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Annual Wellness Visits vs GRACE-augmented Annual Wellness Visits For Older Adults With High Needs - Phase 2
Supporting Practices In Respecting Elders Phase 2
Who can join
Ages 18 and older · All sexes
Full eligibility criteria
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.)
About the study
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) to improve patient and caregiver outcomes and reduce hospitalizations in older adults with complex health needs. The objectives are to:
1. Co-design a community-centric implementation strategy for the AWVs vs AWVs + GRACE -augmented care (AWV GRACE) study arms 2. Develop a referral pathway and algorithm to optimize enrollment of eligible participants 3. Conduct a pilot clinical trial to assess the feasibility of the AWV GRACE intervention.
What is being tested
- Annual Wellness Visit (other)
- Annual Wellness Visits + Geriatric Resources and Assessment for the Care of Elders (AWV + GRACE) (other)
Sponsor: Massachusetts General Hospital · Participants: 6,080 · Started: Jan 6, 2026
Contact the study team
- Christine S Ritchie, MD, MPH · Phone: 617-726-1382
Official record on ClinicalTrials.gov — NCT07166861
Locations in the U.S.
| Connecticut | Griffin Health, Derby (Not yet recruiting) |
| Massachusetts | Mass General Brigham, Boston (Not yet recruiting) |
| North Carolina | Atrium Health Wake Forest Baptist, Winston-Salem |
| Texas | Baylor Scott & White Health, Temple (Not yet recruiting) |
From ClinicalTrials.gov, data retrieved Sep 30, 2026. Each study sets its own eligibility; the study team decides who can join.