What is this study trying to find out about older adults with complex health needs?

This study is evaluating how adding the GRACE care model to Annual Wellness Visits affects outcomes for older adults with complex needs. Researchers aim to see if this combined approach improves patient and caregiver experiences and reduces hospital visits. The study is sponsored by Massachusetts General Hospital to help improve care for high-need seniors.

Who may be eligible for this aging clinical trial?

Adults aged 65 or older who are eligible for Medicare Annual Wellness Visits and live within reach of the study's home visits may qualify. Participants must speak English or Spanish and have complex health needs based on specific health risk scores. Please review eligibility criteria for more details.

Is there any cost to participate in this aging clinical trial?

Study-related care, including the Annual Wellness Visit and the GRACE program, along with all trial visits, is provided at no cost. Personal travel expenses may vary and are not guaranteed to be covered. Participants can expect that all study procedures related to care are free.

Actively Recruiting

Phase Not Applicable

Age: 18Years +

All Genders

ID07166861

Supporting Practices In Respecting Elders Phase 2 Annual Wellness Visits Compared with GRACE-Augmented Care for Older Adults with Complex Needs

Led by Massachusetts General Hospital · Updated on 2026-01-22

6080

Participants Needed

Research Sites

13 weeks

Total Duration

AI-Summary

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.

CONDITIONS

Brief Title

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

Who Can Participate

Age: 18Years +

All Genders

Eligibility Criteria

You may qualify if you...

Age 65 years or older
Eligible for an Annual Wellness Visit (Medicare/Medicare Advantage) during the study period
Live within a reachable distance for a home visit by the practice
Speak English or Spanish
Able to provide consent or have a proxy who can consent
Have complex health care needs defined by a Probability of Repeated Admissions score of 0.35 or higher and/or a Kim Syndrome on Aging score of 0.35 or higher
Caregivers must be 18 years or older, English or Spanish speaking, able to consent, and identified by an eligible patient
Clinicians must be 18 years or older, English or Spanish speaking, able to consent, and work at participating ACOs or primary care sites

You will not qualify if you...

Research Team

Christine S Ritchie, MD, MPH

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