Comparing Annual Wellness Visits with and without GRACE Support for Older Adults with Complex Health Needs

What this Trial Is About

Researchers are evaluating the feasibility and impact of adding the Geriatric Resources and Assessment for the Care of Elders GRACE model to structured Annual Wellness Visits AWVs for older adults with complex health needs. This study aims to improve patient and caregiver outcomes and reduce hospitalizations among this vulnerable population. The study includes three main goals designing a community-focused implementation strategy, creating a referral pathway to enroll eligible participants, and conducting a pilot clinical trial to assess the interventions feasibility. The study compares two groups one receiving the standard AWV and the other receiving AWVs augmented with the GRACE program. AWVs involve completing a structured questionnaire to guide personalized care plans, while the AWVGRACE group receives additional in-home assessments by a nurse practitioner and social worker team. This team develops individualized care plans addressing various geriatric conditions using evidence-based protocols. Practices are randomized to either group, with around 90 participants recruited per practice. Participants will be involved in surveys before the intervention and 18 months later to assess outcomes such as hospitalizations, patient experience, physical and mental health, caregiver strain, and clinician well-being. Data collection includes the Consumer Assessment of Healthcare Providers and Systems Clinician and Group Survey CG-CAHPS and other health measures. The study will last over two years, with monitoring at 12, 18, and 24 months to evaluate the impact of the interventions on high-risk older adults.

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