Annual Wellness Visit Research Articles

Expansion of a postgraduate year 2 ambulatory care pharmacy residency program utilizing Medicare annual wellness visits within primary care

BackgroundFunding for pharmacy residency programs is traditionally allocated by the Centers for Medicare and Medicaid Services. In 2003, funding for postgraduate year 2 (PGY-2) was retracted. PGY-2 sites must develop additional funding methods to facilitate program expansion. ObjectiveTo describe the impact of expanding a PGY-2 ambulatory care pharmacy residency through an innovative funding model. Practice descriptionSt. Joseph’s/Candler Health System (SJC) employs pharmacists, including ambulatory care pharmacists, supported by revenue from Medicare annual wellness visits (AWVs) and pharmacy residents. Practice innovationThe PGY-2 ambulatory care program at SJC historically offered 1 position supported by SJC. The program expanded in 2020 to further patient outreach with disease state management by increasing the number of pharmacists providing comprehensive patient care. The additional position was primarily supported using funding from AWVs completed by pharmacy residents. To ensure adherence with the American Society of Health-System Pharmacists, residents were evaluated quarterly by preceptor based on feedback provided by clinicians at the practice site. Evaluation methodsIn addition to conducting AWVs, residents worked with physicians within the state-defined scope of practice to optimize medications, support office visits, promote medication adherence and antimicrobial stewardship improvement activities, and implement a blood pressure monitoring program. ResultsFrom July 15, 2020 to March 31, 2021, 407 AWVs were completed by SJC PGY-2 ambulatory care residents, and average AWVs per day increased from 4.5 to 6.9. As compared with the previous year, total AWVs at the primary clinic doubled after pharmacy resident addition, increasing from 251 to 550 (P < 0.001). ConclusionThrough an additional position fiscally supported by reimbursement from AWVs, SJC Ambulatory Care PGY-2 residents increased patient outreach to preventative services as compared with the previous year, expanded pharmacy practice to a new practice site, and generated revenue. This funding method is a viable option to expand postgraduate pharmacy training and ensure optimal patient care in the outpatient setting.

Reimbursement for clinical services provided by ambulatory care pharmacists via telehealth

AbstractIntroductionData specific to pharmacists' value in patient‐provided clinical services in New York are limited due to their scope of practice restrictions. However, due to the coronavirus disease 2019 (COVID‐19) pandemic, there has been an expansion of telehealth and allowance for billable services for pharmacists.ObjectivesThe objective of this study was to complete a retrospective review to assess reimbursement of clinical services provided by pharmacists via telehealth during the pandemic in a primary care setting.MethodsA report was generated which identified patients 18 years and older, who were provided services by pharmacists within a primary care group via telehealth during March to July 2020 in New York. It identified patients with an appointment type code of “PharmD Telemed 30” or “PharmD TM Follow UP 15,” including Medicare Annual Wellness Visits or AWVs (G0438‐G0439) with procedural codes, and incident‐to CPT codes (99211‐99214). Information received included medical record number, name, date of birth, carrier plan name, billed procedure code and description, carrier payment amount, and patient responsible amount.ResultsA total of 485 patients were provided services during the timeframe. There were 223 encounters billed for the 99 211 CPT code, 156 of which received payment from insurers with an average of $20.14. For initial and subsequent AWVs there were a total of 48 and 150 encounters, respectively, billed by the pharmacists. Forty‐one of the encounters billed as a G0438 received payment from insurers with an average of $175.75. One hundred thirty‐three of the encounters billed as a G0439 received payment from insurers with an average payment of $114.09.ConclusionThe results of this study provided insight into whether specific services or insurances should be targeted for payment of services. Expansion of these services could show improvement in patient care and can assist in gathering outcomes to better support pharmacists gaining provider status on the state and national level.

145-OR: Annual Wellness Visits Are Associated with Increased Use of Diabetes Preventive Services in the Diabetes Belt and Surrounding Counties

Background: The Affordable Care Act created annual wellness visits (AWVs) for Medicare beneficiaries to have one yearly visit to primary care physicians and discuss preventive care for the upcoming year. We assessed whether AWVs were associated with increased use of these preventive services in Medicare patients with diabetes living in the Diabetes Belt and surrounding counties. Methods: We used claims files from a longitudinal sample of ∼1,000,000 Medicare patients with diabetes living in the diabetes belt or surrounding counties, covering years 2014-2015. The Diabetes Belt was identified by the CDC as 644 counties across Appalachian and southeastern counties in the US that had diabetes prevalence ≥ 11% in 2008. We used these data to examine associations between AWVs and preventive service use in the next year. We examined four preventive services recommended annually for patients with diabetes by the ADA, including A1c tests, foot exam, eye exam, and microalbuminuria (MA) tests. Results: Of all patients, only 19.6% used AWVs in 2015. Eye exams (61% vs. 56%), foot exams (92% vs. 83%), A1C tests (78% vs. 73%), and MA tests (42% vs. 31%) were more common among patients who had an AWV in the preceding year compared with those who did not. These differences remained after adjusting for patient demographics, comorbidities, county level medical resources, and geographic factors: eye exam (Odds Ratio 1.13, 95% CI 1.12-1.15); A1c Test (1.28, CI 1.26-1.31); Foot Exam (2.06, CI 2.01-2.11); MA Test (1.45, CI 1.42-1.47). Conclusions: This study shows that AWVs were significantly associated with increased recommended preventive care use among patients with diabetes living in and near the diabetes belt. The low rates of AWV utilization by patients with diabetes in and around the Diabetes Belt is concerning and should receive more policy attention. Disclosure T. L. Mcmurry: None. S. Kim: None. J. M. Lobo: None. H. Kang: None. M. Sohn: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (R01DK113295)

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Return-On-Investment for Billable Pharmacist-Provided Services in the Primary Care Setting

Background: Pharmacists are increasingly fulfilling roles on primary care teams, yet business models for pharmacist services in these settings have not been optimized. This study describes how an ambulatory care pharmacy department implemented various billing methods to generate revenue for pharmacist services. Objectives: (1) Describe pharmacist-delivered billable and non-billable services; and (2) Assess the impact of various billing methods on the return-on-investment (ROI) for billable services. Methods: This study was conducted from September 2016 to August 2017 in Virginia. Pharmacist time spent performing billable encounters using current procedural technology (CPT) codes (e.g., incident-to a physician, annual wellness visits) was calculated. Encounters eligible for the hospital-based facility (G0463) and chronic care management (CCM) codes were considered to be potentially billable services. The ROI was calculated for billable and potentially billable services. Results: A total of 948.3 hours (0.46 full-time equivalents (FTE)), 17% of all clinical services, were billed using CPT codes. This resulted in a total revenue of $173,638.66. Missed revenue from not billing for the G0463 and CCM codes was $68,268.37. The cost of pharmacist services for 0.46 FTE was $78,613.08, resulting in a ROI for billed pharmacist services of 1.2:1. The ROI increased to 1.6:1 when considering potentially billable services. Conclusion: It is feasible to have a positive ROI for billable pharmacist services. To achieve a sustainable business model, there must be a high volume of billable services. G0463 and CCM codes are often underutilized, yet represent significant opportunities in revenue for pharmacist services and should be pursued.

Annual wellness visits and care management before and after dialysis initiation

IntroductionDemands of dialysis regimens may pose challenges for primary care provider (PCP) engagement and timely preventive care. This is especially the case for patients initiating dialysis adjusting to new logistical challenges and management of symptoms and existing comorbid conditions. Since 2011, Medicare has provided coverage for annual wellness visits (AWV), which are primarily conducted by PCPs and may be useful for older adults undergoing dialysis.MethodsWe used the OptumLabs® Data Warehouse to identify a cohort of 1,794 Medicare Advantage (MA) enrollees initiating dialysis in 2014–2017 and examined whether MA enrollees (1) were seen by a PCP during an outpatient visit and (2) received an AWV in the year following dialysis initiation.ResultsIn the year after initiating dialysis, 93 % of MA enrollees had an outpatient PCP visit but only 24 % received an annual wellness visit. MA enrollees were less likely to see a PCP if they had Charlson comorbidity scores between 0 and 5 than those with scores 6–9 (odds ratio (OR) = 0.59, 95 % CI: 0.37–0.95), but more likely if seen by a nephrologist (OR = 1.60, 95 % CI: 1.01–2.52) or a PCP (OR = 15.65, 95 % CI: 9.26–26.46) prior to initiation. Following dialysis initiation, 24 % of MA enrollees had an AWV. Hispanic MA enrollees were less likely (OR = 0.57, 95 % CI: 0.39–0.84) to have an AWV than White MA enrollees, but enrollees were more likely if they initiated peritoneal dialysis (OR = 1.54, 95 % CI: 1.07–2.23) or had an AWV in the year before dialysis initiation (OR = 4.96, 95 % CI: 3.88–6.34).ConclusionsAWVs are provided at low rates to MA enrollees initiating dialysis, particularly Hispanic enrollees, and represent a missed opportunity for better care management for patients with ESKD. Increasing patient awareness and provider provision of AWV use among dialysis patients may be needed, to realize better preventive care for dialysis patients.

Rare Case of Huge Adrenocortical Carcinoma in Surprisingly Asymptomatic Patient

Introduction: Adrenal Carcinoma (AC) is a rare endocrine malignancy of the adrenal glands. It can affect up to 3–10% of the human population. It is common in children as secondary malignancies or as a manifestation of a tumor syndrome. Typically patients with AC start to become symptomatic after extensive tumor development- 10–13 cm. The presentation of AC includes signs of hormone excess. The most common hormone in excess is cortisol. Thus individuals with AC typically present with symptoms of hypercortisolism or Cushing’s Syndrome. In chronic cases the high concentration of glucocorticoids can start stimulating aldosterone receptors causing hypertension and hypokalemia. Furthermore, patients with AC also have symptoms of tumor growth, such as abdominal pain, flank pain, and early satiety. Currently prognostic factors for AC are undefined. AC generally has a poor prognosis as a majority of patients are diagnosed during advanced stage of disease (stage IV). Furthermore, it was found that patients with stage IV disease had a survival of less than one year. Currently the only curative treatment is complete tumor resection. Medical management with chemotherapy can be utilized in cases of extensive metastasis and poor prognosis. A common chemotherapeutic agent is mitotane, which is a steroidogenesis inhibitor. Case Presentation:Patient is a 19 year old female, who initially presented to her primary care provider’s (PCP) office for an annual wellness visit during August 2020. She was subsequently discovered to have elevated blood pressure. At this time she was not symptomatic. She was advised on lifestyle modifications. She was also stopped on her birth control medication. Furthermore, she later presented to her PCP with continued elevated blood pressure, still not symptomatic. In an outpatient cardiology office, she presented with blood pressures in the 200s/100s range and a new murmur. She was sent to the ED for evaluation (11/2020). On her presentation to the ED, she still did not have any symptoms. She also denied any fatigue or unintentional weight changes. Her only concern was mild edema in the lower legs after standing for extended periods of time. Her medical history was insignificant. Her family history was significant for her paternal essential HTN diagnosed in the early 20s. Laboratory evaluation revealed unremarkable electrolyte levels and CBC. Furthermore, her TSH level was also normal. A chest ray revealed multiple pulmonary nodules ranging from 3–5 mm. A renal ultrasound revealed a large mass in the RUQ (16.9x9.6x12 cm). She was also found to have mildly elevated cortisol levels at 22.9, suppressed ACTH levels, and normal levels of aldosterone and metanephrines. Subsequent CT imaging and biopsy revealed adrenal carcinoma with extensive metastasis to the lungs and liver. Patient was referred to Oncology service to start Chemotherapy.

Conversations about wellness: A qualitative analysis of patient narratives post annual wellness visit

Support for successful aging in place requires an understanding of the factors that impede or support health promotion behaviors. Nurse-led monthly follow-up calls between annual wellness visits (AWV) offer the opportunity to both provide support and collect data which can inform development of effective health promotion strategies. The aim of this research was to provide ongoing support for health promotion efforts and explore factors playing a role in meeting AWV recommendations. A total of 144 visit summaries for 47 Medicare beneficiaries (65+) who had completed an AWV within the last year were analyzed using a thematic approach. Themes were organized into 7 categories with findings indicating the complexity of factors which influence health promotion behaviors. The importance of ensuring personalization of health promotion recommendations using data collected during the AWV and provision of ongoing support between visits may enhance health outcomes.

Building Cancer Prevention and Control Research Capacity in Rural Appalachian Kentucky Primary Care Clinics During COVID-19: Development and Adaptation of a Multilevel Colorectal Cancer Screening Project.

This study describes the development of a colorectal cancer (CRC) screening multilevel intervention with four primary care clinics in rural Appalachian Kentucky. We also discuss barriers experienced by the clinics during COVID-19 and how clinic limitations and needs informed project modifications. Four primary care clinics were recruited, key informant interviews with clinic providers were conducted, electronic health record (EHR) capacity to collect data related to CRC screening and follow-up was assessed, and a series of meetings were held with clinic champions to discuss implementation of strategies to impact clinic CRC screening rates. Analysis of interviews revealed multilevel barriers to CRC screening. Patient-level barriers included fatalism, competing priorities, and financial and literacy concerns. The main provider- and clinic-level barriers were provider preference for colonoscopy over stool-based testing and EHR tracking concerns. Clinics selected strategies to address barriers, but the onset of COVID-19 necessitated modifications to these strategies. Due to COVID-19, changes in clinic staffing and workflow occurred, including provider furloughs, a state-mandated pause in elective procedures, and an increase in telehealth. Clinics adapted screening strategies to match changing needs, including shifting from paper to digital educational tools and using telehealth to increase annual wellness visits for screening promotion. While significant delays persist for scheduling colonoscopies, clinics were encouraged to promote stool-based tests as a primary screening modality for average-risk patients.

Implementation of Universal Adolescent Depression Screening: Quality Improvement Outcomes

Introduction Despite the increasing incidence of adolescent depression, suicide and evidence-based recommendations for adolescent depression screening, 70% of teens report not discussing depression with their provider. The aim of this quality improvement project was to improve the identification and management of adolescent depression by implementing a practice-based, universal depression screening. Method The Patient Health Questionnaire-9 modified for Adolescents was implemented during annual wellness visits for adolescents aged 12–18 years over 3 months. Retrospective chart reviews were conducted to determine a change in the rates of depression screening, depression diagnoses, referrals to mental health, and pharmaceutical treatment of depression. Results Pre/postimplementation data were compared. Documented adolescent depression screening increased from 0% to 74.5%. Increased rates of diagnosed depression (12.1%), mental health referrals (8%), and pharmaceutical treatment of depression (4.9%) were clinically and statistically significant. Discussion Adopting evidence-based recommendations for universal depression screening in pediatric primary care can improve the early diagnosis and management of adolescent depression. Despite the increasing incidence of adolescent depression, suicide and evidence-based recommendations for adolescent depression screening, 70% of teens report not discussing depression with their provider. The aim of this quality improvement project was to improve the identification and management of adolescent depression by implementing a practice-based, universal depression screening. The Patient Health Questionnaire-9 modified for Adolescents was implemented during annual wellness visits for adolescents aged 12–18 years over 3 months. Retrospective chart reviews were conducted to determine a change in the rates of depression screening, depression diagnoses, referrals to mental health, and pharmaceutical treatment of depression. Pre/postimplementation data were compared. Documented adolescent depression screening increased from 0% to 74.5%. Increased rates of diagnosed depression (12.1%), mental health referrals (8%), and pharmaceutical treatment of depression (4.9%) were clinically and statistically significant. Adopting evidence-based recommendations for universal depression screening in pediatric primary care can improve the early diagnosis and management of adolescent depression. Jeff Bose, Nurse Practitioner, Kiddie West Pediatric Center, Columbus, OH. Rosie Zeno, Assistant Professor of Clinical Nursing and Director of MS in Nursing Program, The Ohio State University, Columbus, OH. Barbara Warren, Professor of Clinical Nursing and Psychiatric Mental Health Nursing Across the Lifespan Specialty Track Director, The Ohio State University, Columbus, OH. Loraine T. Sinnott, Research Statistician, The Ohio State University, Columbus, OH. Elizabeth A. Fitzgerald, Associate Professor of Clinical Nursing, The Ohio State University, Columbus, OH.

Variation in biochemistry test results between annual wellness visits in apparently healthy Golden Retrievers.

BackgroundAnnual wellness testing is widely recommended for apparently healthy dogs, but there is little data to assist with distinguishing normal variation from clinically important changes.ObjectivesTo define variability in biochemistry analytes between annual wellness tests in healthy Golden Retrievers.AnimalsFour hundred thirty‐four Golden Retrievers undergoing annual health assessments by their primary care veterinarians as part of a prospective cohort study.MethodsChanges in 23 biochemistry analytes were calculated between year 1 and year 2 health checks for 196 dogs classified as healthy for ≥3 consecutive years. Using a direct nonparametric method, annual change intervals were constructed to define normal variability. A validation cohort of 238 dogs without a diagnosis of systemic disease for ≥3 consecutive years were compared with the reference and annual change intervals, and the proportions of dogs outside annual change intervals and a population‐based reference interval were compared by using a McNemar test.ResultsAnnual change intervals were calculated based on 190 dogs after outlier removal. For all 23 analytes, >90% of dogs in the validation cohort were within the annual change interval. There were no significant differences in the classification by reference versus annual change intervals.Conclusions and Clinical ImportanceThe annual change intervals met performance requirements for classification of dogs that did not develop systemic disease in the year following wellness testing as normal.

The effect of direct cognitive assessment in the Medicare annual wellness visit on dementia diagnosis rates.

To evaluate the relationship between direct cognitive assessment introduced with the Medicare Annual Wellness Visit (AWV) and new diagnoses of dementia, and to determine if effects vary by race. Medicare Limited Data Set 5% sample claims 2003-2014 and the HRSA Area Health Resources Files. Instrumental Variable approach estimating the relationship between AWV utilization and new diagnoses of dementia using county-level Welcome to Medicare Visit rates as an instrument. Three hundred twenty-four thousand three hundred and eighty-five fee-for-service Medicare beneficiaries without dementia when the AWV was introduced in 2011. Annual Wellness Visit utilization was associated with an increased probability of new dementia diagnosis with effects varying by racial group (categorized as white, black, Hispanic/Latino, or Asian based on Social Security Administration data). Hazard ratios (95% confidence intervals) for new dementia diagnosis within 6months of AWV utilization were as follows: 2.34 (2.13, 2.58) white, 2.22 (1.71, 2.89) black, 4.82 (2.94, 7.89) Asian, and 6.14 (3.70, 10.19) Hispanic (P<.001 for each). Our findings show that estimates that do not control for selection underestimate the effect of AWV on new diagnoses. Dementia diagnosis rates increased with AWV implementation with heterogenous effects by race and ethnicity. Current recommendations by the United States Preventive Services Task Force state that the evidence is insufficient to recommend for or against screening for cognitive impairment in older adults.

Enhancing Annual Wellness Visit Outcomes: Patient Perceptions and Provider Practices

This brief report describes factors that impact the effectiveness of Medicare’s Annual Wellness Visit (AWV). Patients who participated in an AWV at a large accountable care organization were contacted monthly via phone for up to 1 year to discuss their health promotion efforts. Data from visit narratives and secondary review of AWV documentation by researchers indicate that improved efforts are needed to ensure personalization of recommendations and support patient health promotion efforts. Enhancement of the AWV process, workflow redesign, and development of strategies to provide ongoing support between AWVs are vital to improve AWV outcomes.

Factors influencing implementation of personalized prevention plans among annual wellness visit patients using the theory of planned behavior: A quantitative study.

The Affordable Care Act provides Medicare Part B beneficiaries access to cost-free Annual Wellness Visits (AWVs). Patients receive health behavior recommendations from a Personalized Prevention Plan (PPP) during AWV encounters. To identify factors clinical pharmacists can use to influence adoption of PPPs in primary care practices. Utilizing a cross-sectional design, 77 Medicare patients (mean age 74.05 ± 8.04 years) presenting for subsequent AWV completed a theory of planned behavior (TPB) based questionnaire at two primary care practices. 66.2% reported they were in the process of implementing PPPs and 51.9% reported implementing recommendations in the previous 12 months. TPB constructs accounted for 35.8% (p < .001) of the variation in intention, with subjective norm (SN) (β = 0.359, p = 0.004) as the strongest determinant, followed by attitude (β = 0.195, p = 0.093), and perceived behavioral control (PBC) (β = 0.103, p = 0.384). Intention accounted for 27.1% of the variance for implementing PPPs and was not a significant determinant (β = 0.047, p = 0.917). Addition of past behavior with TPB constructs significantly improved the predictability of the TPB model, accounted for 55% of the variation in intention (p < .001), and demonstrated a significant positive influence (β = 0.636, p < 0.001) on future PPP implementations. This study demonstrates utility of the TPB in predicting implementation of PPPs. Clinical pharmacists positioned as providers of AWVs can strengthen intention to adopt PPPs by integrating referents into AWV processes, and evaluating past behavior trends to improve future PPP implementation.

Medicare Annual Wellness Visit for Nursing Home Residents

The 2010 Patient Protection and Affordable Care Act includes the Annual Wellness Visit (AWV) for older adult (OA) patients. Medicare pays for an initial AWV per beneficiary and subsequent visits annually. Many Medicare beneficiaries have not taken advantage of the AWV preventive health benefit. The Saint Louis University Geriatrics Workforce Enhancement Program (GWEP) developed an AWV for OA, NH residents. This project describes the NH AWV and reports results. Data include age, gender, comorbidities, medications, hospitalizations, depression, frailty, pain, sarcopenia, sensory impairment, cognition, nutrition, smoking, falls, and advance directives. Two suburban academic for-profit NHs are included in this study (2016-17). OA NH residents (N=247) completed an AWV and 36.8% (n=91) had a 1-year follow-up AWV. OA NH residents were female (n = 177, 71.7%) and a majority ages 75+ (n = 172, 69.7%). Most (96.3%) had a documented advance directive. Comorbidities (7.8±2), polypharmacy (92.3%), vision impairment (52.8%), hearing impairment (52.8%), depression (65.2%), frailty (75.7%), sarcopenia (84.4%), risk of weight loss (53.9%), MCI (11.7%), and dementia (75.8%) were prevalent. Among OA NH residents (n=91) with an AWV follow-up, there was modest worsening in total comorbidities and medications as well as frailty, sarcopenia, and cognition scores (ps≤0.05). Pain, depression, and nutrition did not change. To our knowledge, no one has specifically analyzed the Medicare AWV in NHs. Data from the traditional AWV is an extension of the routine clinical care of OAs and therefore could also be useful for healthcare professionals focused on providing care to OA patients in the NH setting.

Primary Care Provider Attitudes and Perceptions of Routine Cognitive Screening in Older Adults

The 2011 Annual Wellness Visit (AWV) Medicare benefit includes a cognitive screening component intended to improve screening of older adults. However, available literature only presents physician perspectives on cognitive screening prior to 2011. The purpose of this study was to explore primary care provider (PCP) attitudes and perceptions of cognitive screening in older adults. An Internet-based survey link was sent to Virginia professional organizations and clinics to distribute to PCPs serving older adults. Likert scale, multiple choice, and free response questions were used to understand current attitudes, perceptions, and practices. The sample (N=39) was comprised of 26 nurse practitioners (NPs), 9 physicians, and four who did not disclose role. Most participants were aware of the AWV (n=31, 88.6%) and agreed that early detection “promotes earlier diagnosis and access to resources” (mean ± standard deviation,1.58±0.69). However, less than half of NPs screened annually (n=10/26, 38.5%) and even less conducted screening during an AWV (n=7/26, 26.9%). About half of MDs conducted cognitive screening during an AWV (n=5/9, 55.6%). Although NPs screened less, they more strongly agreed that screening should occur annually (1.92±1.15 vs. 2.67±1.23) and “additional training would improve [screening] ability” (2.04±1.0 vs. 3.22±1.20). Also, few NPs independently managed impairment (n=5/26, 19.2%) compared to MDs (n=5/9, 55.6%). Our findings demonstrate that NPs screen less and feel less prepared to conduct cognitive screenings. It is important to provide additional resources and training for all PCPs, but especially NPs who are rapidly entering primary care to help improve identification and management of cognitive impairment.

Screening for Cognitive Function in Primary Care

A comprehensive program for early detection and treatment of Alzheimer’s and related dementias requires a systematic process for provider education, assessment of cognitive function and referral to appropriate resources when indicated. This discussion will focus on the implementation of cognitive screening into primary care. Over 200 staff across 11 primary care sites were trained on screening for dementia in the annual wellness visit. In the following 6 months nearly 2000 annual wellness visits were conducted. The annual wellness visit was designed to include a cognitive screen. 83% of the patients were asked the cognitive screen questions and 13% responded “yes” to the question. Further testing was offered to that group and 71% of those who had responded “yes” agreed to be tested with a picture memory screen. 32% scored less than 5 on that screen and were referred to gero-psychiatry, geriatricians and community based organizations for caregiver support services.

Neighborhood Socioeconomic Position and Social Support in a Clinical Population of Older Adults

Models of successful aging underscore the critical role of external social resources in older adults’ health and well-being. Neighborhood socioeconomic position is known to influence health, but little is known about the linkages between neighborhood conditions, social relationships and health among older adults. We identified a cohort of 12,434 adults (aged 65+) who attended a Medicare Annual Wellness Visit from the NEOCARE Learning Health Registry. NEOCARE includes electronic health record (EHR) and neighborhood data from 1999-2017 on over 3 million unique Northeast Ohio individuals. The study population was 60% White, 32% Black or African American, 64% female, and 90% non-Hispanic. Over 60% were ages 65-74, 29% 75-84, and 10% 85 years or older (range from 65 to 101). We used ANOVA and chi square tests to examine variation in social support by quintile of the census tract area deprivation index. Compared to those in less disadvantaged neighborhoods, older adults in more disadvantaged neighborhoods were more likely to report needing help with care needs (Bonferroni-corrected x2=95.21, df=4, n=8,967, p<.001) but were less likely to report having help at home (x2=85.72, 4, n=12,354, p<.001). Similarly, adults in more disadvantaged neighborhoods reported less help available to them compared to those in more advantaged communities (F=39.31, df=4, n=12,099, p<.001). Furthermore, older adults living in more disadvantaged neighborhoods experienced significantly less functional independence (F=3.68, df=4 , n=8,571, p<.01). Our results suggest that the pathway from neighborhood socioeconomic conditions to successful aging includes perceived social needs and social support.

Promoting Conversations About Cognitive Decline Between Older Adults and Primary Care Providers

Alzheimer’s disease and related dementias often begin with symptoms of mild memory loss, eventually leading to more severe cognitive impairment, functional impairment, and ultimately, death. Data from the Behavioral Risk Factor Surveillance System core questions related to chronic diseases and from the cognitive decline optional module on subjective cognitive decline (SCD) from the years 2015-2018 were aggregated across the participating 50 states, D.C., and Puerto Rico for this analysis. Among U.S. adults aged 65 years and older, only 39.8% (95%CI=37.6-42.1) of those experiencing SCD reported discussing their SCD symptoms with a healthcare provider. The prevalence of discussing SCD symptoms with a provider was higher among those with at least one chronic condition than among those with no chronic conditions. 30.7% (28.6-32.8) of those aged 65 years and older reported that their SCD led to functional limitations and 28.8% (26.5-31.2) needed assistance with day-to-day activities. For patients aged 65 years and older, Welcome to Medicare visits and Medicare Annual Wellness Visits are critically underutilized primary care access points. Primary care providers can manage chronic conditions, cognitive health, and initiate referrals for testing. Efforts to promote the use of toolkits and diagnostic codes that are available to primary care providers to initiate conversations about memory loss with patients may be utilized to improve detection, diagnosis, and planning for memory problems. Discussions may lead to earlier detection and diagnosis of cognitive impairment, such as Alzheimer’s disease, or other treatable conditions such as delirium or pressure in the brain and avoid costly hospitalizations.

Age-Friendly Initiatives and Primary Care in Rural Arkansas

The Arkansas Geriatric Education Collaborative (AGEC)’s Geriatric Workforce Enhancement Program is partnering with a plethora of community based organizations (CBO) and with ARcare, an Arkansas federally qualified healthcare clinic network, to implement the 4Ms of age-friendly care in rural clinics. Baseline clinical data related to the Age-Friendly 4M Framework has been gathered and quality improvement projects initiated to improve the outcomes. Initiatives to improve depression and cognitive screenings are addressing Mentation; fall prevention screens and the offering of fall prevention programs have been added for Mobility; high risk medication screens and chronic pain educational programs are being implemented to address Medications; and finally, Medicare Annual Wellness Visits is the cornerstone to improve what Matters to older adults. A campaign that involves partnered CBOs to address health literacy and increase involvement in evidence-based programs is also helping to drive improvements in age-friendly care in rural Arkansas.