Supporting Practices In Respecting Elders Phase 2
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.
• 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.)