topic has items to review with the PCP and routine intervention suggestions.

Topics include:
  • Dementia
  • Depression
  • Difficulty walking and falls
  • Urinary incontinence
  • Malnutrition and weight loss
  • Chronic pain
  • Visual impairment
  • Hearing impairment
  • Medication management
  • Health maintenance
  • Advance care planning
  • Caregiver burden

Links to the Tool:
This tool is available at: (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)


Indiana University Center for Aging Research

Funding Sources

Indiana University School of Medicine

QualityTool Topic



  • Release Date: 03/2003
  • Original Summary: 08/2008
Disclaimer: The inclusion of a tool in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality or Westat of the tool or of the submitter or developer of the tool. Read more.
QualityTool Classification
Patient Care Process:

Last updated: October 09, 2013.