Effectiveness and Implementation of Geriatrics Resources for Assessment and Care of Elders With HIV (GRACE-HIV) (GRACE-HIV)

The GRACE-HIV intervention is a 24-month intervention of RN care coordination guided by a multidisciplinary geriatric and HIV or "GRACE HIV" support team conducted in collaboration with a participant's health care team including any community service providers.

Study Overview

• Status: Not yet recruiting
• Conditions: HIV; Geriatrics; Geriatric Assessment; Collaborative Care
• Intervention / Treatment: Behavioral: GRACE-HIV

Detailed Description

The GRACE-HIV intervention is a 24-month intervention of RN care coordination guided by a multidisciplinary geriatric and HIV or "GRACE HIV" support team conducted in collaboration with a participant's health care team including any community service providers. The intervention is designed to integrate geriatric and HIV services to ensure older adults with HIV experiencing poverty receive appropriate and evidence based care for comorbid and geriatric conditions.

• Study Type: Interventional
• Enrollment (Estimated): 372
• Phase: Not Applicable

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 50 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Eligible participants will be a) age 50 or older, b) receive HIV care (at least 1 visit at the same site within the past 12 months) from either Eskenazi Health IDC or LifeCare clinics, c) able to provide informed consent or have a legally authorized representative provide informed consent based on teach back processes described in recruitment procedures below , d) have a household income below 300% of the federal poverty level, and e) be English or Spanish speaking. The income criteria correspond to the eligibility criteria to receive Ryan White Services in Indiana.

Exclusion Criteria:

• We will exclude patients who are long-term nursing home residents as the nursing home team is their primary medical team and Ryan White funding does not support long term care services.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: GRACE-HIV	Behavioral: GRACE-HIV; Each participant randomized to the intervention will undergo an initial visit at their home or preferred location, where the RN will conduct a comprehensive geriatric assessment including physical, cognitive, functional, psychosocial and community needs assessment, and a medication review including prescribed and over the counter medications. After the initial visit, the RN attends the weekly multidisciplinary team meeting to discuss the findings which trigger evidence-based geriatric HIV care protocols for inclusion in the personalized care plan. After multidisciplinary review, the RN will coordinate with the participant's HIV care team, and when relevant, with primary care, specialists, pharmacists, social workers, and community service organizations to refine and implement the care plan.
No Intervention: Measure of Usual Care

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Health Related Quality of Life	Medical Outcomes Short Form Survey36 (SF-36) to measure health related quality of life. The SF-36 includes eight scales measuring domains of physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional, and mental health. Our primary outcome measure is the Component Summary Scores	Baseline, 6month, 12 month, 18month and 24 month.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Geriatric Syndrome Identification and Management	This outcome is a 24-month participant level Geriatric Syndrome Identification and Management Process Score, derived from EHR, medication, and referral data in both study arms. The composite will be defined as the number of eligible care processes completed divided by the number of eligible care processes during 24 months of follow-up. Components will include: (1) identification of key geriatric syndromes in the EHR, including falls/fall risk, depression, cognitive impairment or dementia, urinary incontinence, and polypharmacy and (2) management of identified syndromes, including medication reconciliation, syndrome-specific treatment or referral, prescribing of indicated medications such as antidepressants or dementia medications when clinically appropriate, and deprescribing of potentially inappropriate medications. Higher scores will indicate better delivery of recommended geriatric care processes.	Baseline, 6month, 12 month, 18month and 24 month.
Acute care healthcare utilization	We will collect emergency department visits and hospitalization data from the Indiana Network for Patient Care, the health information exchange for the State of Indiana.	Baseline, 6month, 12 month, 18month and 24 month.

Collaborators and Investigators

• Sponsor: Indiana University
• Collaborators: National Institute on Aging (NIA)

Study record dates

Study Major Dates

• Study Start (Estimated): March 1, 2027
• Primary Completion (Estimated): June 1, 2032
• Study Completion (Estimated): June 1, 2032

Study Registration Dates

• First Submitted: November 9, 2026
• First Submitted That Met QC Criteria: November 9, 2026
• First Posted (Actual): November 13, 2026

Study Record Updates

• Last Update Posted (Actual): November 13, 2026
• Last Update Submitted That Met QC Criteria: November 9, 2026
• Last Verified: November 1, 2026

More Information

Terms related to this study

• Other Study ID Numbers: 32913; 1R01AG102221-01 (U.S. NIH Grant/Contract)

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No