Group Facilitation and Project Plan Development for Implementing an adapted version of the GRACE Model

Proposals welcome up to $50,000

An area of interest of the CAP is the care of older adults in a rural setting where assisted-living and transportation services are limited and community members strongly prefer to stay at home as long as possible.

In Hood River and Wasco counties, adults over age 65 will increase in the next 12 years to approximately 21-25% of the population.   Current approaches to support older adults have limited capacity and will be overwhelmed by this aging population.  Beginning this summer there will be an influx of dual eligible Medicare/Medicaid enrollees into the Medicaid system.  Innovations in defining and developing support systems are needed to limit costs, improve quality of care and improve the health and wellbeing of this population.

In recent years, the Geriatric Resources for Assessment and Care of Elders (GRACE) model has emerged as an evidenced-based cost-effective approach for serving high-risk Medicare beneficiaries.  This model utilizes intensive evaluation by different disciplines to identify needs that can be addressed through targeted interventions to promote successful aging in the home. However, the research efforts have largely been demonstrated in urban or more densely populated areas of the nation.

The CAP wishes to develop an implementation plan of an adapted version of the GRACE model for dual-enrolled Medicaid/Medicare, medically fragile and/or cognitively impaired clients residing in Hood River and Wasco Counties and not enrolled in home health or hospice (aka ‘Study Cohort’). The results of the pilot study must gather sufficient information to calculate client, family and financial ROI return on investment as well as a path for sustainable funding.

The CAP is a seeking a consultant to lead the workgroup through the development phase of an Implementation Plan. The elements of the Implementation Plan are to include:

Overview of the population and the study cohort:

Total population age 65+ in Hood River and Wasco County and distribution in the counties including the less populated areas.
Clear identification of the study cohort and the criteria that qualifies them for services.
The number of households and members to be served by location. inclusive of The Dalles and less populated areas of Wasco county including Antelope, Dufur, Maupin, Mosier, Shaniko, Tygh Valley, Wamic and Pine Hollow. In Hood River county, communities would include Hood River and Cascade Locks, Odell, Parkdale, Mt Hood, Rockford and Oak Grove.
An estimate of percentage of the study cohort are expected to be Dual-enrolled Medicaid/Medicare members

Overview of the clinicians currently serving the study cohort:

Primary Care Homes and relative size of the study cohort they serve and general portion of their practice it represents (e.g. Specific practice serves 15% of study cohort)
Dental Homes serving the cohort population and relative size of the study cohort they serve.
Locations of geriatric-specific providers

Overview of the current As-Is landscape of services and resources for the study cohort:

Describe what services are in place already
Identify the “gaps” in the current system; i.e. older adults who need services to stay at home but do not meet current qualifying criteria for home services

Define the implementation plan including:

Which elements of the GRACE model will remain unchanged and which elements need adapting to serve the Gorge rural community.
Which existing services can be augmented and incorporated to meet identified needs and develop a system of support.
The recommended staffing and training approach to establish GRACE care team(s) across the region.
How clients and households are identified to be part of the study cohort
How will medical community learn about the GRACE model and the local implementation

Evaluation plan to support analysis to study client, family and financial ROI as well as a path for sustainable funding including elements that consider:

Financial ROI inclusive of: Emergency Room visits; Hospitalizations; Readmission rates; Hospital cost comparison compared to control group; Transition rate from home to institutionalization after age 65
Client, family caregiver, and family satisfaction

Workforce and employed caregiver satisfaction: Clinician satisfaction; Employed caregiver satisfaction; Employed caregiver turnover
Enhance well being by assisting with Goals of Care and Advanced Care Planning

Total costs including

The length of the pilot study needed to meet the ROI evaluation component
The total cost for implementing including the evaluation
Opportunities for grant funding and in-kind resources for implementation

The consultant will be responsible for the following:

Working closely with the co-conveners to achieve the deliverables outlined above.
Convening a core group of clinicians and key partners not to exceed 12 participants over a period of 6-8 months
Consult 20+ local experts on the issues and care for the study cohort population.
Facilitate at least 4 learning opportunities for the healthcare community to learn about the GRACE model
Handle all logistics with all meetings including minutes and other relevant documentation
Gather and assemble locally specific data using either known information or extrapolating from national and state level information
Seek out examples of GRACE implementations in other rural communities.
Write the Implementation plan inclusive of a comprehensive budget
Define the leadership and oversight group for the duration of the pilot study
Obtain baseline data for program and evaluation

Applicants must have extensive experience facilitating meetings and experience working in and with healthcare functions.