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Abstract
Background The Medicare Annual Wellness Visit (AWV) allows providers to acquire critical information about patients’ health through a review of vitals, environmental risks, and medical and family history. These visits are free to those enrolled in Medicare and prioritize patient–provider relationship building and preventative care. Despite this, AWV completion rates are suboptimal.
Methods A quality improvement project was aimed to increase the percentage of AWVs among Medicare patients in a primary care internal medicine practice from a baseline of 1.7% completion to 2.7% in 3 months from January to April 2023.
Intervention With eligible patients identified, a standardized approach was created where an AWV appointment was ordered, and a patient message explaining the benefit of the appointment was sent by the patient portal.
Results Our AWV intervention resulted in 72 patients being seen for an AWV, which increased the percentage of completed AWVs in the division by 2.1% from 1.7% to 3.8% in 3 months.
Conclusion This intervention will continue to improve AWV rates and improve patient care for Medicare patients in internal medicine. It could be applied to other areas of primary care and within other health systems.
- general practice
- communication
- quality improvement
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The Medicare Annual Wellness Visit (AWV) provides an opportunity for providers to acquire critical information pertaining to patients’ health through a review of vitals, environmental risks, and medical and family history.1 These visits are free to those enrolled in Medicare, a federal health insurance for those 65 years old and older, and prioritize patient–provider relationship building and preventative care. Diminished mortality rates, reductions in hospital admissions and increased recommended screenings are correlated to patients who have relationships with their primary care providers.2 In our internal medicine practice, patient and provider AWV completion was noted as suboptimal though the cause of low AWV rates was not entirely clear. AWVs are often overlooked or dismissed by patients, especially if they have recently undergone a physical exam and assume AWV appointments do not add value to their health.3 Provider-level barriers to AWV completion include limited understanding of benefits, confusion about documentation/billing details and insufficient time.4 We sought to increase Medicare AWV completion to promote preventative medicine, address and control risk factors, improve health outcomes, and save overall healthcare costs. Using the Define, Measure, Analyze, Improve and Control framework, we aimed to increase the percentage of AWVs among Medicare patients in our internal medicine practice from a 1.7% baseline completion to 2.7% in 3 months from January to April 2023.
Baseline data
Only 1.7% of Mayo Clinic internal medicine, Rochester, Minnesota, USA, patients eligible for an AWV had one performed in the last year. Cause-and-effect analysis revealed an inadequate process for identifying AWV eligible patients, a need for a standardized processes for ordering AWVs, insufficient patient communication, and confusion about eligibility and covered services. Further analysis found provider ambivalence to the promotion of AWVs, inadequate training on how to order, perform, document and bill an AWV and nursing shortages also compounded this issue.
At baseline, 10,575 Medicare patients were identified as eligible for an AWV. Using the electronic medical record (EMR), the patient population was narrowed to 3,422 who were considered most in need. Criteria to determine the population most in need were that they (1) had not been seen in internal medicine since before 2020, (2) were between 65 and 85 years old and (3) were covered by Medicare or Medicare Advantage. By using this narrowed criteria, we could first reach out to those patients most in need of healthcare in whom preventative screening was lacking.
Using a Suppliers, Inputs, Process, Outputs, Customers plus Requirement—a tool used to organize the process methodology, stakeholders were identified, and information gathering included internal medicine leadership, schedulers, nursing and providers.5 Stakeholder feedback was organized using an Ishikawa cause-and-effect diagram (fishbone tool) to determine possible interventions. Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guidelines were used to report findings.6
Aim
We aimed to increase the percentage of AWVs among Medicare patients by 1% (approximately 34 AWVs), from 1.7% to 2.7% in 3 months.
Intervention
With eligible, high-risk patients identified, a standardized approach was created where an AWV appointment was ordered, and a message explaining the benefit of the appointment was sent by the patient portal (which is integrated with the EMR). Age, gender, primary care provider, date last seen in internal medicine, gap score (a measure of overdue health maintenance needs with a gap score greater than 1 representing a patient who had 1 or more health maintenance items due), patient portal activity and date of sent message were all documented for those contacted. During our intervention, we also discussed the importance of AWVs with nurses and providers through care team huddles, email and presentation at department meetings and encouraged them to schedule and complete AWVs for eligible patients.
Analysis and results
The Medicare eligible patient AWV completion preintervention and postintervention was determined and revealed a 3.8% completion postintervention (figure 1). Female patients comprised 60% of the total internal medicine patient population and 74% of the AWV patient population. The mean age of patients due for an AWV was 72. Age distribution analysis revealed that patients within the 65–74 age group were more likely to have an AWV completed than those less than 65 or older than 75. The majority of patients due for an AWV had the patient portal (89%), had a gap score of less than 1 (88%) and had not been seen since April 2020.
Patient demographics and intervention outcome. (A) Age distribution of Medicare AWV eligible patients compared to the CIM general population. (B) Gender frequencies of AWV compliant patients compared to the CIM general population. (C) Medicare eligible patient annual 'wellness visit compliance pre- and post- intervention. AWV, Annual Wellness Visit.
Conclusion
AWVs have the potential to improve patient–provider communication and relationships, ensure preventative health measures are up to date, and allow screening and assessment for risks and medical conditions that can improve patient outcomes. This intervention showed improved AWV rates during the 3-month study and will continue to improve AWV completion rates for Medicare patients in internal medicine in the future. Our results showed a higher AWV completion rate in women, patients between 65 and 74, those who used the patient portal, and those who had not been seen in primary care within a 3-year window. By reaching younger Medicare patients and those who had not been seen recently we were able to capture patients in greatest need whom also would still benefit from preventative screening and early intervention. This intervention could be applied to other areas of primary care and other health systems that have the ability to calculate health maintenance gaps and have an EMR with an integrated patient portal. Study limitations include that outside factors may have also led to patients completing an AWV including but not limited to Medicare enrollment information, public advertising campaigns and information from family and friends. However, the lessons learned from this quality improvement project include the importance of educating all patients and providers on the value of AWVs, the need for a systematic process for sending messages and ordering AWVs, and the need to capture the work we provide as a healthcare team.
Supplemental material
Ethics statements
Patient consent for publication
Ethics approval
This was a quality improvement project carried out by internal medicine, which was approved by the institution’s leadership. This study involves human participants. This study was a pilot for a quality improvement project. In our institution, quality improvement projects are not considered research; therefore, the ethics committee exempted this project.
Acknowledgments
The authors would like to recognize the leadership of internal medicine for allowing this work to occur.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors Each member shared equal contributorship to this project. The project was led by DO'L, RO and BS. Data, approval and manuscript editing were provided by MW. DO'L, AM, SC, JP, VH, CC, RO and BS wrote the manuscript. RO did data analysis.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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