Ineffective transitions of care challenge providers Readmission rates have remained high despite the Hospital Readmission Reduction Program (HRRP). The average US all-cause readmission rate is 14.56%, and it ranges from 11.2% to 22.3% across states. Other value-based care programs, where reimbursement is tied to the quality of service, haven’t led to a significant change in readmissions, either.

A recent AARP bulletin story by Dr. Howard Zucker asks, "Where have all the doctors gone?"

Health equity can play a vital role in enhancing and optimizing care delivery across populations.

Annual Wellness Visits (AWVs) go beyond a yearly evaluation. The AWV provides a means to achieving several goals, including:

Clinicians and healthcare policymakers are accepting that physical and mental health are closely interconnected. This view is now influencing the aims and focus of value-based care through Chronic Care Management, care coordination, and Integrated Behavioral Health.

Annual Wellness Visits (AWV) for Medicare beneficiaries can add measurable value to benefit patient health outcomes, quality performance, and service revenue. However, it’s critical to optimize physician and staff time with a reliable, standards-based, and streamlined workflow.

Many physicians and clinicians pride themselves on the relationships they develop with their patients. By creating a patient-centered care plan, providers can enhance engagement, deliver timely interventions, align on outcome goals, and improve care team coordination.

This year brings significant opportunities and changes to care management that invite providers, health plans, and care management service organizations to transform. Central to these changes is the launch of the Advanced Primary Care Management program.

Providers implementing Annual Wellness Visits or quality improvement initiatives identify and hone best practices that meet their unique patient and practice needs. When operationalized, these standards achieve four goals:

The Centers for Medicare & Medicaid Services (CMS) launched the Guiding an Improved Dementia Experience (GUIDE) Model on July 1, 2024. Running from 2024 through 2032, this program is one of the first Innovation Center care models to focus on longitudinal, condition-specific comprehensive care.