Medicare Annual Wellness Visit Research Articles

Cognitive Assessment At Medicare's Annual Wellness Visit In Fee-For-Service And Medicare Advantage Plans.

The Medicare annual wellness visit-a preventive care visit free to Medicare beneficiaries enrolled in Part B-requires detection of cognitive impairment. We surveyed an internet panel of adults ages sixty-five and older who were enrolled in fee-for-service Medicare or Medicare Advantage to measure the use of that benefit and the receipt of structured cognitive assessment by 2019. Overall, approximately one-half of beneficiaries surveyed reported having an annual wellness visit, and fewer than one-third reported having a structured cognitive assessment. Compared with fee-for-service enrollees, Medicare Advantage enrollees were nearly 20percentage points more likely to report that they had an annual wellness visit and 8.6percentage points more likely to report that it included a structured cognitive assessment. The difference suggests that the rate of structured cognitive assessment in fee-for-service Medicare might be increased by offering financial and other incentives for take-up that are similar to those in Medicare Advantage.

Access to clinical pharmacy services in a pharmacist-physician covisit model.

A pharmacist-physician covisit model in which patients see both a pharmacist and physician on the same day was established in a primary care practice. Previously, patients were seen in a referrals-based model in which providers referred patients for clinical pharmacy services on a different day. To assess access to clinical pharmacy services in a pharmacist-physician covisit model compared to a referrals-based model. A retrospective chart review was completed for patients who were seen by physicians on pre-specified half-days of clinic before and after implementation of the covisit model. Covisit model half-days between June 29, 2018 and September 30, 2018 and matched half-days from 2015 were included. Charts were reviewed to determine if patients scheduled to see the physician would benefit from clinical pharmacy services, including being seen for chronic disease management, eligible for a Medicare Annual Wellness Visit (AWV), prescribed medications that required counseling, had an adverse medication-related event, or had adherence concerns. Those eligible for clinical pharmacy services were further reviewed to determine if the patient interacted with a pharmacist within three months of their visit. Prior to implementation of the covisit model, 123 patient visits were completed on the pre-specified half-days. Of these, 61 patients (49.6%) were deemed eligible for clinical pharmacy services. In the covisit model, 149 patients were seen by the physician, of which 69 patients (46%) were eligible for clinical pharmacy services. More patients in the covisit cohort went on to interact with a pharmacist (56 patients, 81% vs. 10 patients, 16%, adjusted OR=32.98, 95% CI [8.89-122.39]). The most common reasons patients were identified for clinical pharmacy services were eligibility for AWV, hypertension, and diabetes. A pharmacist-physician covisit model significantly increased accessibility to clinical pharmacy services compared to a referrals-based model.

Impact of an RN-led Medicare Annual Wellness Visit on Preventive Services in a Family Medicine Practice.

To evaluate the impact of a registered nurse (RN)-led Medicare annual wellness visit (AWV) on preventive services in a family medicine clinic. A retrospective chart review was performed on patients who underwent an RN-led AWV and patients who underwent a standard assessment (SA) between October 2017 and October 2018. A total of 630 patients (330 AWV and 300 SA) were included in this study. There were seven preventive services examined for in women and five preventive services examined for in men. Each service was used more often by patients in the AWV group than the SA group (all odds ratios ≥1.64; all P values ≤.004). The RN-led AWV is an effective way to assist Medicare beneficiaries in meeting their preventive needs while allowing physicians more time to focus on chronic and acute needs.

A Multicenter Focus Group Analysis of Medicare Beneficiaries Perception of Annual Wellness Visits.

National utilization of Medicare's Annual Wellness Visits (AWVs) benefit is low. Few studies have evaluated how beneficiaries perceive this service. This study aimed to characterize beneficiaries' opinion on the value of AWVs, preventive care services offered by Medicare, and barriers and facilitators to receiving those services. This qualitative study used semistructured focus group interviews of Medicare beneficiaries aged 65 years or older with a standardized facilitator guide. Four focus groups were conducted with 30 Medicare beneficiaries in an assisted-living facility, senior housing apartments, and a primary care office. Qualitative thematic analysis of focus group responses revealed that preventive healthcare was valued, but access to quality preventive care remains an issue for patients. Most participants did not know about AWVs and reported confusion over the terminology "wellness visit" compared with checkup or physical. Medicare beneficiaries are not commonly aware of AWVs. Increased promotion of AWV services by healthcare professionals may increase the number of beneficiaries participating in these preventive visits.

High prevalence of geriatric syndromes in older adults.

IntroductionThe geriatric syndromes of frailty, sarcopenia, weight loss, and dementia are highly prevalent in elderly individuals across all care continuums. Despite their deleterious impact on quality of life, disability, and mortality in older adults, they are frequently under-recognized. At Saint Louis University, the Rapid Geriatric Assessment (RGA) was developed as a brief screening tool to identify these four geriatric syndromes.Materials and methodsFrom 2015–2019, the RGA, comprised of the FRAIL, SARC-F, Simplified Nutritional Appetite Questionnaire (SNAQ), and Rapid Cognitive Screen (RCS) tools and a question on Advance Directives, was administered to 11,344 individuals ≥ 65 years of age across Missouri in community, office-based, hospital, Programs of All-Inclusive Care for the Elderly (PACE), and nursing home care settings. Standard statistical methods were used to calculate the prevalence of frailty, sarcopenia, weight loss, and dementia across the sample.ResultsAmong the 11,344 individuals screened by the RGA, 41.0% and 30.4% met the screening criteria for pre-frailty and frailty respectively, 42.9% met the screening criteria for sarcopenia, 29.3% were anorectic and at risk for weight loss, and 28.1% screened positive for dementia. The prevalence of frailty, risk for weight loss, sarcopenia, and dementia increased with age and decreased when hospitalized patients and those in the PACE program or nursing home were excluded.ConclusionsUsing the RGA as a valid screening tool, the prevalence of one or more of the geriatric syndromes of frailty, sarcopenia, weight loss, and dementia in older adults across all care continuums is quite high. Management approaches exist for each of these syndromes that can improve outcomes. It is suggested that the brief RGA screening tool be administered to persons 65 and older yearly as part of the Medicare Annual Wellness Visit.

Impact of quality measures performed through pharmacist collaboration with a primary care clinic

ObjectiveThe objective was to assess the clinical and financial impact of a pharmacist integrated within a primary care practice on quality measures of the merit-based incentive payment system (MIPS). SettingThe study was conducted in a multidisciplinary primary care practice in Charlotte, NC. Practice descriptionA collaborating pharmacist from an independent community pharmacy is integrated within clinic workflow. In this team-based model, pharmacists work alongside providers to furnish comprehensive care, focusing on MIPS quality measure improvement through Medicare annual wellness visits (AWVs) and chronic care management (CCM). Practice innovationQuality measure achievement was assessed from completed face-to-face AWVs, phone call CCM, or both. EvaluationFrom January 1, 2017, to December 31, 2018, 403 patients in 2017 and 565 patients in 2018 were eligible to be seen by the collaborating pharmacist for either an AWV, CCM, or both services. Measure achievement was characterized using descriptive statistics. Billing reports were used to determine the average monthly dollar amount of Medicare Part B claims submitted. ResultsThe percentage of patients achieving quality measures increased for 3 measures, decreased for 2 measures, and was neutral for 1 measure. The percentage of patients achieving quality measures resulted in a MIPS quality performance score of 60 of 60 points, which contributed to a final MIPS score of 100 of 100 points and a positive (+) 1.88% payment adjustment in 2019. Extrapolating from previous volume, the provider’s total MIPS payment adjustment may result in an additional $16,920 in annual reimbursement. ConclusionPharmacist-provided collaborative clinical services in the primary care setting appear to ensure achievement of MIPS quality measure benchmarks, potentially increasing the practice’s annual MIPS reimbursement by $16,920.

Leveraging the Annual Wellness Visit to Improve Rural Depression Management

Purpose: Depression is a common condition in rural primary care associated with significant adverse health and quality of life outcomes. Despite evidence-based practice recommendations, depression screening and follow-up are inconsistent in practice. The purpose of this quality improvement project was to improve the rate of depression screening and management as a component of the Annual Wellness Visit (AWV) in the rural, primary care setting. The overarching project aim was to increase the rate of depression screening and treatment in adult Medicare patients by 50% through the implementation of a standardized screening instrument and management plan within eight weeks of project implementation. Sample: The sample population included 66 Medicare beneficiaries receiving a Medicare Annual Wellness Visit at a primary care practice in rural Northeast Texas. Method: The central focus of this quality improvement project was to initiate standardized depression screening and management in the Medicare population as a component of the annual wellness visit. Patients were screened for depression using the Patient Health Questionnaire-9 (PHQ-9) instrument. An evidence-based depression management plan based on the PHQ-9 score guided follow-up and management. Findings: When depression screening was performed as a component of the AWV, 98.5% of patients received depression screening with a validated instrument. 73.3% of patients who had a PHQ-9 score of five or greater had a documented follow-up plan, and 93.3% had recommended treatment initiated. A strong positive correlation was found among patients who screened positive for depression and received a documented follow-up plan (rho (63) = .993, p <.001) and had treatment plan initiated (rho (63) = .998, p <.001). Conclusions: Implementing standardized workflows, such as the annual wellness visit, is foundational to consistently identify and treat depression to remission in the rural primary care setting. DOI: http://dx.doi.org/10.14574/ojrnhc.v20i1.602 Keywords: depression, screening, preventive services, Patient Health Questionnaire-9, annual wellness visit.

Medicare Annual Wellness Visits: A New Primary Care Opportunity for Diabetes Care and Education Specialists

Medicare Annual Wellness Visits: A New Primary Care Opportunity for Diabetes Care and Education Specialists

Assessing Medicare Patients' Salient Beliefs to Improve Annual Wellness Visit Health Outcomes.

OBJECTIVE: To identify key beliefs that influence behavior, regarding Medicare's Annual Wellness Visit (AWV) and older patients' willingness to implement personalized prevention plans.<br/> DESIGN: Cross-sectional. In-depth semi-structured focus group sessions with Medicare patients in July 2018.<br/> SETTING: Two primary care physician-based practices.<br/> INTERVENTION: A trained moderator facilitated two focus group sessions, and used open-ended questions based on the theory of planned behavior to elicit behavioral, normative, and control beliefs associated with implementing personalized prevention plans.<br/> MAIN OUTCOME MEASURE: Content analysis of the focus groups' transcribed data was used to identify modal salient beliefs. Transcribed focus group sessions were analyzed utilizing grounded-theory methods for emergent themes.<br/> RESULTS: A total of 13 older patients participated in the focus group sessions. Prevalent behavioral beliefs among participants influenced by patient-centered care outcomes included improvement in physical activity, adopting a healthy balanced diet, and weight loss.<br/> Interpersonal and environmental disparities influenced commonly reported control factors such as lack of support at home and affordable fitness facilities. Macro-level influences such as physicians and social marketing by insurance providers, and health partners and spousal support were identified as important normative factors.<br/> CONCLUSION: Identified salient beliefs were congruent to social determinants of health in Medicare patients. Results of the study demonstrate perceived enablers and barriers of elderly patients regarding implementing health-promoting advice. AWV pharmacists should address perceived barriers to improve attitudes and self-efficacy; and incorporate enabling beliefs into adherence strategies to improve adoption of health recommendations.

BUILDING AN AGE-FRIENDLY HEALTH CARE SYSTEM

Gateway GWEP has partnered with a rural Missouri critical access hospital to establish an age-friendly health system in their community. Program innovations include development and training of: 1) electronic health records integration of the Rapid Geriatric Assessment (RGA) for all patients 65+ years old; 2) RGA-based protocol for Medicare Annual Wellness Visits (MAWV); 3) Multidisciplinary health care assessment team 4) Evidence-based or Evidence Informed treatment interventions, including Cognitive Stimulation Therapy (CST), exercise and strengthening program for persons participating in CST, Care of Persons with Dementia in their Environments (COPE) and caregiver support. Since 2015, 1,200 RGAs, 338 MAWVs have been completed; 165 persons with dementia participated in CST; and 74 have participated in exercise and strengthening. Data supports positive outcomes in functional independence, cognitive status, and care-giver dementia management skills and well-being. Successes and lessons learned regarding strategies to develop an age-friendly health systems will be discussed.

FEASIBILITY AND ACCEPTABILITY OF DETECTING COGNITIVE IMPAIRMENT AND DEMENTIA IN PRIMARY CARE PRACTICES

As the age of the US population increases, so does cognitive impairment (CI); therefore early detection of CI is critical for ensuring its appropriate management. As part of a NINDS Consortium to detect CI and dementia in primary care (DetectCID), we are implementing and evaluating a brief 2-step CI detection paradigm (MyCog), that can be delivered in clinics with diverse populations via the electronic health record (step 1) and iPad (step 2). We conducted focus groups with 25 clinicians and administrative leaders from academic and community primary care practices to 1) understand how CI is being assessed, and 2) evaluate the feasibility of implementing the MyCog paradigm into existing primary care workflows. Several key themes emerged from the discussions. No proactive detection strategy for CI was regularly used outside of the Medicare Annual Wellness Visits (AWV); variable assessments including the Minicog, MoCA, or MMSE were used to fulfill the AWV requirement. Regarding the feasibility of our MyCog Paradigm, our 2-step process was positively received, with the brief case-finding step 1 satisfying AWV requirements and replacing the longer assessments currently being used. Clinicians preferred that step 2 be self-administered due to limited clinician time for wellness visits, and highlighted logistical challenges such as room availability and storage and maintenance of the iPad. Overall, clinicians felt that the identification of CI was valuable and supported standardization, but indicated regular case finding was unlikely without clear guidance on clinical decision-making.

A UNIQUE APPROACH TO INTERPROFESSIONAL TRAINING USING THE ANNUAL WELLNESS VISIT HEALTH RISK ASSESSMENT

The Kentucky (KY) Rural & Underserved Geriatric Interprofessional Education Program (KRUGIEP) participated in a unique innovative approach to the implementation of the Medicare Annual Wellness visit in collaboration with the Dartmouth GWEP. The model focused on the integration of students into the process of conducting the Health Risk Assessment through community based home visits. This talk will focus on this unique program and the participation in a multi-GWEP learning collaborative.

INTEGRATING PRINCIPLES OF VALUE-BASED CARE THROUGH COMMUNITY-BASED ORGANIZATION PARTNERSHIPS

To develop programming consistent with value-based care principles, two GWEPs share strategies and policy implications when partnering with community-based organizations (CBO). Because the aims of value-based care – better patient outcomes and population health, reduced health care costs – cannot be achieved by changing medical practice alone, RI Geriatric Education Center (RIGEC) partners with multiple CBOs to deliver evidence-based patient education programming to empower patients/caregivers to take charge of their health. RIGEC will work directly with physician practices to bring education directly to their high-risk patient census. Saint Louis University CBO partners integrated geriatric assessment into routine care to identify geriatric syndromes. Introduction of protocols for Medicare Annual Wellness Visits, Cognitive Stimulation Therapy and exercise/strengthening enables CBOs to offer interventions. Value-based care is achieved by reducing costs as geriatric syndromes are identified earlier, enabling diagnosis, treatment, and management; improving patient outcomes and satisfaction; and strengthening provider competence in geriatric care.

A pharmacist-led pilot program to facilitate deprescribing in a primary care clinic

ObjectiveTo develop and pilot-test a model in which a community-based clinical pharmacist was incorporated as part of a Medicare Annual Wellness Visit (AWV) to make deprescribing recommendations targeted at potentially inappropriate medications (PIMs) in seniors. SettingA family medicine patient-centered medical home (PCMH) clinic in Buffalo, NY. Practice descriptionImplementation and evaluation of a pilot program incorporating a pharmacist-provided medication review targeting PIMs in seniors as part of a Medicare AWV. Practice innovationA community pharmacy–based clinical pharmacist provided face-to-face medication reviews for patients older than 65 years as part of their AWV with a focus on deprescribing PIMs. No clinical pharmacy service existed at the practice when this program was implemented. EvaluationIdentified PIMs, pharmacist recommendations, recommendation acceptance rate, time spent on intervention, health care utilization at 6 months postvisit, and barriers to implementation. ResultsOf the 21 patients enrolled, 13 unique patients received a total of 20 deprescribing recommendations from the pharmacist. The overall acceptance rate for pharmacist recommendations was 20%. The pharmacist spent a mean (± SD) of 34 (± 6) minutes per patient encounter. One patient in the intervention group was hospitalized, and 1 was seen in the emergency department (ED) during the 6-month follow-up period compared with 1 patient in the control group who had an ED visit. We identified multiple logistical and organizational barriers to the implementation of the intervention. ConclusionIn this prospective pilot study, a workflow to include a pharmacist medication review to facilitate deprescribing in the primary care setting was tested. We encountered several barriers to integrating the pharmacist into the AWV workflow to deliver the intervention. Future pragmatic clinical trials are warranted to improve provider awareness and comfort with deprescribing PIMs in seniors.

Association Of Medicare's Annual Wellness Visit With Cancer Screening, Referrals, Utilization, And Spending.

Medicare's annual wellness visit was introduced in 2011 to promote evidence-based preventive care and identify risk factors and undiagnosed conditions in aging adults. Use of the visit has risen steadily since then, yet its benefits remain unclear. Using national Medicare data for 2008-15, we examined claims from fee-for-service Medicare beneficiaries attributed to practices that did or did not adopt the visit. We performed difference-in-differences analysis to compare differential changes in appropriate and low-value cancer screening, functional and neuropsychiatric care, emergency department visits, hospitalizations, and total spending. Examining 17.8million beneficiary-years, we found modest differential improvements in rates of evidence-based screening and declines in emergency department visits. However, when we accounted for trends that predated the introduction of the visit, none of these benefits persisted. In sum, we found no substantive association between annual wellness visits and improvements in care.

Hospital utilization and expenditures among a nationally representative sample of Medicare fee-for-service beneficiaries 2 years after receipt of an Annual Wellness Visit

Medicare's Annual Wellness Visit (AWV) provides an opportunity to link beneficiaries to cancer screenings and immunizations, however, research has not examined its effectiveness. The aim of this study was to examine the effect of receiving an AWV on outcomes while accounting for the healthy user effect.This study used 2013–2017 Medicare claims data to compare hospital utilization and total expenditures among a 5% random sample of Medicare fee-for-service (FFS) beneficiaries with and without AWV use in 2014 (228,053 AWV users were propensity-score matched to 228,053 nonusers). Linear fixed effects regression models examined differences in study outcomes 12 and 24 months after AWV use, controlling for baseline differences in sociodemographics, health status, utilization, and accountable care organization attribution.The proportion of Medicare FFS beneficiaries that used the AWV increased from 13% in 2013 to 24% in 2017. Users of the AWV had a marginally significant reduction in Medicare spending 12 months (−$122, 95% CI −$256, $11, p = 0.073) and significant reductions (−$162, 95% CI, −$310, −$14, p = 0.032) 24 months after the visit, relative to non-users. However it remains unclear what is driving these savings as there was no change in hospital-related utilization and results may still be biased due to inherent differences between users and non-users.The AWV provides an opportunity for providers to focus on prevention and geriatric needs not covered in typical office visits. Practices adopting AWVs have noted increased revenue, more stable patient populations, and stronger provider-patient relationships. While utilization remains low, it is steadily increasing over time.

Persistent Disparities in Medicare’s Annual Wellness Visit Utilization

The Medicare Annual Wellness Visit (AWV) is a preventive care visit introduced in 2011 as part of the Affordable Care Act provided without cost to beneficiaries. The AWV is associated with higher preventive services utilization. Although AWV utilization increased during 2011-2013, utilization was lower among ethnoracial minority beneficiaries who may benefit the most. To determine if AWV utilization disparities have persisted using the most recent data available. The authors analyzed AWV utilization in 2011-2013 and 2015-2016 by beneficiary-reported race and ethnicity, adjusting for potential confounders. Weighted sample of 78,639,501 fee-for-service Medicare beneficiaries aged 66 years and older who participated in the Medicare Current Beneficiary Survey 2011-2013 or 2015-2016. AWV utilization was identified using Medicare claims. AWV utilization increased from 8.1% to 23.0% of all beneficiaries between 2011 and 2016. Compared with non-Hispanic white beneficiaries, utilization was significantly lower among non-Hispanic Black and non-Hispanic other race beneficiaries in both the minimally and fully-adjusted models. Hispanic/Latino beneficiaries had lower utilization in the minimally adjusted model, but not in the fully-adjusted model. In 2016, compared with non-Hispanic white beneficiaries, AWV utilization was 10.2 points lower for non-Hispanic black, 11.6 points lower for Hispanic/Latino, and 8.6 points lower for non-Hispanic other race beneficiaries, and these differences were attenuated after adjusting for all covariates to 6.8 points lower, 9.4 points lower, and 7.2 points lower, respectively. The AWV has the potential to increase the use of preventive care, improve health, and reduce ethnoracial disparities among Medicare beneficiaries, but realizing these goals will require increasing utilization by minority groups. If ethnoracial minority beneficiaries had used the AWV at the same rate as non-Hispanic white beneficiaries during the study period, then ~1.6 million additional AWVs would have been used.

Primary Care-Based Staff Ideas for Implementing a Mammography Decision Aid for Women 75+: a Qualitative Study.

We previously developed a pamphlet decision aid (DA) on mammography screening for women ≥ 75years. However, implementing DAs in primary care may be challenging and may require support from non-physician healthcare team members. To learn from primary care administrators, nurses, and staff their thoughts on how best to implement a mammography DA for women ≥ 75years in practice. Qualitative study entailing in-person individual interviews using a semi-structured interview guide. Thirty-two non-physician healthcare team members (69.6% of those approached) participated from 8 different primary care practices (community and academic) in the Boston area or in Chapel Hill, NC. Participants were asked to provide feedback on the DA, their thoughts on ways to make the DA available to older women, and factors that would make it easier and/or harder to implement. Participants felt the DA was clear, balanced, and understandable, but felt that it needed to be shorter for women with low health literacy. Most participants felt that as long as use of the DA was approved and supported by clinicians that women ≥ 75years should receive the DA before a visit from staff (usually medical assistants) so that patients could ask their clinicians questions during the visit. Facilitators of DA use included its perceived helpfulness with decision-making, its format, and that existing systems (panel management, electronic medical record alerts) could be accessed to get the DA to patients especially at Medicare Annual Wellness visits. Participants perceived a need for training, albeit minimal, to provide the DA to patients. Barriers of DA use included competing demands on clinician and staff time. Participants felt that as long as use of the mammography DA for women ≥ 75years was supported by clinicians, it would be feasible to implement with minimal refinements to existing healthcare system processes.

Hearing Wellness Toolkit for Primary Care

Hearing Wellness Toolkit for Primary Care

Outcomes of primary care-based Medicare annual wellness visits with older adults: A scoping review

The increasing aging population creates many challenges for countries around the world. Keeping this population healthy to prevent frailty and functional decline requires a stronger focus on health promotion and disease prevention. Maximization of well-being and quality of life of older adults can occur if determinants of health are addressed and preventive behaviors are supported. Primary care-based preventive visits such as the Medicare annual wellness visit can be used with older adults to enhance health promotion efforts. A scoping review of studies was conducted to identify current evidence concerning the impact of this visit on preventive practices, risk reduction and lifestyle behavior changes for community-dwelling older adults. A total of 11 studies were included in this review. Preventive services use outcomes including vaccinations and screenings were most frequently reported. Visits such as these can provide a platform for development of strategies to provide ongoing support for health promotion efforts.