Annual Wellness Visits vs GRACE-augmented Annual Wellness Visits For Older Adults With High Needs - Phase 1
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:

Co-design a community-centric implementation strategy for the AWVs vs AWVs + GRACE -augmented care (AWV GRACE) study arms
Develop a referral pathway and algorithm to optimize enrollment of eligible participants
Conduct a pilot clinical trial to assess the feasibility of the AWV GRACE intervention.
- EligibilityCriteria: Inclusion Criteria:  be 65 years of age or older be eligible for an AWV during the study period have a residential mailing address within a 45-mile radius of the Vanderbilt clinics have a working home/mobile telephone number where they can be reached be English or Spanish speaking be able to provide consent and /or have a proxy able to consent to study participation  Exclusion Criteria:  are receiving hospice care are currently housed at Long Term Care Facilities are incarcerated - HealthyVolunteers: No - Gender: All - MinimumAge: 65 Years - StdAgeList: Older Adult