Status:

NOT_YET_RECRUITING

Annual Wellness Visits vs GRACE-augmented Annual Wellness Visits For Older Adults With High Needs - Phase 2

Lead Sponsor:

Massachusetts General Hospital

Collaborating Sponsors:

Brandeis University

Indiana University School of Medicine

Conditions:

Aging

Preventive Care

Eligibility:

All Genders

18+ years

Phase:

NA

Brief Summary

This study consists of three aims focused on examining the feasibility of adding the Geriatric Resources and Assessment for the Care of Elders (GRACE) model to structured Annual Wellness Visits (AWVs)...

Detailed Description

In the United States, 10% of patients account for half of health care costs. Many of these are older adults with complex health and social care needs (referred to as "older adults with complex needs")...

Eligibility Criteria

Inclusion

  • Patient Inclusion Criteria:
  • Age 65 years or older
  • Eligible for an AWV (Medicare/Medicare Advantage) during the study period
  • Residential mailing address within a radius of the practice that can be achievably reached via a home visit
  • English or Spanish speaking
  • Be able to provide consent and / or have a proxy able to consent to study participation.
  • Meet criteria for complex health care needs, by virtue of having a Probability of Repeated Admissions (PRA) score of 0.35 or greater AND/OR Kim Syndrome on Aging (efrailty indicator) score of 0.35 or greater
  • Caregiver Inclusion Criteria:
  • Age 18 years or older
  • English or Spanish speaking
  • Be able to provide consent to study participation
  • Be identified by an eligible patient for participation in the study
  • Clinician Inclusion Criteria:
  • Age 18 years or older
  • English or Spanish speaking
  • Be able to provide consent to study participation
  • Adult health professionals who work at participating ACOs and primary care practice sites (e.g. physicians, advanced practice clinicians, nurses, social workers, clinic staff.)

Exclusion

    Key Trial Info

    Start Date :

    January 1 2026

    Trial Type :

    INTERVENTIONAL

    Allocation :

    ESTIMATED

    End Date :

    January 1 2030

    Estimated Enrollment :

    6080 Patients enrolled

    Trial Details

    Trial ID

    NCT07166861

    Start Date

    January 1 2026

    End Date

    January 1 2030

    Last Update

    December 30 2025

    Active Locations (4)

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    Page 1 of 1 (4 locations)

    1

    Griffin Health

    Derby, Connecticut, United States, 06418

    2

    Mass General Brigham

    Boston, Massachusetts, United States, 02124

    3

    Atrium Health Wake Forest Baptist

    Winston-Salem, North Carolina, United States, 27157

    4

    Baylor Scott & White Health

    Temple, Texas, United States, 76508

    Annual Wellness Visits vs GRACE-augmented Annual Wellness Visits For Older Adults With High Needs - Phase 2 | DecenTrialz