Annual Wellness Visits for Older Adults with High Needs

This study is looking at ways to improve care for older adults with complex health needs. It compares two approaches: the standard Annual Wellness Visit (AWV) and an AWV augmented with the Geriatric Resources and Assessment for the Care of Elders (GRACE) program. The GRACE program involves a team of healthcare professionals working with you and your caregivers to create personalized care plans. The study aims to see if adding GRACE can reduce hospitalizations and improve your experience with healthcare. You may be able to join if you are 65 or older, eligible for an AWV, and can provide consent. The study is currently unclear on its recruitment status and plans to enroll 6080 participants.

Study design
This is an interventional study comparing two different approaches to Annual Wellness Visits. It plans to enroll 6080 participants.
What's involved
Not specified in the trial record.
Compensation
Not stated in the trial record.
Follow-up
Your hospitalizations will be tracked for 12, 18, and 24 months. Your patient experience will be assessed at the beginning of the study and at 18 months.

AI-generated from the public study record. Only the study team can confirm whether you're eligible — confirm details with them before making decisions.

NCT07166861

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

Recruiting
NAAges 18+InterventionalHealth services
Massachusetts General Hospital
~6,080 participants
Updated 2026-01-22 on ClinicalTrials.gov
What's tested:Annual Wellness VisitAnnual Wellness Visits + Geriatric Resources and Assessment for the Care of Elders (AWV + GRACE)

At a glance

Recruiting sites
1 of 4 listed sites are recruiting right now
RecruitingSuspended, closed, or not yet open
What they're measuring
Hospitalizations
Measured over 12, 18, and 24 months.
+1 more outcome measured
Aging
Preventive Care
Multimorbidity
Palliative Care

NCT07166861

Where you'd take part

This study runs at 4 sites. They're the same protocol — you choose where, and that choice sets who your contact draft is addressed to.

  • Atrium Health Wake Forest Baptist

    Winston-Salem, North Carolinastudy coordinator listed

    Recruiting

  • Baylor Scott & White Health

    Temple, Texasstudy coordinator listed

    Not yet recruiting

  • Griffin Health

    Derby, Connecticutstudy coordinator listed

    Not yet recruiting

  • Mass General Brigham

    Boston, Massachusettsstudy coordinator listed

    Not yet recruiting

Sites open and close at different times, so the status above is per site — it can differ from the study's overall status.

Opens a ready-to-send draft in your own email app — review before sending.

Want this trial checked against your situation?

Add a private profile and we'll compare every criterion below against your situation — and tell you which ones are met, uncertain, or excluding.

Check eligibility for this trial ~2 min · HIPAA-protected · delete anytime
Eligibility criteria

Inclusion

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
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
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.)
  • Hospitalizations12, 18, and 24 months.

    Count of hospitalizations during the observation period, evaluated at the participant level.

  • Patient experience: Consumer Assessment of Healthcare Providers and Systems Clinician and Group Survey (CG-CAHPS) with Patient Centered Medical Home 1.0 supplement (PCMH CAHPS)Baseline and 18 months.

    The CAHPS Clinician \& Group Survey (CG-CAHPS) asks patients to report on their experiences with providers and staff in primary care and specialty care settings, using a 6 month recall period. The Patient-Centered Medical Home (PCMH) Item Set is a set of supplemental questions that is added to the adult version of the CAHPS Clinician \& Group Survey (CG-CAHPS) to gather more information on patient experience with the domains of primary care that define a medical home. Scoring for most items is on a 4 point scale 1=never 2=sometimes 3=usually 4=Always. Minimum and Maximum scores vary with the number of items used. The Provider Rating item is on a 11 point scale from 0 to 10,where 9,10 are considered "high" scores.