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Annual Wellness Visit

Case Studies Highlight Best Practices for Annual Wellness Visits

January 8th, 2025 | 13 min. read

Kathryn Anderton, BSN, RN, BC-RN, CCM

Kathryn Anderton, BSN, RN, BC-RN, CCM

Vice President of Clinical Operations, ThoroughCare

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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:

  • Create a long-term, sustainable AWV program
  • Optimize automation and technology to reach more Medicare patients
  • Maximize staff and physician time and patient satisfaction
  • Develop a revenue-positive service

Four real-world AWV examples reveal best practices

The following four case studies highlight quality improvement projects that yielded best practices for any Annual Wellness Visit program. These outcomes demonstrate strategies that can significantly improve AWV completion rates and heighten the service’s value.

Figure 1 summarizes the four provider initiatives, their outcomes and the most notable best practices that are expanded on further below.

Four real-world AWV improvement initiatives with outcomes and best practices.

Figure 1: Four AWV improvement initiatives with outcomes and best practices. Sources: Case study 1, 2, 3 and 4.

Case #1: Two residency-faculty primary care practices

The Department of Family and Community Medicine at Eastern Virginia Medical School was completing only about 7% of Annual Wellness Visits for over 4,000 eligible Medicare patients. By implementing the following best practices, they completed 500 AWVs in 12 months.

Their improvements and AWV growth generated more than  $58,000 in revenue, not counting AWV add-on services, care management enrollments, or Subsequent AWVs they garnered. Subsequent AWVs alone were expected to generate $17,500 in annual revenue.

Additionally, the AWV program’s success opened the door to enrolling patients in other care management programs, such as:

Two best practices are unique to this case

Best practice: Physician direct recommendation for AWV 

This provider surveyed patients who had received an AWV and those who had not yet participated. They found that 90% of patients who had received an AWV did so because their physician recommended it. Nearly 61% of those who hadn’t had one had never heard of it. 

With this knowledge, the team ensured that physicians were told which of their daily patients were eligible for an AWV. They were reminded to encourage and direct them to schedule one.

Best practice: Focus on key assessment findings

The findings from the AWV and Health Risk Assessment were valuable. The provider team paid particular attention to specific areas that significantly impact patient health and quality of life. 

These priority areas included:

  • Cognitive functioning
  • Mobility and fall risk
  • Mood disorders
  • Weight management
  • Incontinence
  • Hearing

One AWV study found patients frequently struggle with these conditions: 

  • 44.2% were at risk for falls or had balance concerns
  • 42.3% did not have a documented advance directive 
  • 39.9% had a sedentary lifestyle
  • 35.1% were experiencing incontinence

Case #2: Five-practice rural PCMH across three states 

Appletree Bay Primary Care (ABPC) is a patient-centered medical home with approximately 571 Medicare beneficiaries. Led by nurse practitioners, all NPs see patients while also serving as faculty for undergraduate and graduate-level nursing training. 

As shown in Figure 2, their pilot study achieved several goals:

  • Increased the number of total AWVs by nearly 9%
  • Increased RN-led AWVs by more than 200% 
  • Decreased the need for provider-led AWVs by 43%
  • Increased physician capacity to see four more patients per day

Additionally, they realized the benefits of the 4M model as part of an age-friendly approach to Annual Wellness Visits, detailed with their best practices.

Breakdown of RN-led versus Provider-led AWVs from pre-, intra-, and post-intervention.

Figure 2: Breakdown of RN-led versus Provider-led AWVs from pre-, intra-, and post-intervention. Source.

Two best practices are unique to this case

Best practice: Geriatric Interprofessional Team Transformation in Primary Care (GITT-PC)

Geriatric Interprofessional Team Transformation in Primary Care (GITT-PC) is an initiative of the Geriatric Workforce Enhancement Program at the Dartmouth Centers for Health and Aging. 

The initiative’s goal is to increase the delivery of high-quality primary care. They want to improve outcomes for  senior adults by training healthcare professionals in:

  • Team skills and optimal team function
  • Quality improvement tools and methods
  • Implementation of Medicare-reimbursable services and AWVs
  • Meeting billing requirements 

GITT-PC was the foundation of ABPC’s training to enable RN-led Annual Wellness Visits.

Best practice: Asking the “What Matters?” question

Medicare requires specific AWV elements. However, providers can adapt existing elements and incorporate additional components that enhance or facilitate better patient engagement during the AWV. 

The John A. Hartford Foundation and the Institute for Health Improvement created the 4M framework of age-friendly healthcare. This aligns with the Medicare AWV. The 4M asks each patient, “Currently in your life, in one or two sentences, what matters most to you?” 

This simple question efficiently led to the heart of a patient’s concerns. It resulted in referrals for community services or follow-up with the primary care physician or other professionals. 

Figure 3 highlights the most often referred concerns to asking “What Matters?”.

Responses to the “What Matters?” question during RN-led AWVs.

Figure 3: Responses to the “What Matters?” question during RN-led AWVs. Source.

Case #3: Health system-based internal medicine clinic 

The Mayo Internal Medicine Clinic had 10,000 AWV-eligible patients but only completed 1.7%, which was their baseline.

Through quality improvement efforts focused on AWV, they resolved identified issues, including:

  • Inadequate processes for identifying AWV-eligible patients
  • Need for a standardized AWV workflow
  • Insufficient patient communication
  • Confusion about eligibility and covered services

Additionally, as shown in Figure 4, they increased the AWV completion rate by 120%+, growing from 1.7% to 3.8% in three months.

The average AWV patient completion rate shows how this provider exceeded their target goal.

Figure 4: The average AWV patient completion rate shows how this provider exceeded their target goal. Source.

Two best practices are unique to this case

Best practice: Narrow criteria to focus on highest-need patients

This care team decided to focus on the 3,000 Medicare patients who were most in need. This ensured that the pilot had the most impact and could scale. 

They centered on the following patient criteria:

  • Not seen in the previous three years
  • Between 65 and 85 years old
  • Insured by Medicare or Medicare Advantage

By using narrowed criteria, they could reach out to those patients whose preventative screening was likely well overdue.

Best practice: Leverage the patient portal

Eighty-nine percent of patients who met the narrowed criteria were using the patient portal. Therefore, the team leveraged their portal as the primary AWV recruitment and education method.

By using technology, the initiative reached younger Medicare patients and those who had not been seen recently. This resulted in a higher AWV completion rate among women between 65 and 74. 

Case #4: Large health system with ACO 

Spread across three states, this Mayo Accountable Care Organization concentrates on rural communities. With more than 80,000 AWV-eligible patients, their goal was to prove the value of a team-based Annual Wellness Visit service. 

Through this initiative, Mayo increased its AWV completion rate by 1,000%+, growing from 1,148 in 2022 to more than 14,000 in 2023. They went from conducting AWVs for 1% of all eligible patients to 17%. The project also built a sustainable AWV workflow that proved scalable across all three clinics.

Three best practices are unique to this case

Best practice: Iterative improvements focused on six implementation areas 

The initiative’s workgroup prioritized six areas as part of building a scalable, sustainable AWV workflow, including: 

  • Patient outreach and visit scheduling
  • Visit workflow and education
  • Communication
  • Software tools
  • Metrics and data monitoring
  • Compliance and quality assurance

Workgroups met weekly to design, communicate and implement new processes. A quality assurance workgroup met as needed to review eligibility reports and required documentation. 

Best practice: Low-effort workflow

When reorienting the clinics’ goals to prioritize AWVs, the team created low-effort workflows that concentrated on scheduled outreach. Each quarter, automated notifications alerted patients of recommended preventive services coming due. 

Additionally, they developed parameters that allowed patients to self-schedule their AWV before an appointment. These automated steps were vital to creating a sustainable system that supported broad outreach to many more patients.

Best practice: Integrate AWVs with existing appointments

Initially, AWVs were scheduled as part of ongoing outreach to close care gaps. However, the team found that patients responded well to extending existing appointments to include an AWV before or after. This also made it easier for staff to match upcoming appointments with AWV eligibility and provide patient education, clarifying the paid and free aspects of the visit.

This dual-visit model was most effective when an RN-led AWV occurred before the scheduled physician appointment. This permitted the clinician to address specific patient concerns from the AWV without the patient returning for a second appointment.

Common best practices across AWV initiatives 

Several best practices were common across most or all four AWV improvement initiatives.

Team-based and RN/NP-led AWVs

Utilizing qualified, non-physician resources, such as nurses or nurse practitioners, was central to making Annual Wellness Visits a sustainable and scalable service. 

The nurse leader would only engage the physician if the clinical situation merited it. 

Others shared the responsibility of AWV, prioritizing most activities for the nurse or NP. Some utilized a care manager to carry out most of the AWV, engaging a physician only when escalation was clinically necessary.

Patient promotion and education

An essential aspect of AWV success was a proactive and planned campaign of education to ensure that patients understood the following:

  • What the AWV includes and does not include
  • Who will conduct their AWV, and how they can access their physician if needed
  • The Medicare AWV is free and at no cost to the patient
  • The value an AWV delivers for current and long-term patient health 

Provider teams used various tactics, technologies and tools, including those in Figure 5, to educate and recruit patients for AWVs. 

When the patient’s primary care physician explicitly said they wanted the patient to participate in an AWV, completion rates reflected it.

The care team in case #1 identified various recruitment strategies that increased their AWV completion rate.
Figure 5: The care team in case #1 identified various recruitment strategies that increased their AWV completion rate. Source.

Robust staff and clinician education

Every case discussed a proactive regimen of internal education. 

Conducted by nursing faculty, care managers, or clinical practice leaders, all created a training schedule that shared:

  • The AWV’s importance and value to the patient and practice
  • Operational workflow steps
  • Medicare documentation and billing requirements

Standardized AWV workflow

All teams created a standardized workflow that integrated with existing clinical services and technologies. 

Everyone emphasized how Annual Wellness Visits fit within larger care quality objectives, practice performance and patient outcomes. 

Technology that made AWV management seamless ensured the service was sustainable and scalable, so initial and subsequent AWVs became a care standard for patients and staff. 

Iterative feedback loop

Like any healthcare quality improvement project, these cases featured iterative development and multidisciplinary workgroups. They met regularly to offer feedback and update procedures and processes. At the end of the initiative, the AWV service included bespoke best practices proven through real-world testing.

Critical to success was having a clear vision of desired AWV outcomes, engaging all stakeholders, and iterating quickly to uncover what worked best for patients and the team.

ThoroughCare enables care management operations

Our platform provides a complete workflow for Annual Wellness Visits, assisting with CMS rules, tracking activities and making billing easier. In addition to AWVs, ThoroughCare offers care management modules for PCM, CCM, RPM, and others, such as Transitional Care Management and Advance Care Planning. 

Every module gives the care team instant access to enroll patients into new programs and begin using powerful features that make care management seamless, including:

  • Guided workflows and automated documentation
  • Evidence-based assessments
  • Integrated CMS requirements
  • Standards-based activities
  • EHR integration with enhanced date tracking for AWV and other deadlines 
  • Seamless shared, team-based patient care activities 
  • Powerful data analytics, dashboards and reports

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Key questions answered

What best practices support a successful Annual Wellness Visit service?

Four real-world AWV quality improvement initiatives demonstrate several common best practices that support increased AWV completion rates, including:

  • Using a team-based approach where AWVs are conducted solely by RNs and nurse practitioners or are shared with physicians. Alternatively, some teams engaged physicians only when clinically necessary.
  • Implementing a proactive, repetitive and planned education campaign helped patients understand the value of an AWV
  • Staff education ensured all stakeholders understood the AWV workflow and Medicare requirements for documentation and billing
  • Adopting an iterative feedback loop helped share lessons learned, improve workflows and communication in real time and create a sustainable and scalable service for long-term results

What other best practices did providers implement through the four Annual Wellness Visit improvement pilots?

The four AWV improvement projects included varied providers: a three-state ACO, a rural group practice, an academic PCMH, and a major internal medicine clinic. All experienced improvements in AWV completion rates, ranging from increases of 120% to over 1,000%. Some of the novel best practices they discovered include:

  • Physicians who directly asked patients to participate in an AWV saw higher completion rates.
  • Pay attention to select assessment findings that have an outset effect on health and quality of life, including cognitive functioning, mobility and fall risk, incontinence, hearing, and overall self-confidence.
  • Utilize the “What Matters?” question to identify patient priorities that should be prioritized.
  • Narrow the criteria used to identify which AWV-eligible patients should be engaged first.
  • Create a low-effort workflow that optimizes technology and automation for communication and operations.
  • Test to see if integrating AWVs with existing patient appointments improves completion rates.