Introduction to the Annual Wellness Visit for the Older AdultGorin, Sherri, Sheinfeld;Resnick,, Barbara
doi: 10.1093/ppar/pry052pmid: N/A
Introduction to the Annual Wellness Visit for the Older Adult In 2011, the Centers for Medicare and Medicaid introduced the annual wellness visit (AWV) for older adults who are receiving Medicare. The AWV is an exciting opportunity for older adults—and their providers—to focus on health promotion and disease prevention and the early recognition of disease, rather than solely the management of acute and chronic medical problems. In the AWV, primary-care providers can identify health risks and promote and encourage healthy behaviors, encourage and facilitate the appropriate screening for disease, and manage and prevent syndromes of aging, such as falls and urinary incontinence. Specifically, the AWV includes assessments of depression; cognition; physical function; psychosocial risks; behavioral risks, such as smoking, alcohol consumption, and sedentary behavior; home safety; nutritional status; and obesity, as well as an opportunity to discuss the need for immunizations; and screening for relevant diseases, such as cancer, diabetes, and cardiovascular disease. Also incorporated into the AWV is the opportunity to discuss the difficult topics of advanced directives, retirement, and driving, so critical to geriatric assessments. The visit concludes with giving the patient a plan for preventive services and behavior changes. The AWV is often an opportunity to bond the patient with the practice and improve the patient relationship, which in turn could improve care (Hollmann, 2018). The papers in this comprehensive and timely volume look at the AWV through a variety of professional lenses across the service continuum, from prevention, screening, and diagnosis to intervention. They provide multiple suggestions for additional clinical, research, and policy approaches that can inform the future of the AWV and improve the health of older adults. Implementation of the AWV and Inequities Implementation of the AWV has been slow; according to Ganguli et al. (2017), only about 16% of eligible Medicare beneficiaries actually receive an AWV. Using national Medicare data, Ganguli et al. (2018) found that 51.2% of medical practices provided no annual wellness visits. Only 23.1% provided visits to at least a quarter of their eligible beneficiaries. Inequities persist in the adoption and implementation of the AWV, across racial/ethnic subgroups, by social-economic status, by gender, by risk level, for those dually eligible, for rural residency, and by types of practices (Ganguli et al., 2018; Lind et al., 2018); looking at individuals, uptake of the AWV is lowest among non-Hispanic Blacks and highest among Whites. As discussed by Tipirneni et al. (2018), these underserved older adults face disparities in healthy aging, likely due to social determinants of health, such as social isolation, food insecurity, poor housing quality, and difficulty affording medications. Underserved older adults who don’t receive an AWV may forego potential benefits of the visit, including increased preventive services, such as vaccinations and screening for depression (Camacho, Yao, & Anderson, 2017; Jiang, Hughes, & Wang, 2018). To address these inequities, Tipimeni et al. (2018) suggest that new AWV models should move beyond current AWV assessments, to address important root causes of poor health among older underserved adults, such as social, environmental, and behavioral determinants of health. They propose adding existing assessment tools for the social determinants of health into the AWV, particularly in safety-net practices (such as the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences [PRAPARE], that was developed by the National Association of Community Health Centers). Tipimeni et al. (2018) also support increased employment of community health workers as a part of the AWV delivery team, with additional funding. On the policy level, Tipimeni et al. (2018) spotlight the Centers for Medicare and Medicaid’s Accountable Communities For Health programs (Alley, Asomugha, Conway, & Sanghavi, 2016; Developing a common framework for assessing accountable communities for health, 2018), that could hold promise for reducing inequities in the dissemination of the AWV. Team-Based AWV Taking a systematic, team-based approach can make these services valuable for physicians and patients (Cuenca, 2012). For providers, the AWV provides more reimbursement than the traditional visit, as well as more overall revenue (Ganguli et al., 2018), particularly if diagnostic coding accuracy and completeness can be improved, as discussed by Hollmann (2018). Yet, providers may not have the additional time required to complete the AWV, as they may be more accustomed to the annual physical exam without the AWV-required components. The AWV also challenges the provider’s ability to address acute medical problems that might arise during the visit. Office workflows and the electronic health record must accommodate the AWV’s focus on prevention, screening, and diagnosis, and its required components. To address these feasibility issues, some practices employ nurses as a part of the AWV team, as discussed by Simpson (2018). She suggests that advanced practice nurses are particularly well suited to the health promotion and disease prevention efforts that are the core of the AWV. Simpson (2018) proffers five recommendations to optimize the contribution of nurses to the AWV, by designing an efficient workflow that involves the entire team, including those responsible for billing and coding, electronic health record development and management, interfacing with the patient upon arrival, and with those providing direct care. She further highlights the centrality of developing strong collaborations and evaluating the outcomes of the AWV, so that evidence-based policies might result. Evidence-Based Health Risk Assessments As discussed by Gorin & Balasubramanian (2018), evidence-based health risk assessment tools—like the My Own Health Record (MOHR)—are key to developing patient-centered treatment plans, as well as generalizing the findings from the AWV across patient populations, providers, and settings. The MOHR is a web-based health risk assessment that is evidence-based and patient-centered. The MOHR tool systematically assesses health behavior and mental health among patients in a primary-care setting; the MOHR is paired with a feedback system to promote patient counseling and goal-setting for adults. This automated assessment and feedback tool is designed to encourage collaborative goal setting between primary-care providers and patients presenting for AWV, usual care, or chronic care visits. The MOHR tool has been rigorously evaluated within a practice-level, national, cluster-randomized pragmatic, implementation study. The findings revealed high reach, and significant changes in risk assessment, goal-setting, and risk modification in key domains. Yet, evidence-based health risk assessment tools, like the MOHR, while available, are not widely implemented, leaving gaps in our understanding of the health needs of older adults that could be gained from study of the AWV. Screening for Cognitive Impairment Loskutova sees the AWV as an opportunity for an early recognition of cognitive decline. This cognitive decline may eventually lead to dementia, including Alzheimer’s dementia, with the enormous medical, social, and economic burden on the estimated 5.7 million Americans who are diagnosed with Alzheimer’s disease (Alzheimer’s Association, 2018). The opportunity for timely screening of cognitive decline in the AWV is enriched by the wide availability of brief, evidence-based screening measures (Lin, O’Connor, Rossom, Perdue, & Eckstrom, 2013), These instruments can also be used to screen for dementia within the AWV (Lin et al., 2013; Loskutova, 2018), and are more reliable than subjective cognitive complaints that are reported by patients or their family members. At the population level, early cognitive assessment in the AWV may have limited impact on important patient, caregiver, or societal outcomes (Fowler et al., 2018; Lin et al., 2013) At the policy level, however, the Alzheimer’s Association has supported the application of their Medicare Annual Wellness Visit Algorithm for Assessment of Cognition (Cordell et al., 2013), which includes multiple assessment sources and informants. Counseling for Behavior Change Resnick (2018) highlights the importance of age- and function-appropriate screening measures for older adults. While the AWV provides an opportunity for the discussion of cancer screening, the visit does not necessarily include decision aids (Breslau et al., 2016) to help patients to decide about the appropriateness of cancer screening. A recent study suggested that those who receive an AWV have higher screening rates than those who do not (Camacho et al., 2017; Jiang et al., 2018); yet, more screening may be a better outcome for younger adults than for those who are 90 years of age and older. Systematically assessing the appropriateness of cancer screening (Breslau et al., 2016), for example, could reduce the harms of overdiagnosis or over-treatment due to false positive screenings, as well as save health-care dollars. Importantly, the visit provides a “teachable moment” for counseling in prevention; evidence-based guides for primary-care providers counseling for prevention have proliferated of late. For example, the 5 A’s are available to assist the provider to counsel for tobacco cessation (Fiore, Hatsukami, & Baker, 2002) and the United States Preventive Services Task Force (USPSTF) recently provided evidence-based guidance for dietary and physical activity change (Patnode, Evans, Senger, Redmond, & Lin, 2017). As learned by Gorin & Balasubramanian during the MOHR study, to sustain behavioral change post-AWV, follow-up counseling visits, reimbursement for behavioral health specialists, provider training, and support for community referrals are required. Effectiveness of the AWV The effectiveness of the AWV continues to be a primary concern. Resnick (2018) proposes that future efforts to assess patient function, to decrease hospitalizations and readmissions, and to help older adults to stay in the least restrictive environments are key. A full assessment of the costs of the AWV, to both individuals and the health care system, is warranted. As Kaskie (2018) notes, however, it is unclear whether the AWV is associated with improved health, or simply increased health services. Little work has been done to assess the implementation of specific components of the AWV and the value of the behavior-change interventions that are associated with each (or all) of the AWV’s components. Further, since current implementation of the AWV is so limited and uneven, outcomes must be systematically evaluated so that any benefits that accrue from the AWV are distributed equitably across the older adult population. Future Policy and Research Directions for the AWV While each of the contributors to this report has identified future research needs, creating a data infrastructure for the assessment of the AWV could be fundamental. A combination of data, systematically collected from assessment tools such as the MOHR, integrated with practice-based electronic health records could create a unique resource for the longitudinal study of the processes and outcomes of the AWV among older adults and across patient panels and populations. The addition of cost data could enrich these databases; comparative effectiveness approaches could be most informative for future policy initiatives. Relying on a comprehensive data infrastructure, and the resulting findings from its study, novel AWV policy models could emerge to systematically assess and address disparities due to social and behavioral determinants of healthy aging. As discussed throughout this volume, the proposed research and policy approaches could undergird a healthier future for older adults. As discussed throughout this volume, the proposed research and policy approaches could undergird a healthier future for older adults. ...since current implementation of the AWV is so limited and uneven, outcomes must be systematically evaluated so that any benefits that accrue from the AWV are distributed equitably across the older adult population. A full assessment of the costs of the AWV, to both individuals and the health care system, is warranted. References Alley , D. E. , Asomugha , C. N. , Conway , P. H. , Sanghavi , D. M . ( 2016 ). Accountable health communities—addressing social needs through medicare and medicaid . The New England Journal of Medicine , 374 , 8–11 . Google Scholar Crossref Search ADS PubMed Alzheimers Association . ( 2018 ). 2018 Alzheimer’s disease facts and figures . Alzheimer’s Dementia , 14 , 367 – 429 . Crossref Search ADS Breslau , E. S. , Gorin , S. S. , Edwards , H. M. , Schonberg , M. A. , Saiontz , N. , & Walter , L. C . ( 2016 ). An individualized approach to cancer screening decisions in older adults: a multilevel framework . Journal of General Internal Medicine , 31 ( 5 ), 539 – 547 . doi: https://doi.org/10.1007/s11606-016-3629-y Google Scholar Crossref Search ADS PubMed Camacho , F. , Yao , N. A. , & Anderson , R . ( 2017 ). The effectiveness of medicare wellness visits in accessing preventive screening . Journal of Primary Care & Community Health , 8 ( 4 ), 247 – 255 . doi: https://doi.org/10.1177/2150131917736613 Google Scholar Crossref Search ADS PubMed Cordell , C. B. , Borson , S. , Boustani , M. , Chodosh , J. , Reuben , D. , Verghese , J., … Fried , L. B .; Medicare Detection of Cognitive Impairment Workgroup . ( 2013 ). Alzheimer’s Association recommendations for operationalizing the detection of cognitive impairment during the medicare annual wellness visit in a primary care setting . Alzheimer’s & Dementia , 9 ( 2 ), 141 – 150 . doi: https://doi.org/10.1016/j.jalz.2012.09.011 Google Scholar Crossref Search ADS Cuenca , A. E . ( 2012 ). Making medicare annual wellness visits work in practice . Family Practice Management , 19 ( 5 ), 11 – 16 . Google Scholar PubMed Levi, J., Fukuzawa, D. D., Sim, S. C., Simpson, P., Standish, M., Kong, C. W., & Weiss AF. Developing a common framework for assessing accountable communities for health. Health Affairs Blog, October 24, 2018. doi: 10.1377/hblog20181023.892541. Retrieved from: https://www.healthaffairs.org/do/10.1377/hblog20181023.892541/full Fiore , M. C. , Hatsukami , D. K. , & Baker , T. B . ( 2002 ). Effective tobacco dependence treatment . JAMA , 288 ( 14 ), 1768 – 1771 . Google Scholar Crossref Search ADS PubMed Fowler , N. R. , Campbell , N. L. , Pohl , G. M. , Munsie , L. M. , Kirson , N. Y. , Desai , U., … Boustani , M. A . ( 2018 ). One-year effect of the medicare annual wellness visit on detection of cognitive impairment: a cohort study . Journal of the American Geriatrics Society , 66 ( 5 ), 969 – 975 . doi: https://doi.org/10.1111/jgs.15330 Google Scholar Crossref Search ADS PubMed Ganguli , I. , Souza , J. , McWilliams , J. M. , & Mehrotra , A . ( 2017 ). Trends in use of the US Medicare annual wellness visit, 2011-2014 . JAMA , 317 ( 21 ), 2233 – 2235 . doi: https://doi.org/10.1001/jama.2017.4342 Google Scholar Crossref Search ADS PubMed Ganguli , I. , Souza , J. , McWilliams , J. M. , & Mehrotra , A . ( 2018 ). Practices caring for the underserved are less likely to adopt Medicare’s annual wellness visit . Health Affairs (Project Hope) , 37 ( 2 ), 283 – 291 . doi: https://doi.org/10.1377/hlthaff.2017.1130 Google Scholar Crossref Search ADS PubMed Gorin , S. S. , & Balasubramanian , B. A . ( 2019 ). The my own health report (MOHR): opportunities for implementation in the annual wellness visit . Public Policy & Aging Report , 29 ( 1 ), 33 – 40 . Hollmann , P. A . ( 2019 ). The medicare annual wellness visit: challenges and opportunities in practice . Public Policy & Aging Report , 29 ( 1 ), 5 – 7 . Jiang , M. , Hughes , D. R. , & Wang , W . ( 2018 ). The effect of Medicare’s annual wellness visit on preventive care for the elderly . Preventive Medicine , 116 , 126 – 133 . doi: https://doi.org/10.1016/j.ypmed.2018.08.035 Google Scholar Crossref Search ADS PubMed Kaskie , B , & Dreissen , J . ( 2019 ). Efforts Over 50 Years . Public Policy & Aging Report , 29 ( 1 ), 41 – 44 . Lin , J. S. , O’Connor , E. , Rossom , R. C. , Perdue , L. A. , & Eckstrom , E . ( 2013 ). Screening for cognitive impairment in older adults: a systematic review for the U.S. preventive services task force . Annals of Internal Medicine , 159 ( 9 ), 601 – 612 . doi: https://doi.org/10.7326/0003-4819-159-9-201311050-00730 Google Scholar PubMed Lind , K. E. , Hildreth , K. , Lindrooth , R. , Crane , L. A. , Morrato , E. , & Perraillon , M. C . ( 2018 ). Ethnoracial disparities in medicare annual wellness visit utilization: evidence from a nationally representative database . Medical Care , 56 ( 9 ), 761 – 766 . doi: https://doi.org/10.1097/MLR.0000000000000962 Google Scholar PubMed Loskutova , N . ( 2018 ). The annual wellness visit: assessment of cognitive impairment . Public Policy & Aging Report , 29 ( 1 ), 20 – 25 . Patnode , C. D. , Evans , C. V. , Senger , C. A. , Redmond , N. , & Lin , J. S . ( 2017 ). Behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults without known cardiovascular disease risk factors: updated evidence report and systematic review for the US preventive services task force . JAMA , 318 ( 2 ), 175 – 193 . doi: https://doi.org/10.1001/jama.2017.3303 Google Scholar Crossref Search ADS PubMed Resnick , B . ( 2018 ). Description of the annual wellness visit . PPAR . Simpson , V . ( 2018 ). Policy and practice recommendations for nurse practitioner-led medicare annual wellness visits . Public Policy & Aging Report , 29(1), 13–19. Tipirneni , R. , Ganguli , I. , Ayanian , J. Z. , & Langa , K. M . ( 2018 ). Reducing disparities in healthy aging through an enhanced medicare annual wellness visit . Public Policy & Aging Report , 29(1), 26–32. © The Author(s) 2019. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: [email protected]. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
The Medicare Annual Wellness Visit: Challenges and Opportunities in PracticeHollmann, Peter, A
doi: 10.1093/ppar/pry049pmid: N/A
Annual Wellness Visit, Preventive Services, Medicare Once upon a time, Medicare did not cover preventative services. In July of 1965, when Medicare became law, the goal was “To provide a hospital insurance program for the aged under the Social Security Act with a supplementary medical benefits program and an expanded program of medical assistance, to increase benefits under the Old-Age, Survivors, and Disability Insurance System, to improve the Federal-State public assistance programs, and for other purposes.” (available at https://www.govinfo.gov/content/pkg/STATUTE-79/pdf/STATUTE-79-Pg286.pdf) Like all health insurance of the day, it was not about promoting health; it was about payment for sickness care. For example, before 1988, when Medicare first began to cover screening mammography, women only had diagnostic mammograms for abnormal findings on clinical breast examinations. While traditional Medicare continued to limit coverage of preventative services for decades to come, in 1973, Medicare was expanded to include Health Maintenance Organizations (now Part C Medicare Advantage Plans), which explicitly recognized wellness and prevention as key components of clincial care. In 2009, Medicare began paying for the only preventative “physical” it covers today: the Initial Preventative Physical Exam (IPPE), which is available once in the life of a beneficiary, if performed within the first 12 months of Part B enrollment. Medicare did seek geriatrics expertise on implementing the IPPE benefit; the challenge of giving advice was to make it consistent with geriatric principles of care for a relatively young population, but also to not make the requirements so extensive as to be incompatible with the daily challenges of primary care. An even greater challenge was reconciling medical science with the “Congressional science,” which required that any “real” physical include a screening electrocardiogram (EKG). In 2011, the ACA ushered in an era of an evidence-based medicine approach to coverage of preventive services by creating the annual wellness visit (AWV). The AWV is not a physical, nor is it really a physician/non-physician professional (i.e., advance practice nurse or physician assistant) exam, even though the physician/nonphysician professional must bill the service to Medicare. Facilities may also report the service. It is “a visit to develop or update a personalized prevention plan and perform a health risk assessment,” as stated in Centers for Medicare and Medicaid (2018; p. 1) publications. The service has grown by nearly 1 million visits every year, but nonetheless, less than 25% of traditional fee-for-service Medicare beneficiaries receive the IPPE or AWV service each year (Ganguli, Souza, McWilliams, & Mehrotra, 2018; https://www.cms.gov/Research-Statistics-Data-and-Systems/Downloadable-Public-Use-Files/Part-B-National-Summary-Data-File/Overview.html). Table 1 shows the required elements of the initial AWV. The subsequent AWV is very similar. Many of the data points are exactly what defines good geriatric care and the type of assessments that were atypical in most primary-care annual exams in 2011, if not today. For example, activities of daily living and instrumental activities of daily living are included. Some are less relevant to geriatrics, such as family history. Others are patient dependent, such as United States Preventative Services Task Force guidelines when the patient is healthy or frail. Table 1. Initial AWV Action Elements Perform a Health Risk Assessment Self-assessment of health; assess psychosocial and behavioral risks; ADL/IADL Medical and Family History (FH) Medical and FH; complete medication review List other providers/suppliers Create list Measure Height, weight, BMI, and blood pressure Detect cognitive impairment Global assessment or standardized screening tool Review risk factors and experiences with mood disorders History and use of any screening instrument Review functional ability and safety Observation or screening for ADL, fall risk, hearing impairment, and home safety Written schedule of prevention USPSTF and immunizations (Advisory Committee on Immunization Practices) List risk factors and conditions for which there are recommendations Mental health, substance use, cognition, and medical conditions Furnish personalized health advice and appropriate referrals to health education or preventive counseling services or programs Refer to community-based lifestyle and self-management interventions for falls, nutrition, tobacco cessation, physical activity, and nutrition/weight loss Advance Care Planning At the discretion of the beneficiary Action Elements Perform a Health Risk Assessment Self-assessment of health; assess psychosocial and behavioral risks; ADL/IADL Medical and Family History (FH) Medical and FH; complete medication review List other providers/suppliers Create list Measure Height, weight, BMI, and blood pressure Detect cognitive impairment Global assessment or standardized screening tool Review risk factors and experiences with mood disorders History and use of any screening instrument Review functional ability and safety Observation or screening for ADL, fall risk, hearing impairment, and home safety Written schedule of prevention USPSTF and immunizations (Advisory Committee on Immunization Practices) List risk factors and conditions for which there are recommendations Mental health, substance use, cognition, and medical conditions Furnish personalized health advice and appropriate referrals to health education or preventive counseling services or programs Refer to community-based lifestyle and self-management interventions for falls, nutrition, tobacco cessation, physical activity, and nutrition/weight loss Advance Care Planning At the discretion of the beneficiary Note. Table adopted from Centers for Medicare and Medicaid, 2018. ADL = activities of daily living; AWV = Annual Wellness Visit; BMI = body mass index; IADL = instrumental activities of daily living; USPSTF = United States Preventative Services Task Force. View Large Table 1. Initial AWV Action Elements Perform a Health Risk Assessment Self-assessment of health; assess psychosocial and behavioral risks; ADL/IADL Medical and Family History (FH) Medical and FH; complete medication review List other providers/suppliers Create list Measure Height, weight, BMI, and blood pressure Detect cognitive impairment Global assessment or standardized screening tool Review risk factors and experiences with mood disorders History and use of any screening instrument Review functional ability and safety Observation or screening for ADL, fall risk, hearing impairment, and home safety Written schedule of prevention USPSTF and immunizations (Advisory Committee on Immunization Practices) List risk factors and conditions for which there are recommendations Mental health, substance use, cognition, and medical conditions Furnish personalized health advice and appropriate referrals to health education or preventive counseling services or programs Refer to community-based lifestyle and self-management interventions for falls, nutrition, tobacco cessation, physical activity, and nutrition/weight loss Advance Care Planning At the discretion of the beneficiary Action Elements Perform a Health Risk Assessment Self-assessment of health; assess psychosocial and behavioral risks; ADL/IADL Medical and Family History (FH) Medical and FH; complete medication review List other providers/suppliers Create list Measure Height, weight, BMI, and blood pressure Detect cognitive impairment Global assessment or standardized screening tool Review risk factors and experiences with mood disorders History and use of any screening instrument Review functional ability and safety Observation or screening for ADL, fall risk, hearing impairment, and home safety Written schedule of prevention USPSTF and immunizations (Advisory Committee on Immunization Practices) List risk factors and conditions for which there are recommendations Mental health, substance use, cognition, and medical conditions Furnish personalized health advice and appropriate referrals to health education or preventive counseling services or programs Refer to community-based lifestyle and self-management interventions for falls, nutrition, tobacco cessation, physical activity, and nutrition/weight loss Advance Care Planning At the discretion of the beneficiary Note. Table adopted from Centers for Medicare and Medicaid, 2018. ADL = activities of daily living; AWV = Annual Wellness Visit; BMI = body mass index; IADL = instrumental activities of daily living; USPSTF = United States Preventative Services Task Force. View Large The AWV and the education provided by Medicare has evolved. The AWV is often an opportunity to bond the patient with the practice and improve the patient relationship, which in turn could improve care. Beneficiaries who receive the AWV also receive more preventive services (Camacho, Yao, & Anderson, 2017). Careful medication review can be performed. Gaps in care can be closed and quality measures addressed. It may help identify the patient who needs care management services and address population management needs. The degree to which there was ambiguity (including fear of audit) or discordance with long-standing practice has been a likely factor in the slower uptake of the AWV, however. Changing anything in the workflow and world of busy primary-care schedules is a challenge. Those with electronic medical records are more likely to perform the service and build templates to address the requirements. Having more Medicare beneficiaries as a percent of the population, being in an Accountable Care Organization (ACO), having Medicare patients who are less sick, and having fewer Medicaid patients are all associated with greater adoption (Ganguli et al., 2018). The practices with high Medicaid and high illness burden and their patients are likely more stressed, and the focus is the immediate need, possibly to the detriment of longitudinal care. AWV did not lead to more primary-care visits overall, and nearly half of the time an AWV is reported with a traditional problem(s) evaluation and management service. Those who more commonly perform the AWV have greater revenue (Ganguli et al., 2018). Table 2 provides the 2018 national, non-facility, Medicare Physician Fee Schedule allowances. Advance care planning may be separately reported and is not subject to beneficiary cost sharing when done at the time of an AWV. Other preventative services may be done on the same date and billed. As a result, a comprehensive preventative visit program can significantly improve revenue. Table 2. Codes and Allowances, as of October 2018 Code Description Non-Facility Fee G0438 Annual wellness visit: includes a personalized prevention plan of service and initial visit $175.32 G0439 Annual wellness visit: includes a personalized prevention plan of service and subsequent visit $119.16 99497 Advance care planning, including the explanation and discussion of advance directives, such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes are face-to-face with the patient, family member(s), and/or surrogate. $86.04 Code Description Non-Facility Fee G0438 Annual wellness visit: includes a personalized prevention plan of service and initial visit $175.32 G0439 Annual wellness visit: includes a personalized prevention plan of service and subsequent visit $119.16 99497 Advance care planning, including the explanation and discussion of advance directives, such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes are face-to-face with the patient, family member(s), and/or surrogate. $86.04 Note: Additional preventive or problem-oriented (evaluation and management) services to those listed may be performed and reported. View Large Table 2. Codes and Allowances, as of October 2018 Code Description Non-Facility Fee G0438 Annual wellness visit: includes a personalized prevention plan of service and initial visit $175.32 G0439 Annual wellness visit: includes a personalized prevention plan of service and subsequent visit $119.16 99497 Advance care planning, including the explanation and discussion of advance directives, such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes are face-to-face with the patient, family member(s), and/or surrogate. $86.04 Code Description Non-Facility Fee G0438 Annual wellness visit: includes a personalized prevention plan of service and initial visit $175.32 G0439 Annual wellness visit: includes a personalized prevention plan of service and subsequent visit $119.16 99497 Advance care planning, including the explanation and discussion of advance directives, such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes are face-to-face with the patient, family member(s), and/or surrogate. $86.04 Note: Additional preventive or problem-oriented (evaluation and management) services to those listed may be performed and reported. View Large The AWV is a time when diagnostic coding accuracy and completeness can be improved. This is essential for the risk adjustment methods applicable to ACO and Medicare Advantage plans, as well as the Medicare Merit-based Incentive Payment System. The AWV service and the advance care planning components are designed around team-based care. Many of the most effective practices or programs utilize pharmacists and/or nurses to perform the AWV. Medicare Part B covers an AWV if performed by a physician (a doctor of medicine or osteopathy); a qualified non-physician practitioner (a physician assistant, nurse practitioner, or certified clinical nurse specialist); a medical professional (including a health educator, registered dietitian, nutrition professional, or other licensed practitioner); or a team of medical professionals directly supervised by a physician (doctor of medicine or osteopathy). It is free for the beneficiary. The AWV may enhance patient care, the care delivery system, and revenue. Only one AWV may be billed per year and, unfortunately, some wellness vans provide this and also charge cash for a set of medically-unnecessary services the public commonly thinks useful, such as screening electrocardiograms and carotid ultrasounds, without providing any longitudinal care. Not only are primary-care clinicians confronted with test results for services that were not indicated, but they also have their own AWV claim rejected as being over the benefit limit. These modest issues do not significantly degrade the value of the service. Even the multi-morbid or cognitively-impaired patients may benefit from addressing the relevant components of the AWV. It is time for all practices to reap the benefits in patient care, team care enhancement, and revenue that these services provide. The investment in overcoming the barrier of relatively modest change is necessary and will pay dividends. References Camacho , F. , Yao , N. A. , & Anderson , R . ( 2017 ). The effectiveness of medicare wellness visits in accessing preventive screening . Journal of Primary Care & Community Health , 8 , 247 – 255 . doi: https://doi.org/10.1177/2150131917736613 Google Scholar Crossref Search ADS PubMed Centers for Medicare and Medicaid. (2018). Medicare learning network booklet . Annual wellness visit . Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/awv_chart_icn905706.pdf. Centers for Medicare and Medicaid Services. (2018) . Medicare utilization summary data for CY2000-CY2017. Retrieved from https://www.cms.gov/Research-Statistics-Data-and-Systems/Downloadable-Public-Use-Files/Part-B-National-Summary-Data-File/Overview.html. Ganguli , I. , Souza , J. , McWilliams , J. M. , & Mehrotra , A . ( 2018 ). Practices caring for the underserved are less likely to adopt medicare’s annual wellness visit . Health affairs (Project Hope) , 37 , 283 – 291 . doi: https://doi.org/10.1377/hlthaff.2017.1130 Google Scholar Crossref Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: [email protected]. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
Description of the Annual Wellness VisitResnick,, Barbara
doi: 10.1093/ppar/pry045pmid: N/A
Wellness Visit, Health Promotion, Prevention The Medicare Annual Wellness Visit (AWV) was introduced in 2011 as part of the Medicare Part B expansion under the Affordable Care Act. The purpose of the AWV was to encourage preventive care and mitigate health risks in aging patients through required, age-appropriate, and risk-modifying screenings and assessments. The intention was to change the focus away from acute medical problems, and have patients and providers engage in a conversation that focused on health history, health behaviors, and prevention. The overall goal of the AWV was to create a plan of care that addresses prevention and/or the optimal management of clinical problems (Centers for Medicare and Medicaid, 2018). Eligibility Individuals are eligible for an AWV if they have Part B coverage from Medicare. In the first year of transition to Medicare, a “Welcome to Medicare” preventive visit is done instead of an AWV. The AWV can start the year following the Welcome to Medicare visit. Only one visit per year is allowed (Centers for Medicare and Medicaid, 2018). What is Covered Under the AWV The AWV is not a comprehensive physical exam. This is often surprising for patients, who traditionally expect this type of exam when seeing a health care provider. Rather, the AWV involves more talking than direct touch. The health care provider evaluates routine biometric assessments, including height, weight, and blood pressure, and reviews the patient’s past medical history and family history, as relevant. Additional assessments are based on questionnaires and screening tools, which can vary from provider to provider. These assessments include an evaluation of cognition, mood, balance, vision, hearing, risk of falls, basic and instrumental activities of daily living (e.g., preparing meals and taking medications), current immunization status, safety factors (e.g., fall prevention, seat belt use, neighborhood safety), status of cancer screenings, and completion of advanced directives. In addition, the provider should develop a current medication list; develop a list of health care providers (e.g., specialists, as relevant for the patient); note the use of durable equipment, such as oxygen, and the supplier; and create an updated list of immunizations and screenings, with dates and results. A five- to ten-year screening schedule should be established. Coverage and Costs Associated with the AWV Medicare covers the AWV at 100% of the Medicare-approved amount when the service is provided by a participating provider. Medicare Advantage plans are required to cover AWVs without applying deductibles, copayments, or coinsurance when the patient is seen by an in-network provider. In the event that a problem is identified during the AWV that requires additional testing (e.g., there are concerns about anemia and blood work is done), Medicare will bill the patient for any diagnostic care that is needed (Centers for Medicare and Medicaid, 2018). The screenings recommended and encouraged during the AWV are generally covered by Medicare (Table 1), although if a screening returns as abnormal, additional diagnostic testing will be billed to the patient. In addition to screenings, there is coverage for health education and training around the management of diabetes, counseling for depression, nutritional guidance and weight management, and support for smoking and alcohol cessation. Unfortunately, the majority of patients and/or providers still may not take full advantage of these opportunities for discussions of heath during the AWV. The AWV focus may continue to be on diagnosis and management of disease, rather than on prevention and adherence to healthy behaviors. Table 1. Screening Coverage Screening Type Coverage Additional Patient Costs Obesity Screening and Counseling Screening based on Basal Metabolic Index calculated from height and weight. Counseling up to one year for weight loss. Interventions beyond one year or interventions such as bariatric surgery; medication interventions; or exercise intervention programs. Mammography Screening Mammogram once every 12 months. Screenings more often than every 12 months; diagnostic work-up for any positive findings. Prostate Screening Prostate-Specific Antigen (PSA) blood work once every 12 months and/or a digital rectal exam. The PSA is at no charge to the patient, but there is a 20% copay associated with the digital rectal exam. Colon Screening - A barium enema is covered once every 48 months if you’re age 50 or over or once every 24 months if you’re at high risk for colorectal cancer, when this test is used instead of a flexible sigmoidoscopy or colonoscopy. - A colonscopy is covered once every 24 months if you’re at high risk for colorectal cancer. If you aren’t at high risk for colorectal cancer, Medicare covers this test once every 120 months or 48 months after a previous flexible sigmoidoscopy - Multi-target stool DNA test is covered once every three years for people who meet all of these conditions: between 50–85; show no signs or symptoms of colorectal disease, including, but not limited to: lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test, average risk for developing colorectal cancer (have no personal history of Adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn’s disease and ulcerative colitis, and no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer). - A screening flexible sigmoidoscopy is covered once every 48 months for most people age 50 or older. If you aren’t at high risk, Medicare covers this test 120 months after a previous screening colonoscopy. Additional diagnostic testing or biopsies would be billed to the patient. Bone Density Testing All qualified people with Part B who are at risk for osteoporosis and meet one or more of these conditions: - A woman whose provider determines both of these (based on her medical history and other findings): she’s estrogen deficient and she’s at risk for osteoporosis. - A person whose X-rays show possible osteoporosis, osteopenia, or vertebral fractures. - A person taking prednisone or steroid-type drugs or who is planning to begin this treatment. - A person who has been diagnosed with primary hyperparathyroidism. - A person who is being monitored to see if their osteoporosis drug therapy is working. Testing more frequently than every 24 months would be billed to the patient, as would treatment for osteoporosis. Cardiovascular Screening Screening blood tests for cholesterol, lipid, and triglyceride levels every five years are covered. Additional diagnostic testing or treatment would be billed to the patient. Cardiovascular Behavior Health Screening One visit per year is covered for you to review behavioral aspects of cardiovascular disease. The visit is with your primary care provider and addresses the following: discuss aspirin use (if appropriate); check blood pressure; and review appropriate heart healthy diet. Additional diagnostic testing or treatment would be billed to the patient. Pap Test Pap tests and pelvic exams are covered once every 24 months for all women and once every 12 months if the patient is at high risk for cervical or vaginal cancer. Diabetes Screening Two screenings per year for diabetes are covered if the patient has the following risk factors: high blood pressure; a history of abnormal cholesterol and triglyceride levels; obesity; high blood sugar; or if the individual has two or more of the following: is 65 or older, overweight, has a family history of diabetes, history of gestational diabetes, or delivery of a baby weighing more than 9 pounds. More frequent testing or additional diagnostic work such as a hemoglobin a1c would be billed to the patient. Diabetes Management Education Outpatient 10 hours of diabetes self-management training is covered for individuals at risk for complications from diabetes. This training may include 1 hour of individual training and 9 hours of group training, with 2 hours of follow up training each year. Additional training or diagnostic work would be billed to the patient. Lung Cancer Screening An annual computed tomography test (a CT scan) is covered annually for individuals who are 55–77 years of age, asymptomatic, and are current smokers or quit within the past 15 years, have a tobacco smoking history of 30 pack years, or get a written order from a provider. Additional diagnostic work-ups, such as a biopsy, would be billed to the patient. Immunizations Immunizations for flu and pneumonia (both pneumonia vaccines) are covered for all Medicare beneficiaries at no charge. Hepatitis B is covered if the individual is at risk based on a diagnosis of end-stage renal disease, diabetes, or living with someone with Hepatitis B. There may be some charge to the patient, depending on the type of vaccine given (e.g., type of flu vaccine). Glaucoma screening All people with Part B who are at high risk for glaucoma are eligible for testing. This includes individuals with diabetes, with a family history of glaucoma, who are African American and over 50 years of age, or who are Hispanic and over 65 years of age. There is a 20% copay. Screening Type Coverage Additional Patient Costs Obesity Screening and Counseling Screening based on Basal Metabolic Index calculated from height and weight. Counseling up to one year for weight loss. Interventions beyond one year or interventions such as bariatric surgery; medication interventions; or exercise intervention programs. Mammography Screening Mammogram once every 12 months. Screenings more often than every 12 months; diagnostic work-up for any positive findings. Prostate Screening Prostate-Specific Antigen (PSA) blood work once every 12 months and/or a digital rectal exam. The PSA is at no charge to the patient, but there is a 20% copay associated with the digital rectal exam. Colon Screening - A barium enema is covered once every 48 months if you’re age 50 or over or once every 24 months if you’re at high risk for colorectal cancer, when this test is used instead of a flexible sigmoidoscopy or colonoscopy. - A colonscopy is covered once every 24 months if you’re at high risk for colorectal cancer. If you aren’t at high risk for colorectal cancer, Medicare covers this test once every 120 months or 48 months after a previous flexible sigmoidoscopy - Multi-target stool DNA test is covered once every three years for people who meet all of these conditions: between 50–85; show no signs or symptoms of colorectal disease, including, but not limited to: lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test, average risk for developing colorectal cancer (have no personal history of Adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn’s disease and ulcerative colitis, and no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer). - A screening flexible sigmoidoscopy is covered once every 48 months for most people age 50 or older. If you aren’t at high risk, Medicare covers this test 120 months after a previous screening colonoscopy. Additional diagnostic testing or biopsies would be billed to the patient. Bone Density Testing All qualified people with Part B who are at risk for osteoporosis and meet one or more of these conditions: - A woman whose provider determines both of these (based on her medical history and other findings): she’s estrogen deficient and she’s at risk for osteoporosis. - A person whose X-rays show possible osteoporosis, osteopenia, or vertebral fractures. - A person taking prednisone or steroid-type drugs or who is planning to begin this treatment. - A person who has been diagnosed with primary hyperparathyroidism. - A person who is being monitored to see if their osteoporosis drug therapy is working. Testing more frequently than every 24 months would be billed to the patient, as would treatment for osteoporosis. Cardiovascular Screening Screening blood tests for cholesterol, lipid, and triglyceride levels every five years are covered. Additional diagnostic testing or treatment would be billed to the patient. Cardiovascular Behavior Health Screening One visit per year is covered for you to review behavioral aspects of cardiovascular disease. The visit is with your primary care provider and addresses the following: discuss aspirin use (if appropriate); check blood pressure; and review appropriate heart healthy diet. Additional diagnostic testing or treatment would be billed to the patient. Pap Test Pap tests and pelvic exams are covered once every 24 months for all women and once every 12 months if the patient is at high risk for cervical or vaginal cancer. Diabetes Screening Two screenings per year for diabetes are covered if the patient has the following risk factors: high blood pressure; a history of abnormal cholesterol and triglyceride levels; obesity; high blood sugar; or if the individual has two or more of the following: is 65 or older, overweight, has a family history of diabetes, history of gestational diabetes, or delivery of a baby weighing more than 9 pounds. More frequent testing or additional diagnostic work such as a hemoglobin a1c would be billed to the patient. Diabetes Management Education Outpatient 10 hours of diabetes self-management training is covered for individuals at risk for complications from diabetes. This training may include 1 hour of individual training and 9 hours of group training, with 2 hours of follow up training each year. Additional training or diagnostic work would be billed to the patient. Lung Cancer Screening An annual computed tomography test (a CT scan) is covered annually for individuals who are 55–77 years of age, asymptomatic, and are current smokers or quit within the past 15 years, have a tobacco smoking history of 30 pack years, or get a written order from a provider. Additional diagnostic work-ups, such as a biopsy, would be billed to the patient. Immunizations Immunizations for flu and pneumonia (both pneumonia vaccines) are covered for all Medicare beneficiaries at no charge. Hepatitis B is covered if the individual is at risk based on a diagnosis of end-stage renal disease, diabetes, or living with someone with Hepatitis B. There may be some charge to the patient, depending on the type of vaccine given (e.g., type of flu vaccine). Glaucoma screening All people with Part B who are at high risk for glaucoma are eligible for testing. This includes individuals with diabetes, with a family history of glaucoma, who are African American and over 50 years of age, or who are Hispanic and over 65 years of age. There is a 20% copay. View Large Table 1. Screening Coverage Screening Type Coverage Additional Patient Costs Obesity Screening and Counseling Screening based on Basal Metabolic Index calculated from height and weight. Counseling up to one year for weight loss. Interventions beyond one year or interventions such as bariatric surgery; medication interventions; or exercise intervention programs. Mammography Screening Mammogram once every 12 months. Screenings more often than every 12 months; diagnostic work-up for any positive findings. Prostate Screening Prostate-Specific Antigen (PSA) blood work once every 12 months and/or a digital rectal exam. The PSA is at no charge to the patient, but there is a 20% copay associated with the digital rectal exam. Colon Screening - A barium enema is covered once every 48 months if you’re age 50 or over or once every 24 months if you’re at high risk for colorectal cancer, when this test is used instead of a flexible sigmoidoscopy or colonoscopy. - A colonscopy is covered once every 24 months if you’re at high risk for colorectal cancer. If you aren’t at high risk for colorectal cancer, Medicare covers this test once every 120 months or 48 months after a previous flexible sigmoidoscopy - Multi-target stool DNA test is covered once every three years for people who meet all of these conditions: between 50–85; show no signs or symptoms of colorectal disease, including, but not limited to: lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test, average risk for developing colorectal cancer (have no personal history of Adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn’s disease and ulcerative colitis, and no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer). - A screening flexible sigmoidoscopy is covered once every 48 months for most people age 50 or older. If you aren’t at high risk, Medicare covers this test 120 months after a previous screening colonoscopy. Additional diagnostic testing or biopsies would be billed to the patient. Bone Density Testing All qualified people with Part B who are at risk for osteoporosis and meet one or more of these conditions: - A woman whose provider determines both of these (based on her medical history and other findings): she’s estrogen deficient and she’s at risk for osteoporosis. - A person whose X-rays show possible osteoporosis, osteopenia, or vertebral fractures. - A person taking prednisone or steroid-type drugs or who is planning to begin this treatment. - A person who has been diagnosed with primary hyperparathyroidism. - A person who is being monitored to see if their osteoporosis drug therapy is working. Testing more frequently than every 24 months would be billed to the patient, as would treatment for osteoporosis. Cardiovascular Screening Screening blood tests for cholesterol, lipid, and triglyceride levels every five years are covered. Additional diagnostic testing or treatment would be billed to the patient. Cardiovascular Behavior Health Screening One visit per year is covered for you to review behavioral aspects of cardiovascular disease. The visit is with your primary care provider and addresses the following: discuss aspirin use (if appropriate); check blood pressure; and review appropriate heart healthy diet. Additional diagnostic testing or treatment would be billed to the patient. Pap Test Pap tests and pelvic exams are covered once every 24 months for all women and once every 12 months if the patient is at high risk for cervical or vaginal cancer. Diabetes Screening Two screenings per year for diabetes are covered if the patient has the following risk factors: high blood pressure; a history of abnormal cholesterol and triglyceride levels; obesity; high blood sugar; or if the individual has two or more of the following: is 65 or older, overweight, has a family history of diabetes, history of gestational diabetes, or delivery of a baby weighing more than 9 pounds. More frequent testing or additional diagnostic work such as a hemoglobin a1c would be billed to the patient. Diabetes Management Education Outpatient 10 hours of diabetes self-management training is covered for individuals at risk for complications from diabetes. This training may include 1 hour of individual training and 9 hours of group training, with 2 hours of follow up training each year. Additional training or diagnostic work would be billed to the patient. Lung Cancer Screening An annual computed tomography test (a CT scan) is covered annually for individuals who are 55–77 years of age, asymptomatic, and are current smokers or quit within the past 15 years, have a tobacco smoking history of 30 pack years, or get a written order from a provider. Additional diagnostic work-ups, such as a biopsy, would be billed to the patient. Immunizations Immunizations for flu and pneumonia (both pneumonia vaccines) are covered for all Medicare beneficiaries at no charge. Hepatitis B is covered if the individual is at risk based on a diagnosis of end-stage renal disease, diabetes, or living with someone with Hepatitis B. There may be some charge to the patient, depending on the type of vaccine given (e.g., type of flu vaccine). Glaucoma screening All people with Part B who are at high risk for glaucoma are eligible for testing. This includes individuals with diabetes, with a family history of glaucoma, who are African American and over 50 years of age, or who are Hispanic and over 65 years of age. There is a 20% copay. Screening Type Coverage Additional Patient Costs Obesity Screening and Counseling Screening based on Basal Metabolic Index calculated from height and weight. Counseling up to one year for weight loss. Interventions beyond one year or interventions such as bariatric surgery; medication interventions; or exercise intervention programs. Mammography Screening Mammogram once every 12 months. Screenings more often than every 12 months; diagnostic work-up for any positive findings. Prostate Screening Prostate-Specific Antigen (PSA) blood work once every 12 months and/or a digital rectal exam. The PSA is at no charge to the patient, but there is a 20% copay associated with the digital rectal exam. Colon Screening - A barium enema is covered once every 48 months if you’re age 50 or over or once every 24 months if you’re at high risk for colorectal cancer, when this test is used instead of a flexible sigmoidoscopy or colonoscopy. - A colonscopy is covered once every 24 months if you’re at high risk for colorectal cancer. If you aren’t at high risk for colorectal cancer, Medicare covers this test once every 120 months or 48 months after a previous flexible sigmoidoscopy - Multi-target stool DNA test is covered once every three years for people who meet all of these conditions: between 50–85; show no signs or symptoms of colorectal disease, including, but not limited to: lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test, average risk for developing colorectal cancer (have no personal history of Adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn’s disease and ulcerative colitis, and no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer). - A screening flexible sigmoidoscopy is covered once every 48 months for most people age 50 or older. If you aren’t at high risk, Medicare covers this test 120 months after a previous screening colonoscopy. Additional diagnostic testing or biopsies would be billed to the patient. Bone Density Testing All qualified people with Part B who are at risk for osteoporosis and meet one or more of these conditions: - A woman whose provider determines both of these (based on her medical history and other findings): she’s estrogen deficient and she’s at risk for osteoporosis. - A person whose X-rays show possible osteoporosis, osteopenia, or vertebral fractures. - A person taking prednisone or steroid-type drugs or who is planning to begin this treatment. - A person who has been diagnosed with primary hyperparathyroidism. - A person who is being monitored to see if their osteoporosis drug therapy is working. Testing more frequently than every 24 months would be billed to the patient, as would treatment for osteoporosis. Cardiovascular Screening Screening blood tests for cholesterol, lipid, and triglyceride levels every five years are covered. Additional diagnostic testing or treatment would be billed to the patient. Cardiovascular Behavior Health Screening One visit per year is covered for you to review behavioral aspects of cardiovascular disease. The visit is with your primary care provider and addresses the following: discuss aspirin use (if appropriate); check blood pressure; and review appropriate heart healthy diet. Additional diagnostic testing or treatment would be billed to the patient. Pap Test Pap tests and pelvic exams are covered once every 24 months for all women and once every 12 months if the patient is at high risk for cervical or vaginal cancer. Diabetes Screening Two screenings per year for diabetes are covered if the patient has the following risk factors: high blood pressure; a history of abnormal cholesterol and triglyceride levels; obesity; high blood sugar; or if the individual has two or more of the following: is 65 or older, overweight, has a family history of diabetes, history of gestational diabetes, or delivery of a baby weighing more than 9 pounds. More frequent testing or additional diagnostic work such as a hemoglobin a1c would be billed to the patient. Diabetes Management Education Outpatient 10 hours of diabetes self-management training is covered for individuals at risk for complications from diabetes. This training may include 1 hour of individual training and 9 hours of group training, with 2 hours of follow up training each year. Additional training or diagnostic work would be billed to the patient. Lung Cancer Screening An annual computed tomography test (a CT scan) is covered annually for individuals who are 55–77 years of age, asymptomatic, and are current smokers or quit within the past 15 years, have a tobacco smoking history of 30 pack years, or get a written order from a provider. Additional diagnostic work-ups, such as a biopsy, would be billed to the patient. Immunizations Immunizations for flu and pneumonia (both pneumonia vaccines) are covered for all Medicare beneficiaries at no charge. Hepatitis B is covered if the individual is at risk based on a diagnosis of end-stage renal disease, diabetes, or living with someone with Hepatitis B. There may be some charge to the patient, depending on the type of vaccine given (e.g., type of flu vaccine). Glaucoma screening All people with Part B who are at high risk for glaucoma are eligible for testing. This includes individuals with diabetes, with a family history of glaucoma, who are African American and over 50 years of age, or who are Hispanic and over 65 years of age. There is a 20% copay. View Large Implementation and Use of the AWV Since the inception of the AWV, the implementation and use of the AWV across health care practices has been relatively low. In the first full year that the AWV was available, less than 10% of patients had an AWV done, and this low rate has persisted in many areas of the country (Bluestein, Diduk-Smith, Jordan, Persaud, & Hughes, 2017). The percentage of beneficiaries receiving an AWV increased from 7.5% in 2011 to only 15.6% by 2014 (Ganguli, Souza, McWilliams, & Mehrotra, 2017). Less than one fifth of all eligible Medicare patients received an AWV, less than half of primary care practices offered AWVs to their Medicare beneficiaries, and only 23% of practices provided AWVs to at least a quarter of their eligible patients (Bynum, Meara, & Chang, 2016). Further, there are health disparities in terms of who receives this service. Generally, those who are White, live in urban areas, have higher socio-economic statuses, and have only one or two comorbidities are most likely to receive an AWV (Ganguli, Souza, McWilliams, & Mehrotra, 2018). Challenges to Implementation of the AWV Numerous challenges to implementing the AWV have been raised by providers and within practices. These include a lack of knowledge about how to perform, document, and bill for the AWV; having to prioritize time in care interactions and focus on acute medical interactions; a lack of interest on the part of patients; and a lack of belief in the benefit of the service on the part of both patients and providers(Hurley et al., 2016; Simpson, Edwards, & Berlin, 2018; Woodall, Landis, Galvin, Plaut, & Roth McClurg, 2017). Several programs have been developed to overcome these challenges to implementation and increase the value of the AWV for patients and providers. One approach is to prepare charts prior to the AWV encounter, to assure that they are up-to-date in terms of the patient’s immunizations and screenings, so that decisions and a plan can be efficiently made. Patients can be called ahead of time or questioned when they sign in for their visit about whether or not, for example, they had a flu shot or pneumonia vaccine. Another technique used is the Practice Office Encounter Team, which provides patients with a written care summary to prompt them to schedule screenings or other appropriate health care activities prior to the next visit (Kanter, Martinez, Lindsay, Andrews, & Denver, 2010). Engaging medical assistants and all members of the health care team can also help to facilitate the AWV. For example, nurses and/or technicians can help with many of the screenings and assessments (e.g., height, weight, blood pressure, vision, and depression and cognitive screening; Bogrett & Carriel, 2018). To facilitate the scheduling of AWVs, several practices schedule the AWV during patients’ birthday months and invite individuals to their AWVs with a “happy birthday” postcard. Documentation of the AWV can be facilitated by building this into the electronic health record. Templates for the AWV include inputs for each component of the visitm including the health risk assessment, list of current providers, medical and family history, depression screening, fall risk assessment, cognitive assessment, screenings and immunizations, medication review, advance directives, and, ultimately, a personalized prevention plan. A template within the electronic health record helps to facilitate documentation of the AWV. In addition, there can be reminders within the electronic health record to cue providers to complete these visits annually. To make the AWV optimally useful for patients, it is also helpful to have opportunities for patient follow-up with any questions about their plan of care. This can be done within an electronic patient portal or via a telephone call set to occur during specific hours of the day. Benefits of AWVs At this point in time, there are limited data on the impact of the AWV for long-term health benefits, costs of care for patients, and the cost to the health care system. Conceptually, the advantage for patients is that they receive a comprehensive health assessment and personalized prevention plan. Providers are able to focus on prevention and health promotion versus disease management. Some practices have noted that the AWVs resulted in more appropriate cancer screenings and less unnecessary screening, better adherence to immunizations, and better adherence to the completion of advanced directives (Alhossan, Kennedy, & Leal, 2016; Bluestein et al., 2017; Camacho, Yao, & Anderson, 2017; Resnick, 2018). There was little evidence that there was a benefit to doing AWVs, in terms of early detection of cognitive impairment or depression, when comparing those who were or were not exposed to an AWV (Fowler et al., 2018; Pfoh, Mojtabai, Bailey, Weiner, & Dy, 2015). There was some evidence that the AWV helped to screen more individuals for reversible causes of dementia by checking thyroid-stimulating hormone and B12 and folate levels (Fowler et al., 2018), and use of the AWV may increase screening rates for diabetes and hyperlipidemia (Alhossan et al., 2016). Further, there was evidence that the AWV, particularly when there was pharmacy involvement, helped to identify medication-related problems (Alhossan et al., 2016; Woodall et al., 2017). Risks Associated With the AWV There are also some risks that have been identified with regard to performing AWVs, particularly when working with older adults whose life expectancy is less than 10 years. The focus of the AWV is on the prevention of disease and screening to identify illness before it causes symptoms. Careful consideration needs to be given, however, to whether or not a screening—for example, for breast or prostate cancer—is of any value for the older individual. There are tools available to help guide providers and patients in the decision-making process around whether or not to undergo screening. Examples of such tools include an approach developed by Lee and Kim (2018), in which life expectancy is estimated for each individual and the time-to-benefit for prevention interventions is determined. When life expectancy is substantially longer than the time-to-benefit, the intervention should be recommended. When life expectancy is not longer than the time-to-benefit, there is no value to the intervention and there is risk of harm in having the patient undergo the screening or preventative behavior. Alternatively, there is an online program, eprognosis (https://eprognosis.ucsf.edu/), that allows patients or providers to put in basic demographic information, including age, height, weight, medical diagnosis, and other psychosocial factors. Based on this information, a recommendation is made as to whether or not screening for cancer—specifically, breast and/or colorectal cancer—would be beneficial. Conclusion The AWV provides patients and providers with an exciting opportunity to focus on health behaviors versus disease. The use of the AWV is being incorporated into practices slowly, due to concerns about workflow, patient preferences, and the ongoing need for providers to address the acute medical problems of patients. There is also a need for more public awareness about the AWV as an opportunity for older adults. Future considerations should be given to more direct-to-consumer advertising about the AWV. Ongoing research is clearly needed to establish the long-term benefit or lack of benefit of providing AWVs for patients. To date, benefits have focused more on quantitative analyses of the number of screenings performed, immunizations provided, or early identification of cognitive impairment or diabetes. Future research needs to consider factors such as maintaining function, decreasing hospitalizations, and helping individuals remain in the least-restrictive environment. The costs of the AWV to both individuals and the health care system must be evaluated and considered. Lastly, it may useful to integrate tools within the AWV to help providers and patients determine whether not screenings are appropriate, given an individual’s age and other associated factors. References Alhossan , A. , Kennedy , A. , & Leal , S . ( 2016 ). Outcomes of annual wellness visits provided by pharmacists in an accountable care organization associated with a federally qualified health center . American Journal of Health-System Pharmacy , 73 , 225 – 228 . doi: https://doi.org/10.2146/ajhp150343 Google Scholar Crossref Search ADS PubMed Bluestein , D. , Diduk-Smith , R. , Jordan , L. , Persaud , K. , & Hughes , T . ( 2017 ). Medicare annual wellness visits: how to get patients and physicians on board . 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Policy and Practice Recommendations for Nurse Practitioner–Led Medicare Annual Wellness VisitsSimpson,, Vicki
doi: 10.1093/ppar/pry046pmid: N/A
Nurse Practitioners, Health Promotion, Annual Wellness Visit, Medicare, Care of Older Adults Problem Increasing demand for primary care services, due to population growth, aging of the population, and expanded access to insurance, is occurring across the United States (Kaiser Family Foundation, 2015; Traczynski & Udalova, 2013). As the older adult population reaches an estimated 21% (74 million) of the U.S. population, access to primary care services is imperative to keep this group healthy, functional, and independent (Kaiser Family Foundation, 2015; Low, Yap, & Brodaty, 2011). Poor health, frailty, loss of independence, and poor quality of life are not inevitable consequences of the aging process. Often, these are outcomes of unhealthy lifestyles and a lack of preventive behaviors, which play a larger role than genetics in decline and deterioration as one ages (Nuñez, Armbruster, Phillips, & Gale, 2003). In 2014, only two out of every five older adults were up to date with a core set of preventive services recommended by the Centers for Disease Control and Prevention (CDC) and few met the guidelines for physical activity and dietary intake (Centers for Disease Control and Prevention, 2017). Evidence suggests that older adults benefit from primary and secondary prevention efforts; the challenge is to determine methods to more effectively engage and empower older adults to better manage their health through preventive activities (Low et al., 2011; Markle-Reid et al., 2011). Increased utilization of preventive care services by this population can significantly impact both population health outcomes and medical costs (Traczynski & Udalova, 2013). In 2011, passage of the Patient Protection and Affordable Care Act (PPACA) enhanced support for primary care services, including the Medicare Annual Wellness Visit (AWV). This visit, solely focused upon wellness, is provided as an annual service with no co-pays or deductibles to Medicare beneficiaries. It offers a focused opportunity to identify and address risks, recommend preventive services and lifestyle behavior changes, and support healthy aging (Hain, 2014). Based upon information gathered during the visit and via a required health risk assessment (HRA), the provider and patient collaboratively develop a personalized prevention plan to target needed preventive services and lifestyle behavior changes (Camacho, Yao, & Anderson, 2017; Galvin et al., 2017). Despite the availability of this free visit, as can be seen in Figure 1, AWV participation rates are low, with only 19.8% of Medicare Part B beneficiaries participating in 2016, as compared to overall participation rates (72.5%) in at least one free preventive service (including the AWV) offered by Medicare (Centers for Medicare and Medicaid Services, 2011, 2012, 2013, 2014, 2016). Additionally, over half of primary care practices indicate that they do not offer an AWV to beneficiaries; this rate is even lower for primary care practices that serve low-income or vulnerable populations (Camacho et al., 2017; Ganguli, Souza, McWilliams & Mehrotra, 2017). Of practices that do conduct AWVs, few are meeting all mandated Centers for Medicare and Medicaid Services (CMS) requirements, even though they believe it is important to do so (Cuenca, Lozoya-Flores, & Hogrefe, 2012; Simpson, Edwards, & Berlin, 2018). Figure 1. View largeDownload slide Medicare part B beneficiary use of preventive services, 2011–2016.a Incomplete data Figure 1. View largeDownload slide Medicare part B beneficiary use of preventive services, 2011–2016.a Incomplete data Reasons for underutilization are related to personal, organizational, structural, and system barriers and challenges for beneficiaries and providers. Beneficiaries are often unaware of the availability of this visit (or the fact that it is free). They may not understand the value of nor attach strong importance to a visit solely focused upon prevention. Providers report being confused and overwhelmed regarding AWV requirements and guidelines, leading to ambivalence concerning visit implementation (Bluestein, Diduk-Smith, Jordan, Persaud, & Hughes, 2017; Cuenca et al., 2012; Simpson et al., 2018). Most practices lack an efficient and effective workflow to support implementation of AWVs, thereby consuming limited practice time (Cuenca et al., 2012). These issues are compounded by a steady decline in the numbers of medical students and residents entering primary care—particularly family practice or general internal medicine—at a time when there are growing numbers of Medicare beneficiaries requiring primary care services (Naylor & Kurtzman, 2010). Meeting Preventive Care Needs: Role of Nurse Practitioners Advanced practice registered nurses (APRNs), such as nurse practitioners (NPs), are increasingly being called upon to meet the increased demand for primary care services. Preventive care needs are being driven by the enhanced focus on prevention by the PPACA, including increased access to clinical preventive services, expanded public health capacity, enhanced funding for existing public health programs, and a movement to value-based care (Chait & Glied, 2018; Salmond & Ecchevarria, 2017). These practitioners are helping to meet primary care needs in Health Professional Shortage Areas and are choosing primary care at a higher rate than physicians and physician assistants (Golden, Silverman, & Issenberg, 2015). The shorter time frame required to educate NPs allows them to enter the workforce faster, helping to close the gap in primary care services. According to the American Association of Nurse Practitioners National NP Database, there were more than 248,000 licensed NPs in 2018a, with 77.8% in primary care. These NPs provided an estimated 1.02 billion visits in 2018b, in a wide range of community settings, including community-based and nurse-managed clinics (many funded through the PPACA) and to a higher proportion of the vulnerable and uninsured population across the health trajectory (Cassidy, 2013; Vincent & Reed, 2014). They play crucial roles in preventive medical care, helping to keep populations healthy by preventing development of or better managing chronic diseases. According to Perloff, DesRoches, and Buerhaus (2016), a significant cost savings could be realized for Medicare if greater numbers of NPs were providing primary care services. Nurses are particularly well suited to health promotion and disease prevention efforts. Health promotion, considered a universal principle of nursing, is a core required competency in NP education (Kemppainen, Tossavainen, & Turunen, 2013; Vincent & Reed, 2014). As well, NPs are patient-centered, focusing upon factors that impact the ability of patients to manage their own care. According to Cassidy (2013), NPs spend more time counseling patients and do better with patient follow-up than physicians. Many studies have documented the effectiveness of health promotion services offered by NPs, including improved quality of life, better adherence and participation in preventive services, self-management of chronic diseases, reduced medical costs, and increased satisfaction with health-care services (Cassidy, 2013; Kemppainen et al., 2013). These outcomes are enhanced when NPs can practice to the full scope of their abilities (Oliver, Pennington, Revelle, & Rantz, 2014). Policy and Practice Recommendations To effectively increase AWV uptake, reasons for underutilization must be addressed for providers, beneficiaries, and health-care entities. A set of recommendations to support a team-based approach to AWV implementation has been compiled based upon research and conversations with a variety of stakeholders. Several literature reviews (two published, one in development) concerning AWV aspects, implementation, and outcomes provided guidance for these recommendations (Simpson, 2018; Simpson & Pedigo, 2017, 2018). In 2017, the author and colleagues conducted a research study concerning AWV implementation with practicing APRNs through a state-based professional organization. This study generated data concerning APRN attitudes and perceptions of the AWV, helping to identify strengths, challenges, and barriers (Simpson et al., 2018). Lastly, discussions and collaboration with leadership and providers in several nurse-managed, community-based clinics and Medicare Accountable Care Organizations (ACOs) working to increase participation in AWVs helped shape these recommendations. While no one recommendation or approach will work for all practice settings, these recommendations provide guidance for AWV implementation by NPs and the health-care team, enhancing the focus on prevention for Medicare beneficiaries. Commit to Prevention Increased commitment to prevention needs to occur at the personal/family provider, organizational, systems, and population levels. While providers overall value prevention, when faced with the current level of disease, disability, and unhealthy lifestyle behaviors, shifting a stronger focus to prevention is difficult. This is compounded by the lengthy lag time between implementation of preventive behaviors and a visualization of improved health outcomes. As health-care reimbursement continues to shift towards a system that rewards quality and keeping populations healthy, providers need to move from a disease-focused to prevention-focused orientation. Conversations and research with NPs indicate that they are interested in ensuring that their patients receive an AWV and other preventive services (Naylor & Kurtzman, 2010; Traczynski & Udalova, 2013; Simpson et al., 2018). However, they struggle with understanding requirements and are unsure how to address patient perceptions concerning the value of these visits. Beneficiaries and providers alike are very used to visits that include physical exams or acute/chronic disease management–focused services. Efforts to increase understanding and perceived value of AWVs are vital to increasing prevention efforts and utilization. To enhance AWV implementation, NPs and other health-care staff must have open discussions about prevention to increase understanding of how the AWV can be used to support preventive efforts. Effective utilization of reimbursed time for the provider, patient, and health-care team to gather relevant information and collaboratively identify goals related to preventive screening, risk reduction, and lifestyle behavior change can help patients and providers embrace prevention. This patient-centered process, focused upon helping patients to better manage their own health, is a current priority for patient care delivery and a primary policy focus at state and national levels (Thornhill & Conant, 2018). Increasing the patient and provider understanding requires the active involvement of the entire health-care team. Support staff can design and implement campaigns to identify those beneficiaries eligible for AWVs, followed by letters or personal phone contact describing the purpose and advantages of the visit, to increase participation. Social workers or those familiar with Medicare benefits, billing, and coding, such as State Health Insurance Assistance Program counselors, can develop educational sessions or tools for beneficiaries and other staff to provide information and answer questions concerning the AWV in acute, long-term, or community-based settings. Medical assistants, registered nurses, and NPs can discuss AWVs and prevention with patients when they arrive for disease management visits, encouraging eligible patients to schedule an AWV before they leave the practice setting. At the organizational and population level, NPs can collaborate with public-health and aging-services networks in the community to develop and support public awareness campaigns to further disseminate the importance of prevention and availability of this visit. In most communities where NPs practice, they are valued and trusted members, with respected opinions. Lending their voice and support to community-based prevention campaigns may encourage more participation in preventive services. Design an Efficient Workflow Creation of an efficient workflow design also requires participation of the entire team, including those responsible for billing and coding, electronic health record development and management, interfacing with the patient upon arrival, providing direct care, and so forth. This group must work together to clearly define roles and responsibilities for AWV implementation, beginning with the identification of eligible beneficiaries and continuing through the completion of all visit components, including the personalized prevention plan. Each team member must be encouraged and allowed to function to the full scope of their practice and abilities. For example, registered nurses or medical assistants could gather all relevant data and summarize it for the NP, freeing the NP to spend more time discussing the results and recommending preventive screenings or lifestyle behavior changes. Maximizing the expertise, roles, and capabilities of the entire team can streamline the visit process: something that is particularly important for smaller practices, such as community-based or nurse-managed clinics. Finding the time for these visits in already-busy schedules can be a daunting task. Committing to prevention requires that the health-care team finds ways to increase the time available for AWVs through changes in workflow design to enhance efficiency. Several large health-care providers and organizations have created toolkits, forms, and workflow designs to support AWV implementation, many of which are freely available for use upon request. The American Academy of Family Physicians (2018) created a toolbox with AWV forms and documents (available at https://www.aafp.org/fpm/toolBox/viewToolType.htm?toolTypeId=20) and the Orange County, California, Aging Services Collaborative (Orange County Healthy Aging Initiative, 2018) developed an extensive toolkit providing AWV guidance, tools, and resources (available at http://www.ocagingservicescollaborative.org/annual-wellness-visit-toolkit). It is important for NPs to utilize professional networks, organizations, and alliances to discuss and share AWV strategies, ideas, and support. Governmental sites, including the CMS and the CDC, also provide tools and guidelines for the AWV. Through the Medicare Learning Network, CMS provides official education for Medicare fee-for-service providers (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html). This site includes summaries of visit requirements and guidelines for the AWV and the personalized prevention plan, with updates occurring when regulatory changes take place. The CDC also provides easy access to resources that can help support implementation. The publication, A Framework for Patient-Centered Health Risk Assessments (available at https://www.cdc.gov/policy/hst/HRA/FrameworkForHRA.pdf), includes a HRA that meets Medicare guidelines and can be used in conjunction with existing, readily-available screening tools to obtain all required data (Goetzel et al., 2011). Review and modification of preexisting tools can decrease the time needed to create AWV support documents to fit specific practice settings. Placing these documents in hard copy or electronic folders provides the NP easy access to AWV information when it is needed. Online resources, such as the Medicare Preventive Services chart, that support development of the personalized prevention plan are also available through the CMS site (Centers for Medicare and Medicaid Services, 2018). Lastly, capitalizing upon the capabilities of electronic health record systems (EHR) can help streamline workflows. Creating flags to indicate those beneficiaries needing an AWV, as well as a separate tab for all AWV documents, eases the provider burden. The placement of templates for required documentation, such as the HRA and personalized prevention plan, in the EHR allows for ease of completion and printing for the patient. For many practice settings, adding custom templates to an EHR system can be very expensive. Modifying existing EHR templates, creating documents using customizable letters, or collaborating with other practices within the same network (or using the same EHR system) to design templates can decrease AWV-associated costs. Develop Strong Collaborations Meeting the complex needs of older adults, including those solely focused on prevention, requires interdisciplinary and intersectoral collaboration. Such collaborations can provide easier access to the resources needed to support healthy behaviors and patient self-management, both within and outside of the practice setting. For many beneficiaries, the AWV is an additional visit, which requires time and transportation, increasing the burden for patients and caregivers, particularly those from vulnerable or rural populations. Combined with uncertainty about the necessity of such a visit, it can be difficult to get beneficiaries to complete the initial AWV, let alone repeat it annually. Making the most of this visit by providing other reimbursable, prevention-related services, scheduling preventive screenings, or bringing in behavioral support specialists or social workers to connect patients with resources before they leave the office will help to reduce the patient burden. After the visit, patients often have difficulty accessing needed resources, due to costs, both direct and indirect (transportation, supplies, etc.). Navigating the fragmented system of available options to find the specific resources needed can be confusing and overwhelming for patients. While relationships often exist between providers and organizations operating in the community, true collaboration to most effectively support improved health outcomes can be difficult to achieve. NPs are well suited to the task of collaborating with others and can be leaders in the movement to increase and strengthen health-care system and public health collaborations to support population health. They bring collaborative and interdisciplinary skills learned as registered nurses to the practitioner role, coordinating and leading collaborative efforts in a variety of settings, including nurse-managed clinics, ACOs, and patient-centered medical home (PCMH) clinics (Bakerjian, 2018). Various health promotion models and theories, including the Expanded Chronic Care Model (Barr et al., 2003) and the PCMH, are already in use in many settings where NPs practice (Agency for Healthcare Quality and Research, n.d.). These models provide support for collaborative relationships that support health promotion and disease prevention strategies. Guided by these models, NPs can create formal relationships with relevant community-based providers, streamlining the care process and providing seamless transitions between the practice setting and the community. For example, the PCMH requires teams of providers to coordinate care across the care continuum. NPs can collaborate with local universities or build virtual teams of pharmacists, nutritionists, social workers, and so forth to support prevention and wellness using the PCMH model (Agency for Healthcare Research and Quality, n.d.). Evaluate Impact/Support Research Efforts Currently, there is very little in the literature concerning the impact of the AWV, particularly when provided and supported by NPs (Simpson, 2018). The use of a structure, process, and outcome approach, as described by Donabedian (2005), to evaluate the impact of AWV implementation by NPs, is important to determine impact from a variety of perspectives. As discussed throughout this article, effective implementation of the AWV requires multiple changes and adaptations involving care focus, workflow, staff roles and responsibilities, policies and procedures, EHR systems, interactions between patients and providers, and so forth. Use of this evaluation approach captures data that reflects all aspects of AWV delivery and outcomes from the provider, patient, and system perspectives. Research concerning the AWV and related interventions is also critically important. Collaboration with academic partners or other researchers to design and implement rigorous studies of the AWV will help determine whether preventive efforts such as this result in improved health outcomes. Research can help identify interventions and strategies that could enhance the AWV process and, ultimately, the health outcomes for Medicare beneficiaries. Many barriers and challenges to this type of evaluation research exist; NP support can increase intervention fidelity and strengthen confidence in study outcomes. Influence Policy Several of these recommendations have policy implications. As front-line providers, NPs play a critical role in advocating for policies that support continued funding for NP education and nurse-managed clinics, broaden their scope of practice, and keep prevention at the forefront of all health policies. The expertise that these providers bring to the table includes personal experience with patients and communities, understanding of the health-care system, and evidence of the effectiveness of NP services (Bauer, 2010; Mantzoukas & Watkinson, 2007; Naylor & Kurtzman, 2010). Many NPs provide services to vulnerable, underserved populations, bringing this perspective to policy discussions as well. Continued support for both the education of NPs through scholarships and loan repayment programs and the funding of nurse-managed clinics are necessary to address primary care gaps. Additional incentives to increase the numbers of NPs who specialize in gerontology may help to increase the numbers of NPs with this specialty focus to meet the unique needs of aging adults. Currently, according to the American Association of Nurse Practitioners (2018a), only 4.4% of NPs have a clinical focus on primary care in gerontology. As well, curricula for the preparation of NPs should further enhance the focus on prevention and population health, emphasizing the importance of health behavior change models and theories. As the number of NPs continues to grow, states should also review and broaden their scope-of-practice guidelines to allow NPs to practice to the full scope of their abilities, as discussed in the Institute of Medicine’s Future of Nursing report (Institute of Medicine, Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, 2011). According to a recent study by Xue and colleagues (2018), state-regulated NP scope-of-practice guidelines affect workforce supply and demand; broader scope of practice guidelines can increase the NP supply in Health Professional Shortage Areas. NPs are already functioning as leaders in preventive efforts in multiple settings, including Medicare ACOs, Veteran’s Affairs settings (which granted full practice authority to APRNs in 2016), and nurse-managed clinics (U.S. Department of Veterans Affairs, 2016). Finally, the need for policies that support primary care and prevention in the community is paramount to engage and empower patients, thereby improving health outcomes and decreasing health-care costs. Support for increased access to more programs focused upon the prevention of chronic disease, such as the Diabetes Prevention Program (accessible to Medicare beneficiaries as a no-cost-sharing benefit beginning in 2018), can improve access to prevention resources and enhance prevention efforts. Conclusion Innovative models of care using NPs and the health-care team to address the preventive needs of older adults through Medicare’s AWV, help address primary-care gaps and improve health outcomes for older adults. NPs are willing and able to be leaders in prevention; determining ways to better implement visits such as these is crucial to achieve a health-care system focused on prevention. To enhance AWV implementation, NPs and other health care staff must have open discussions about prevention to increase understanding of how the AWV can be used to support preventive efforts. Effective utilization of reimbursed time for the provider, patient, and health care team to gather relevant information and collaboratively identify goals related to preventive screening, risk reduction and lifestyle behavior change can help patients and providers embrace prevention. Innovative models of care using NPs and the health care team to address the preventive needs of older adults through Medicare’s AWV help address primary care gaps and improve health outcomes for older adults. NPs are willing and able to be leaders in prevention, NPs and the health care team to address the preventive needsimplement visits such as these is crucial to achieve a health care system focused on prevention. References Agency for Healthcare Research and Quality . ( n.d .). Defining the PCMH . 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The Annual Wellness Visit: Assessment of Cognitive ImpairmentLoskutova,, Natalia
doi: 10.1093/ppar/pry047pmid: N/A
Cognition, Annual Wellness Visit, Screening Tools Dementia is a Major Health Problem Dementia is a general term describing a serious loss in at least two cognitive functions—such as memory, attention, thinking, or language—caused by brain disease. Alzheimer’s disease (AD), which accounts for 60–80% of all dementia cases, is the most common cause (Alzheimer’s Association, 2015). Many studies predict that, with the rapidly-aging population, the number of people with dementia will increase dramatically, and 6.7 million people will have AD by 2025. Dementia places an enormous burden on individuals, their families, caregivers, and society. Medical, long-term, and end-of-life care costs per patient are estimated to be substantially higher, on average, for a person with AD, compared with a person of the same age without dementia, totaling a cost of $200 billion a year for all people with AD (Suehs et al., 2013). Medicare and Medicaid cover most of these costs, placing a strain on federal and state budgets. Many studies have found that the average, total Medicare cost for a person with dementia is much higher than for many other health conditions (McCarthy, 2013; Yang, Zhang, Lin, Clevenger, & Atherly, 2012). The individual financial burden is also substantial; out-of-pocket expenses for all individuals with AD are estimated at $33.8 billion (Hurd, Martorell, Delavande, Mullen, & Langa, 2013). As recently demonstrated by the National Institutes of Health, Medicaid paid for 43% of long-term care in 2006, and almost two-thirds of older people cannot afford even one year of nursing-home costs (U.S. Census Bureau, 2014). This financial burden is particularly relevant in AD, given that more than half the nursing home residents have AD or other related dementia whose length of stay in skilled nursing facilities is significantly longer compared to persons without dementia (Hoffmann, Kaduszkiewicz, Glaeske, van den Bussche, & Koller, 2014; Magaziner et al., 2000; Sabbagh et al., 2003). Dementia (Under)Detection in Primary Care Despite national attention to address dementia, there have been no significant improvements in recognizing dementia over the last two decades (Rait et al., 2010). Because the neurodegenerative diseases progress slowly, symptoms are often mistaken for a normal part of “getting older.” A major challenge for patients, caregivers, and clinicians is to recognize changes in cognitive functions and to distinguish normal aging from early dementia. This is particularly challenging in primary care, where the majority of patients who are diagnosed with dementia (40–80%) go undiagnosed until later stages (Rait et al., 2010). Currently, the diagnosis of dementia is generally initiated by a clinician’s suspicion, based on a patient’s symptoms, or by caregiver concerns. The identification of dementia mostly happens at a time of crisis, hospitalization, or late in the disease progression, when opportunities for harm prevention and maximization of quality of life have passed (Alom Poveda, Baquero, & González-Adalid Guerreiro, 2013). Several studies have identified a common diagnosis gap in primary care, when patients with dementia never receive a diagnosis of dementia (Camicioli et al., 2000; Chodosh et al., 2004; Valcour, Masaki, Curb, & Blanchette, 2000). The reasons for this delay are complex, including—among other things—clinicians not recognizing early symptoms, beliefs that cognitive impairment is normal for aging, the clinicians’ perception of medical futility due to the lack of disease-modifying treatments and unfavorable prognoses, and the lack of financial incentives for assessment and diagnostic work-ups for dementia and quality standards for dementia care (Koch & Iliffe, 2010). Efforts to Improve Dementia Detection and to Reduce the Burden of AD Most recently, efforts to improve the quality of care for people with dementia have focused on increasing diagnoses at an earlier stage. In order to address the burden of dementia, on January 4, 2011, President Barack Obama signed the National Alzheimer’s Project Act (NAPA) (available at https://aspe.hhs.gov/national-alzheimers-project-act.). One of its key objectives is “to improve early diagnosis and coordination of care and treatment of AD.” At the same time, the Patient Protection and Affordable Care Act (ACA) added a new Medicare benefit: the Annual Wellness Visit (AWV). The ACA policy mandates that physicians assess patients for cognitive impairment annually during the AWV. Required documentation should include an assessment of the patient’s general appearance, affect, speech, memory and motor skills. The Centers for Medicare & Medicaid Services (CMS) does not provide any recommendations on a specific cognitive assessment method; the use of an objective cognitive assessment instrument is one of the options, but is not required as a part of AWV. Through the AWV, physicians can provide annual cognitive assessments and receive reimbursement for them, as well as for any subsequent care related to a diagnosis of dementia. The implementation of this legislation, in practice, could incentivize health care, via payment, for the improved quality of services related to dementia (Russell et al., 2013). Benefits of Early and Timely Detection of Cognitive Impairment The AWV provides an opportunity for an early recognition of cognitive decline. Early detection shows some clear benefits. Several studies have reported that the majority of patients accept dementia screening and value it (Fowler et al., 2012; Fowler et al., 2015; Holsinger, Boustani, Abbot, & Williams, 2011). Moreover, studies have found that screening for dementia and interventions that are aimed to improve detection and treatment of dementia can result in significant cost savings, a reduced caregiver burden, and net social benefits (Barnett, Lewis, Blackwell, & Taylor, 2014; Weimer & Sager, 2009). Other benefits of early detection of cognitive decline include: identifying treatable cases; addressing comorbid conditions; according patients more time to make important financial and life decisions; planning for nursing home placement; and making end-of life decisions. Patients may take precautionary measures for injuries and auto accidents, and elder abuse may be prevented through early screening and diagnosis. In cases of dementia, other non-therapeutic benefits to reduce the dementia burden and harms of screening should be considered. Identifying patients earlier in the disease, reducing diagnosis delays, and increasing awareness among providers and families will potentially improve the quality of care received by patients with dementia. Additionally, one of the important but often-overlooked general benefits of screening is reassurance that everything is normal in those who have screened negative (no signs of disease were suspected). Cognitive assessment, delivered as a part of the AWV, can also result in the following benefits to the patient: • If screening results are negative, concerns about memory may be alleviated, at least at that point in time. • If screening results are positive and further evaluation is warranted, the patient and physician can take the next step of identifying the cause of impairment (for example, medication side effects, metabolic and/or endocrine imbalance, delirium, depression, Alzheimer’s disease). This may result in: – Treating the underlying disease or health condition; – Managing comorbid conditions more effectively; – Averting or addressing potential safety issues; – Allowing the patient to create or update advance directives and plan long-term care; – Ensuring the patient has a caregiver or someone to help with medical, legal, and financial concerns; – Ensuring the caregiver receives appropriate information, referrals, and support; and – Encouraging participation in clinical research. Importantly, the AWV provides the only sustainable and regular opportunity to establish baseline measurements of cognitive function and identify changes in cognitive status over time. Implementing the AWC Cognitive Assessment Several professional organizations have developed aids for primary care providers to deliver the ACA cognitive screening benefit. The Alzheimer’s Association published an operational algorithm for the detection of cognitive impairment during AWV (Cordell et al., 2013). As stated by the authors, “widespread implementation of this algorithm could be the first step in reducing the prevalence of missed or delayed dementia diagnosis, thus allowing for better healthcare management and more favorable outcomes for affected patients and their families and caregivers” (Cordell et al., 2013). However, how effectively the ACA AWV cognitive assessment policy is carried out has not yet been thoroughly evaluated (US Department of Health & Human Services Clinical Care Subcommittee). The Gerontological Society of America has also developed a framework for cognitive assessment and a corresponding toolkit (found at https://www.geron.org/programs-services/alliances-and-multi-stakeholder-collaborations/cognitive-impairment-detection-and-earlier-diagnosis). The American Academy of Family Physicians also developed a toolkit to support primary care providers in delivering comprehensive cognitive care, including the assessment of cognitive impairment as a part of AWV (found at aafp.org/cognitive-care). Implementation Challenges Implementing cognitive assessments, as recommended by the CMS during AWV, is not without challenges. First, current implementation recommendations do not provide much guidance on how to solicit cognitive complaints or identify signs of impairment. Suggested strategies imply reliance on subjective cognitive complaints (SCCs): that is, they assume that patients will share their concerns about memory or other cognitive functions during the AWV. While SCCs are very common in older people and reported by 25–80% of patients (Montejo, Montenegro, Fernandez, & Maestu, 2011), studies show that SCCs are not a reliable predictor of dementia (Slavin et al., 2010; Zlatar, Moore, Palmer, Thompson, & Jeste, 2014). At the same time, anosognosia, or patients’ possible inability to recognize their own cognitive issues, is fairly common among persons with mild cognitive impairment and dementia. Currently, the AWV is unclear regarding how to assess individuals who do not have complaints. Secondly, current recommendations for cognitive assessment during AWVs also require the presence of and confirmation of patient cognitive status by an informant, such as a family member, at the AWV. This is problematic, as this assumes that every elderly individual has a reliable, cognitively-intact, knowledgeable, and available informant. However, 29% (11.3 million) of community-dwelling people 65 and older live alone (Vespa, 2017). Also, family members are found to be unreliable sources of a patient’s memory status. Additionally, current recommendations on the selection, use, and scoring of available tools in primary care are very broad and not specific, which creates wide variations in clinical practice. Lastly, no separate Current Procedural Terminology codes exist that can be associated with cognitive assessment, including during AWV, and it is difficult to systemically assess whether delivery of this component affects the AWV utilization, downstream use of relevant diagnostic tests and procedures such as laboratory work or brain imaging, quality of care, or patient outcomes (Fowler et al., 2018). Brief Cognitive Screening Tests It is evident now that most dementias have an asymptomatic stage and begin without detection by the patient or their families. Recognizing signs of dementia is one of the areas where sensitive screening tools can be helpful in distinguishing dementia symptoms from normal aging. Several professional groups and summary studies have identified three tools for use in primary care (Carpenter et al., 2011; Ismail, Rajji, & Shulman, 2010; Sheehan, 2012; Velayudhan et al., 2014): - The Mini-Cog; - Memory Impairment Screen; and - General Practitioner Assessment of Cognition. All three tools are brief and are free for clinician use; however, it is important to keep in mind that they have been validated in a relatively small number of patients for use in primary care. In addition, their sub-optimal specificity and sensitivity may result in the potential of missing cases of dementia and a higher rate of false positives. Computerized assessment tools developed specifically for the detection of cognitive impairments in older individuals show potential for use in clinical practice (Ashford et al., 2006). Computerized tests provide scheduling flexibility, as any trained practice personnel can administer them; the tests are given in a standardized format, are less affected by floor and ceiling effects and human error, are more sensitive to signs of dementia, and are more accurate in recording responses (Wild, Howieson, Webbe, Seelye, & Kaye, 2008). While these tools still need to be further evaluated for use in primary care during the AWV, some studies have reported that computerized tests are more acceptable by patients and test administrators (Collerton et al., 2007; Fredrickson et al., 2010; Tarnanas, Tsolaki, Nef, Müri, & Mosimann, 2014). In general, the systematic use of formal validated brief screening tools can provide practical benefits, such as objective scoring, ease of result interpretation, the ability to track and compare test results over multiple years, and improved documentation. Use of an objective test, rather than simply recording the patient’s and the caregiver’s observations, for example, can also facilitate otherwise-difficult conversations about memory issues between the patient and the provider. It is important to remember that the screening tests are not diagnostic of dementia or mild cognitive impairment. Currently, a diagnosis of dementia is made based on a comprehensive assessment that includes a thorough medical history, physical exam, in-depth cognitive and functional assessment, laboratory tests, and brain imaging, if necessary, and not on the results of a cognitive screening test alone. A diagnostic assessment for dementia is not a part of the AWV, and if the results of a screening test during an AWV suggest possible cognitive impairment, the full diagnostic work-up is highly suggested as a next step after the AVW. Table 1 presents a selection of the available, most frequently-used cognitive impairment screening tools, with their main characteristics. Selected self-administered tools are included. Table 1. Overview of Selected Brief Cognitive Tests for Patients Tool Admin Time Specifications (Sensitivity/ Specificity) Scoring/Cut-Off Cognition (self-administered) “Test Your Memory” <10 min 99/86 0–50 Cut-off score: 42 MCI: 45-41 Mild: 33 Moderate: 25 Self-Administered Gerocognitive Examination 15 min 95/79 0–22 Normal: 17–22 Mild: 15–16 Moderate/Severe: ≤14 Mini Self Montreal Cognitive Assessment Soon to be released Cognition (staff-administered) The Mini–Mental State Examination 10–13 87/82 Range 0–30 Scores below 24 indicate cognitive impairment Mini-Cog 3–4 39–84/78–87 Range 0–8 0–2 positive screen for dementia Memory Impairment Screen 4 43–86/93–97 0–8 Cut off score: 4 Short Portable Mental Status Questionnaire 5 92–100/83.5–100 Normal: 0–2 MCI: 3–4 Moderate: 5–7 Severe: 8 or more Scores are adjustable, based on education level Clock Drawing Test 2 67–98/69–94 Scoring systems used in the literature vary and depend on instructions The Montreal Cognitive Assessment 10 80–100/50–76 0–30 Scores below 26 suggest cognitive impairment General Practitioner Assessment of Cognition 5 96/62 Range 0–15 (for both parts) Scores below 11 suggests patient may have dementia Short Blessed Test 5–10 88–98/61–67 Normal: 0–8 Minimal to moderate impairment: 9–19 Severe impairment: 20–28 Tool Admin Time Specifications (Sensitivity/ Specificity) Scoring/Cut-Off Cognition (self-administered) “Test Your Memory” <10 min 99/86 0–50 Cut-off score: 42 MCI: 45-41 Mild: 33 Moderate: 25 Self-Administered Gerocognitive Examination 15 min 95/79 0–22 Normal: 17–22 Mild: 15–16 Moderate/Severe: ≤14 Mini Self Montreal Cognitive Assessment Soon to be released Cognition (staff-administered) The Mini–Mental State Examination 10–13 87/82 Range 0–30 Scores below 24 indicate cognitive impairment Mini-Cog 3–4 39–84/78–87 Range 0–8 0–2 positive screen for dementia Memory Impairment Screen 4 43–86/93–97 0–8 Cut off score: 4 Short Portable Mental Status Questionnaire 5 92–100/83.5–100 Normal: 0–2 MCI: 3–4 Moderate: 5–7 Severe: 8 or more Scores are adjustable, based on education level Clock Drawing Test 2 67–98/69–94 Scoring systems used in the literature vary and depend on instructions The Montreal Cognitive Assessment 10 80–100/50–76 0–30 Scores below 26 suggest cognitive impairment General Practitioner Assessment of Cognition 5 96/62 Range 0–15 (for both parts) Scores below 11 suggests patient may have dementia Short Blessed Test 5–10 88–98/61–67 Normal: 0–8 Minimal to moderate impairment: 9–19 Severe impairment: 20–28 MCI = mild cognitive impairment. View Large Table 1. Overview of Selected Brief Cognitive Tests for Patients Tool Admin Time Specifications (Sensitivity/ Specificity) Scoring/Cut-Off Cognition (self-administered) “Test Your Memory” <10 min 99/86 0–50 Cut-off score: 42 MCI: 45-41 Mild: 33 Moderate: 25 Self-Administered Gerocognitive Examination 15 min 95/79 0–22 Normal: 17–22 Mild: 15–16 Moderate/Severe: ≤14 Mini Self Montreal Cognitive Assessment Soon to be released Cognition (staff-administered) The Mini–Mental State Examination 10–13 87/82 Range 0–30 Scores below 24 indicate cognitive impairment Mini-Cog 3–4 39–84/78–87 Range 0–8 0–2 positive screen for dementia Memory Impairment Screen 4 43–86/93–97 0–8 Cut off score: 4 Short Portable Mental Status Questionnaire 5 92–100/83.5–100 Normal: 0–2 MCI: 3–4 Moderate: 5–7 Severe: 8 or more Scores are adjustable, based on education level Clock Drawing Test 2 67–98/69–94 Scoring systems used in the literature vary and depend on instructions The Montreal Cognitive Assessment 10 80–100/50–76 0–30 Scores below 26 suggest cognitive impairment General Practitioner Assessment of Cognition 5 96/62 Range 0–15 (for both parts) Scores below 11 suggests patient may have dementia Short Blessed Test 5–10 88–98/61–67 Normal: 0–8 Minimal to moderate impairment: 9–19 Severe impairment: 20–28 Tool Admin Time Specifications (Sensitivity/ Specificity) Scoring/Cut-Off Cognition (self-administered) “Test Your Memory” <10 min 99/86 0–50 Cut-off score: 42 MCI: 45-41 Mild: 33 Moderate: 25 Self-Administered Gerocognitive Examination 15 min 95/79 0–22 Normal: 17–22 Mild: 15–16 Moderate/Severe: ≤14 Mini Self Montreal Cognitive Assessment Soon to be released Cognition (staff-administered) The Mini–Mental State Examination 10–13 87/82 Range 0–30 Scores below 24 indicate cognitive impairment Mini-Cog 3–4 39–84/78–87 Range 0–8 0–2 positive screen for dementia Memory Impairment Screen 4 43–86/93–97 0–8 Cut off score: 4 Short Portable Mental Status Questionnaire 5 92–100/83.5–100 Normal: 0–2 MCI: 3–4 Moderate: 5–7 Severe: 8 or more Scores are adjustable, based on education level Clock Drawing Test 2 67–98/69–94 Scoring systems used in the literature vary and depend on instructions The Montreal Cognitive Assessment 10 80–100/50–76 0–30 Scores below 26 suggest cognitive impairment General Practitioner Assessment of Cognition 5 96/62 Range 0–15 (for both parts) Scores below 11 suggests patient may have dementia Short Blessed Test 5–10 88–98/61–67 Normal: 0–8 Minimal to moderate impairment: 9–19 Severe impairment: 20–28 MCI = mild cognitive impairment. View Large Practical Considerations for Efficient Post-Screening Follow-Up Care after AWV As with any preventive service, in order to provide an optimal, patient-centered cognitive assessment during the AWV and, as necessary, a post-visit follow-up, several practical factors need to be considered: • Patient risks and problems identified through the history, screening, and exam at the AWV must be addressed by continuing interventions already in place, ordering further screening, or recommending new interventions. • Referrals to other providers and community services should be considered and documented as appropriate. • A preventive service plan for the next five to ten years should be developed, and a screening plan or checklist should be provided to the patient following the visit. The preventive plan should include elements related to brain health and the maintenance of function and independence as long as possible. • Establishing protocols for responding to positive screening results and identifying resources for follow-up can save significant time and improve patient and staff satisfaction. • Evaluating and establishing practice workflow and procedures in the following situations can also save significant time: – If a patient gives a positive response to cognitive screening, will you be prepared to conduct a further cognitive evaluation? If dementia is diagnosed, how will you address it? – What patient handouts may be most helpful, and where will you find them? – What community services would benefit your patients (for example, caregiver support groups), and can you share this information easily? Conclusion The Medicare AWV is an opportunity to address the increasing need for early detection of cognitive impairment. Health-care providers should encourage patients to utilize the AWV benefit as a way to decrease years of disability due to physical problems and preventable diseases and as a way to identify early cognitive changes. The AWV cognitive assessment component can serve as a platform to improve detection, diagnosis, and subsequent care of dementia. While the subsequent care is not specified in the AWV delivery, the early identification of cognitive impairment and timely and appropriate follow-up may lead to improving outcomes, as people are given time to make important financial, legal, safety, and life decisions; such as planning for nursing home placement, making end-of life decisions, and identifying caregiving needs and support. Identifying patients earlier in the disease, reducing diagnosis delays, and increasing awareness among providers and families will potentially improve the quality of care received by patients with dementia. Ongoing research is clearly needed to establish the effectiveness of an AWV cognitive assessment component on the early and timely detection of dementia, and the important patient, caregiver, and societal outcomes. Future research needs to investigate implementation strategies for cognitive assessment during AWV, including practice redesign, use of objective tests, and optimal follow-up strategies. References Alom Poveda , J. , Baquero , M. , & González-Adalid Guerreiro , M . ( 2013 ). Clinical stages of patients with Alzheimer disease treated in specialist clinics in Spain. The EACE study . Neurologia (Barcelona, Spain) , 28 , 477 – 487 . doi: https://doi.org/10.1016/j.nrl.2012.10.003 Google Scholar Crossref Search ADS PubMed Alzheimer’s Association . ( 2015 ). 2015 Alzheimer’s disease facts and figures . Alzheimers Dement , 11 , 332 – 384 . Crossref Search ADS PubMed Ashford , J. W. , Borson , S. , O’Hara , R. , Dash , P. , Frank , L. , Robert , P. , … Buschke , H . ( 2006 ). 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Reducing Disparities in Healthy Aging Through an Enhanced Medicare Annual Wellness VisitTipirneni,, Renuka;Ganguli,, Ishani;Ayanian, John, Z;Langa, Kenneth, M
doi: 10.1093/ppar/pry048pmid: 31156322
Medicare, Healthy Aging, Disparities, Social Determinants of Health, Annual Wellness Visit Introduction In its current form, the Medicare annual wellness visit (AWV) is not reaching most older Americans, particularly lower-income or minority adults and those served by safety-net providers (Ganguli, Souza, McWilliams, & Mehrotra, 2018). Yet these underserved seniors face disparities in healthy aging, likely due to individual, social, and behavioral determinants of health, such as low income, limited education, social isolation, food insecurity, poor housing quality, and difficulty affording medications. New AWV models should move beyond traditional assessments of cognition, balance, and vision to identify and address important root causes of poor health, such as individual, social, and behavioral determinants of health. Incorporating these key determinants of health into AWVs has the potential to promote healthy aging among underserved seniors. In this paper, we present local opportunities for AWV-related practice transformation, including screening tools, electronic health record templates, care team member roles, and workflows. At the national level, we suggest updates to Medicare’s current AWV policy guidelines with regard to visit elements and funding models. Disparities in Healthy Aging The gap in healthy aging between individuals of lower and higher socioeconomic status (SES) continues to grow in the United States. With regard to life expectancy, Chetty and colleagues (2016) found that between 2001 and 2014, the top 5% of income earners gained almost 3 years in life expectancy, while the bottom 5% made no real gains. There are similar disparities in life expectancy among those with less and more education. Olshansky and colleagues, building on earlier work by others, found that the difference in life expectancy between those with the greatest and least educational attainment ranged from 3 to 13 years (depending on race and gender), despite a steady rise in the average life expectancy for the population (Meara, Richards, & Cutler, 2008; Olshansky et al., 2012). According to a recent National Academies of Sciences, Engineering, and Medicine report, this disparity appears to have been cumulative; over the past several decades, the overall gap in life expectancy between the lowest and highest income quintiles has grown from 5.1 to 12.7 years among men and from 3.9 to 13.6 years among women (see Figure 1; The National Academies of Sciences, Engineering, and Medicine, 2015). Figure 1. View largeDownload slide Estimated and projected life expectancy at age 50 for males and females born in 1930 and 1960, by income quintile. Data are from the Health and Retirement Study and the figure is from The National Academies of Sciences Engineering Medicine (2018). Figure 1. View largeDownload slide Estimated and projected life expectancy at age 50 for males and females born in 1930 and 1960, by income quintile. Data are from the Health and Retirement Study and the figure is from The National Academies of Sciences Engineering Medicine (2018). Such disparities are likewise apparent in the general health status of older adults. While older adults who are White, well educated, or more affluent have become more likely to experience good health, older adults who are African-American, Hispanic, less educated, or less affluent have become less likely to report good health (Davis, Guo, Sol, Langa, & Nallamothu, 2017). Similarly, improvements in the control of key cardiovascular risk factors, such as smoking and hypertension, have been achieved among high-income U.S. adults in the past 15 years, but not among those living in poverty, leading to a widening of overall cardiovascular risk between rich and poor adults (Odutayo et al., 2017). These differences may translate into functional disabilities and other impairments. Schoeni and colleagues found that between 1982 and 2002, the gap between adults aged 70 or older with lower and higher SES widened substantially in the ability to perform basic activities of daily living (Schoeni, Martin, Andreski, & Freedman, 2005). Low-SES baby boomers, in particular, appear to be experiencing a process of accelerated aging, characterized by greater numbers of chronic conditions and declines in general health, mental health, and functional status, compared with prior cohorts of Americans (Case & Deaton, 2015; Heiss, Venti, & Wise, 2014; Soldo, Mitchell, Tfaily, & McCabe, 2006). Addressing these gaps will require a multi-pronged approach. As Schoeni writes, “Disability is a function of both underlying physical capacity and the environment in which a person lives and works … To close completely the gaps in late-life functioning may require a combination of medical, behavioral, and environmental interventions” (p. 2069) (Schoeni et al., 2005). Thus, healthy aging relies not only on the ability of older adults to maintain a minimum level of physical functioning, but also on (1) factors specific to the individual, such as income and education; (2) factors that are related to an individual’s social context, such as the ability to access healthy food and obtain stable housing; and (3) behavioral factors, such as smoking cessation and maintaining rich social connections with family and friends. Such “social determinants of health” often play a large role in determining the health trajectories of vulnerable populations at all ages (Wilensky & Satcher, 2009). In addition, cardiovascular risk factors, such as smoking and hypertension, are highly influenced by social determinants of health (e.g., ability to afford medications to quit smoking or control blood pressure). Health-care system leaders and policymakers are increasingly recognizing the medical impact of these social determinants and the potential for health-care solutions to address the widening disparities in health and longevity for older adults with lower SES. While these recent efforts have been more common in Medicaid managed-care organizations and hospital systems, there is an opportunity for the Medicare program to further embrace this approach (Alley, Asomugha, Conway, & Sanghavi, 2016; Gottlieb, Ackerman, Wing, & Manchanda, 2017; Gottlieb, Garcia, Wing, & Manchanda, 2016; Johnson, 2018). The Medicare AWV may provide one pathway to addressing social determinants of health in health care and reducing gaps in healthy aging (Tipirneni & Langa, 2018). Elements and Effectiveness of the Current Medicare Annual Wellness Visit The Centers for Medicare and Medicaid Services (CMS) introduced the AWV in January 2011 in an effort to improve healthy aging among older adults. The AWV was meant to go beyond focusing on individual chronic diseases, to identifying and addressing broader health risks and promoting preventive health screenings in seniors. The AWV was also intended to promote a routine point of contact over time, facilitating the development of a continuous relationship with a health-care provider. The visit builds on the initial Welcome to Medicare visit and includes assessments of older adults’ health status, psychosocial risks (including depression screening), behavioral risks, cognitive functioning, physical functioning (i.e., ability to perform activities of daily living, fall risk, hearing impairment, and home safety), and biometric health indicators (e.g., body mass index and blood pressure; Centers for Medicare and Medicaid Services, 2017). At the conclusion of the visit, a primary-care provider and his or her patient create a tailored plan for preventive health screenings, lifestyle interventions, and other wellness goals. Evidence to date on the benefits of AWVs is limited and mixed. Two studies—one of a large, multi-specialty health system (Chung et al., 2015) and the other of five outpatient, community-based clinics (Galvin et al., 2017)—showed greater use of some routine and preventive services (e.g., advance directives, abdominal aortic aneurysm screening, mammography, vaccines) and decreased use of others (e.g., colorectal cancer screening, bone density scans). A third study at a large, multi-site provider network found no change in depression screening rates, despite such screening being a required element of the AWV (Pfoh, Mojtabai, Bailey, Weiner, & Dy, 2015). A fourth study, using national survey data, found no significant change in self-reported preventive service rates before or after the AWV introduction (Jensen, Salloum, Hu, Ferdows, & Tarraf, 2015). Further research is needed to examine the health effects of AWVs in the United States. Current Trends in the Use of Medicare Annual Wellness Visits Since the introduction of the Medicare-covered benefit in 2011, the percentage of eligible beneficiaries receiving an AWV only increased from 7.5% in 2011 to 15.6% in 2014 and 18.8% in 2015 (Ganguli, Souza, McWilliams, & Mehrotra, 2017, 2018). There was also significant individual, practice-level, and regional variation in the AWV rates (Figure 2). Medicare beneficiaries were more likely to receive an AWV if they were White, female, lived in an urban or higher-income area, or had received the visit the year before. Practices participating in an accountable-care organization or the Medicare Electronic Health Record Incentive Program had higher rates of AWV use, as did practices with a larger proportion of primary-care physicians or more Medicare beneficiaries per primary-care physician (Ganguli et al., 2018). Figure 2. View largeDownload slide Distribution of annual wellness visit–adopting practices across the United States in 2015. The figure is from Ganguli, Souza, McWilliams, and Mehrotra (2018). Figure 2. View largeDownload slide Distribution of annual wellness visit–adopting practices across the United States in 2015. The figure is from Ganguli, Souza, McWilliams, and Mehrotra (2018). Using national Medicare data from 2008–2015, Ganguli and colleagues (2018) found that half of primary-care practices offered any AWVs. Lower AWV rates were noted among both underserved populations and the practices that cared for them. Eligible beneficiaries who were non-White, medically complex, or dually enrolled in Medicare and Medicaid (generally older adults with low incomes or those with disabilities) were less likely to receive a visit than other eligible beneficiaries in the same practice. In addition, practices that disproportionately cared for these historically-underserved populations were less likely to provide AWVs to any of their eligible beneficiaries. To the extent that AWVs directly improve the health of seniors, these differences in AWV rates have the potential to worsen existing disparities for this population. In addition, physician practices that adopted AWVs have generated more revenue than non-adopters—in part because Medicare provides greater reimbursement for AWVs than for most traditional, problem-based medical visits—further widening resource gaps between the adopters and the non-adopters that disproportionately serve disadvantaged older adults (Ganguli et al., 2018). Opportunities for Addressing Health Disparities Through Annual Wellness Visits Underserved seniors who don’t receive an AWV may forego the potential benefits of the visit, such as increased engagement with their primary-care provider; identification of health risks, such as concerns for falls or depressed mood; counseling on health behaviors, including diet, exercise, or smoking cessation; and recommendations for preventive health services, such as cancer screenings and vaccinations. A new approach to AWVs might encourage implementation by safety-net practices, such as federally-qualified health centers (FQHCs), and collaboration with Area Agencies on Aging (part of the national Aging Services Network, that assist with a wider variety of services for older adults in the community) in order to reach underserved seniors more effectively (O’Shaughnessy, 2008). As safety-net practices and local agencies frequently have limited resources, new models of AWVs should focus on enhancing activities already emphasized by such practices (Rosenblatt, Andrilla, Curtin, & Hart, 2006). Such activities would include assessments of older adults’ material resource needs (generally assessed by FQHCs to provide a sliding-fee scale) and connection to community-based supports and services, such as those provided by Area Agencies on Aging or other community-based organizations. To promote healthy aging for underserved populations, AWVs should focus on these issues, commonly encountered by vulnerable older adults. For example, while an assessment of fall risk and hearing impairment is certainly important for all older adults, low-SES Medicare beneficiaries may face additional barriers to health and health care, such as difficulty navigating transportation to medical visits, struggles with affording medications, or concerns about meeting basic needs, such as access to healthy food. Screening for health-related social needs without addressing them may also contribute to patient stress (Garg, Boynton-Jarrett, & Dworkin, 2016). Therefore, screening for these issues should include appropriate referrals to community resources or to other skilled members of the health-care team. Proposed Model for an Enhanced Annual Wellness Visit To mitigate growing disparities in health and longevity for underserved seniors, we propose enhancing the traditional Medicare AWV by expanding screening and counseling for social determinants of health. This approach could include screening for behavioral health issues, such as anxiety or post-traumatic stress disorders, in addition to the depression screening already included in the traditional AWV. Screening for and addressing social determinants of health could go hand-in-hand with addressing cardiovascular risk factors that contribute to poor health among low-SES Medicare beneficiaries. At present, safety-net practices frequently consider social determinants of health when determining patient eligibility, but there is no uniform standard to guide which types of health-related social needs are screened for, which screening instruments are used, or how practices address identified needs in real time (Byhoff et al., 2017; Institute of Medicine, 2015). Screening Tools Several screening tools are available to assess multiple domains of social determinants of health and are currently being used by local and national organizations. One prime example is the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) assessment tool, which was developed by the National Association of Community Health Centers (2018). This tool emphasizes social determinant measures that can be addressed in FQHCs or similar safety-net practices. PRAPARE core measures include race/ethnicity, education, income, employment, language, migrant status, veteran status, insurance status, socioeconomic status (including income, education, and employment), material resource needs (such as food or utilities), housing instability, transportation, neighborhood, stress, and social integration and support. Optional measures include assessments of home and neighborhood safety, domestic violence, refugee status, and incarceration history. The PRAPARE screening tool was developed and pilot tested in four states (Hawaii, Iowa, New York, and Oregon) before being disseminated in community health centers across the country; the tool shares similarities to other social determinant screening tools (LaForge et al., 2018; National Association of Community Health Centers, 2018). The PRAPARE developers have also created templates that can readily incorporate the tool into commonly-used electronic health record systems, such as Epic. Such electronic health record templates would ideally be interoperable across health-care systems. Initial pilot studies of electronic health record screening templates have demonstrated that they are feasible to implement (Gold et al., 2018). In addition, the Center for Medicare and Medicaid Innovation in CMS recently initiated a broad, national experiment known as Accountable Health Communities, which emphasizes addressing social determinants of health in routine health care (Alley et al., 2016). CMS is spending $157 million over 5 years on this program, in which 32 organizations in 23 states are participating and conducting social interventions involving approximately 3 million patients annually (Centers for Medicare and Medicaid Services, 2018; Gottlieb, Colvin, et al., 2017). Eligible patients are enrolled in Medicare and/or Medicaid coverage, including enrollees who receive care through managed-care organizations or accountable-care organizations. The program aims to link health-care systems with community services through hubs called “bridge organizations” that coordinate care for beneficiaries across health system and community settings. CMS has developed its own social determinant screening tool for the Accountable Health Communities participating sites, focusing on domains that could negatively impact health and health-care utilization (Billioux, Verlander, Anthony, & Alley, 2017). The tool includes 5 core domains (housing instability, food insecurity, transportation problems, utility needs, interpersonal safety) and 8 supplemental domains (financial strain, employment, family/community support, education, physical activity, substance use, mental health, disabilities), and is another model that could be incorporated into an enhanced AWV. The two screening tools emphasize different items, with the PRAPARE tool focusing on identifying actionable needs and the Accountable Health Communities tool focusing on needs that can be associated with excess health-care utilization. At present, the PRAPARE tool may be easier to integrate into clinical workflows, as it has electronic health record templates, though electronic templates for the Accountable Health Communities tool may also be developed in the future. Adding new requirements for AWVs comes with potential downsides, however. The current AWV’s complexity may have already contributed to low adoption, especially among safety-net practices that face greater patient complexity and workloads (Beran & Craft, 2015; Cuenca, 2012; Muldoon, Rayner, & Dahrouge, 2013). Therefore, CMS should couple expanded requirements for an enhanced AWV with greater flexibility in how practices implement expanded screening and linkage to resources, including which screening tools are selected. Team Member Roles To change practices for an enhanced AWV, it will be important to include all health-care team members, including nurse practitioners, physician assistants, nurses, or health coaches, who can already perform AWVs within primary-care practices (Galvin et al., 2017). Practices might convene representative team members to develop new clinical workflows for enhanced screening and assign team member roles based on areas of expertise. For example, behavioral health screening may be performed by a social worker or mental health professional. Medical assistants or nurses may administer the multi-social determinant screening tool and document the findings in the electronic health record. Individual primary-care providers may review findings from the assessment and lead the team in creating a care plan for the patient that is tailored to their specific needs, resources, and supports. Local agencies within the Aging Services Network could serve as a key potential partner for primary-care practices conducting an enhanced AWV. As individual, social, and behavioral needs are identified by practices, older adults may be referred to case managers in these local agencies to connect to resources. Area Agencies on Aging provide for a wide variety of services to support older adults in the community, including food assistance, transportation to services, legal assistance, personal care and caregiver support, and social support groups (O’Shaughnessy, 2008). Another type of health-care worker that is growing in importance in safety-net clinics is the community health worker, a team member with expert knowledge of the patient’s community who serves as a liaison, connecting the patient to health and social services (American Public Health Association, 2018). Employing community health workers may be a cost-effective approach to implement an enhanced Medicare AWV in safety-net settings. Community health workers could partner with case managers in Area Agencies on Aging to provide comprehensive care that addresses social determinants of health and allows older adults to continue to live in their homes. Sustainable funding for community health workers will be fundamental to the success of their role in a new care model, and payment reforms will likely be needed to facilitate their recruitment, training, and continued employment as care team members. Implementation of Best Practices To implement the Enhanced AWV on a broad scale, challenges to practice transformation will need to be addressed. In creating the PRAPARE tool, for example, the National Association of Community Health Centers also developed an implementation toolkit that can be used by safety-net practices to incorporate new electronic health record templates, new workflows, and new roles for care team members. The toolkit is being updated over time and is freely available for download (National Association of Community Health Centers, 2018). Policy Recommendations To implement an enhanced AWV, the Medicare program should update its policies around required elements of the visit and the funding model supporting it. If the current demonstrations of the National Association of Community Health Centers’ PRAPARE tool or CMS’s Accountable Health Communities model prove successful, either of the social determinant screening tools developed could be suggested as core elements of the enhanced AWV. For efficiency’s sake, the screening tool should contain fewer than 10 elements and enhanced screening requirements should be broad and customizable to individual patient and practice needs, as noted above. The screening tool should also, ideally, have high validity and reliability in measurement. To accommodate potential costs associated with the hiring of new care team members to both screen for and address social determinants of health, CMS should provide an enhanced payment for community health centers and similar safety-net practices that conduct enhanced AWVs, as these practices disproportionately serve older adults with greater social needs. An enhanced payment could also entice other safety-net practices, which are currently less likely to conduct traditional AWVs than practices serving more affluent older adults, to adopt enhanced AWVs. Under the same paradigm as the Accountable Health Communities model, an Enhanced Medicare AWV would reflect “a growing emphasis on population health in CMS payment policy, which aims to support a transition from a health care delivery system to a true health system” (p. 11) (Alley et al., 2016). It also reflects a trend by CMS to coordinate programs across payers to improve health and lower costs. The new emphasis of the Accountable Health Communities model extends the established models of Medicaid wrap-around services and of the Aging Services Network to focus on addressing social determinants of health for vulnerable populations. Programming for addressing social determinants in the health-care setting should be coordinated across Medicare, Medicaid, and the Aging Services Network to efficiently direct funding toward addressing older adults’ individual, social, and behavioral needs. Similar to evaluations of the Accountable Health Communities model and other demonstration programs being conducted by CMS, rigorous research is needed to assess the ideal modes of social determinant screening, as well as potential benefits and costs of current and future AWV models, with regard to quality of care and health outcomes. Ideally, evaluations would include experimental or quasi-experimental study designs and outcomes studied should include mediators of health disparities—such as cardiovascular risk factors and food insecurity—in addition to the overall health status of beneficiaries and program costs to CMS. In this way, policymakers and researchers can assess and refine the current and enhanced AWV models, as well as their payment mechanisms. Conclusion To reduce disparities in healthy aging faced by underserved seniors and the practices that care for them, the Medicare Annual Wellness Visit should be revamped to identify and address social determinants of health. In an enhanced AWV, Medicare beneficiaries would engage with primary-care teams to develop a tailored plan that moves beyond basic lifestyle counseling to identify and address social risk factors that contribute to health disparities. In this way, the enhanced AWV of the future may help to reduce disparities in healthy aging and longevity for the most vulnerable older adults. References Alley , D. E. , Asomugha , C. N. , Conway , P. H. , & Sanghavi , D. M . ( 2016 ). Accountable health communities–addressing social needs through medicare and medicaid . 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The My Own Health Report (MOHR): Opportunities for Implementation in the Annual Wellness VisitGorin, Sherri, Sheinfeld;Balasubramanian, Bijal, A
doi: 10.1093/ppar/pry050pmid: N/A
Annual Wellness Visit, Health Risk Assessments, Implementation Facilitators and Barriers Since the 2011 passage of the Medicare B expansion under the Patient Protection and Affordable Care Act, the annual wellness visit (AWV) has been available to every eligible Medicare beneficiary. The aim of the AWV is to encourage preventive care and address health risks in older adults, in accord with professional recommendations from the United States Preventive Services Task Force, the Advisory Committee on Immunization Practices, and Medicare reimbursable services. Eligible beneficiaries are those who are no longer within their first 12 months of Medicare B coverage and have not received an initial preventive physical exam or AWV over the past year. The AWV includes a health risk assessment (HRA) and Personalized Prevention Plan Services; these involve the assessment of health status indicators and risk factors for cardiovascular disease, cancer, cognitive decline, and diabetes. The mandated HRA (1) may be completed before or as part of a visit; (2) must identify chronic diseases, injury risks, modifiable risk factors, and urgent health needs; and (3) may be furnished through an interactive telephonic or Web-based program (Goetzel et al., 2011). While CMS refers to HRA assessment frameworks for the AWV, no particular HRAs are required (Goetzel et al., 2011). The AWV also provides an opportunity for counseling individuals in tobacco cessation, nutrition, and physical activity, among other risk reduction approaches. The HRA is unique to the AWV, relative to other Medicare-reimbursed prevention services. Yet, merely administering an HRA questionnaire does not produce behavior change (Anderson & Staufacker, 1996; Oremus, Hammill, & Raina, 2011; Soler et al., 2010). Comprehensive, well-resourced follow-up, including referral to community resources, is essential to help individuals gain the skills they need to change health habits, and increase their preventive behaviors, potentially resulting in improved health (Goetzel et al., 2011; Guide to Community Preventive Services, 2014; Krist et al., 2014; Shekelle et al., 2003). The My Own Health Record (MOHR) is a web-based HRA that is evidence-based and patient-centered. The MOHR tool assesses health behavior and mental health among patients in a primary care setting; the MOHR is paired with a feedback system to promote patient counseling and goal-setting for adults. This automated assessment and feedback tool is designed to encourage collaborative goal setting between primary-care providers and patients presenting for the AWV, usual care, or chronic care visits. This paper reports on the implementation of the MOHR tool for behavioral and mental health assessments in a diverse sample of real-world, primary-care settings. Until the Affordable Care Act, the use of HRAs was relatively rare in medical practice (Krist et al., 2011); since 2011, as Ganguli et al. (2017) report, the dissemination of the HRA in the AWV has remained similarly limited. The paper offers suggestions for future practice, policy, and research on the MOHR as a HRA tool for the AWV among older adults. The MOHR Tool The HRA measures included in the MOHR are valid, brief, and actionable, with rapid clinical utility, and are feasible in real-world and low-resource settings. These include 17 health behavior and psychosocial risk screening questions and 6 demographic questions (see Table 1; (Estabrooks et al., 2012; Krist et al., 2014; Lindblad & Gore-Langton, 2011)). The screening issues the MOHR assesses are all recommended by the U.S. Preventive Services Task Force, with the exception of sleep, quality of life, and anxiety. For those patients who initially screen positive for symptoms, additional follow-up services are provided (see Table 1). Table 1. Components of the Annual Wellness Visita and the MOHR Measures and Processesb AWV Component MOHR Domains MOHR Items and Processesc,d HRA: • Demographic data • Self-assessment of health status • Psychosocial risks, behavioral risks, and ADLs, including, but not limited to: dressing, bathing, and walking • Instrumental ADLs, including but not limited to: shopping, housekeeping, managing own medications, and handling finances. Socio-Demographics Gender, race/ethnicity, educational level, marital status, country of birth, occupation, veteran status, speak English/need interpreter Overall health status 1 item: BRFSS Questionnaire Stress 1 item: Distress Thermometer (Roth et al., 1998) Substance abuse 1 item: NIDA Quick Screen (Smith, Schmidt, Allensworth-Davies, & Saitz, 2010) Risky drinking 1 item: Alcohol Use Screener (Smith, Schmidt, Allensworth-Davies, & Saitz, 2009) Smoking/tobacco use 2 items: Tobacco Use Screener (Adapted from YRBSS Questionnaire) Sleep 2 items: (a) adapted from BRFSS; (b) Neuro-QOL (item PQSLP04) Physical activity 2 items: the Exercise Vital Sign (Sallis, 2011) Eating patterns 3 items: modified from Starting the Conversation (adapted from Paxton, Strycker, Toobert, Ammerman, and Glasgow, 2011) List current providers and suppliers Collected separately, on EHR Review medical/family history Collected separately, on EHR Review potential risk factors for depression Anxiety and Depression 4 items: Patient Health Questionnaire—Depression and Anxiety (Kroenke, Spitzer, Williams, & Löwe, 2009) Review functional ability and level of safety: • ADLs • Fall risk • Hearing impairment • Home safety Not collected on the MOHR. May be collected from existing data (electronic health records, administrative data) and brief patient reports. Assess: • Height, weight, BMI (or waist circumference, if appropriate), and blood pressure • Other routine measurements, as deemed appropriate based on medical and family history Height and Weight BMI collected on the MOHR. Biometric and other measures may be collected from existing data (electronic health records, administrative data) and brief patient reports. Detect any cognitive impairment Not collected on the MOHR. Cognitive impairment data may be collected from existing data (electronic health records, administrative data) and brief patient reports. Establish a written screening schedule, based on: • Age-appropriate preventive services that Medicare covers • Recommendations from the USPSTF and the ACIP • The HRA, health status, and screening history • Risk factors and conditions (including mental health, treatment options) Patient responses to all items (except height and weight) are scored and categorized as being of “no concern,” “some concern,” or “high concern.” Patients are asked if they are ready to change and/or discuss topics of some or high concern with their clinician. MOHR then provides patients a summary, containing feedback that identifies any health behavior or mental health risks, paired with the healthy goal, initial steps to make improvements, and a worksheet to start creating specific, measurable, achievable, realistic, and timely (SMART) goals, with a follow-up plan after the visit. Clinicians receive a summary of any positive screens prior to the visit. Personalized health advice, referrals: • Fall prevention • Nutrition • Physical activity • Tobacco-use cessation • Weight loss Patient responses to all items (except height and weight) are scored and categorized as being of “no concern,” “some concern,” or “high concern.” Patients are asked if they are ready to change and/or discuss topics of some or high concern with their clinician. MOHR then provides patients a summary containing feedback that identifies any health behavior or mental health risks paired with the healthy goal, initial steps to make improvements, and a worksheet to start creating specific, measurable, achievable, realistic, and timely (SMART) goals, with a follow-up plan after the visit. Clinicians receive a summary of any positive screens prior to the visit. Advance Care Planning Services (may include an Advance Care Directive) Not collected on the MOHR. Advance Care Directives may be collected from existing data (electronic health records, written patient records, administrative data). AWV Component MOHR Domains MOHR Items and Processesc,d HRA: • Demographic data • Self-assessment of health status • Psychosocial risks, behavioral risks, and ADLs, including, but not limited to: dressing, bathing, and walking • Instrumental ADLs, including but not limited to: shopping, housekeeping, managing own medications, and handling finances. Socio-Demographics Gender, race/ethnicity, educational level, marital status, country of birth, occupation, veteran status, speak English/need interpreter Overall health status 1 item: BRFSS Questionnaire Stress 1 item: Distress Thermometer (Roth et al., 1998) Substance abuse 1 item: NIDA Quick Screen (Smith, Schmidt, Allensworth-Davies, & Saitz, 2010) Risky drinking 1 item: Alcohol Use Screener (Smith, Schmidt, Allensworth-Davies, & Saitz, 2009) Smoking/tobacco use 2 items: Tobacco Use Screener (Adapted from YRBSS Questionnaire) Sleep 2 items: (a) adapted from BRFSS; (b) Neuro-QOL (item PQSLP04) Physical activity 2 items: the Exercise Vital Sign (Sallis, 2011) Eating patterns 3 items: modified from Starting the Conversation (adapted from Paxton, Strycker, Toobert, Ammerman, and Glasgow, 2011) List current providers and suppliers Collected separately, on EHR Review medical/family history Collected separately, on EHR Review potential risk factors for depression Anxiety and Depression 4 items: Patient Health Questionnaire—Depression and Anxiety (Kroenke, Spitzer, Williams, & Löwe, 2009) Review functional ability and level of safety: • ADLs • Fall risk • Hearing impairment • Home safety Not collected on the MOHR. May be collected from existing data (electronic health records, administrative data) and brief patient reports. Assess: • Height, weight, BMI (or waist circumference, if appropriate), and blood pressure • Other routine measurements, as deemed appropriate based on medical and family history Height and Weight BMI collected on the MOHR. Biometric and other measures may be collected from existing data (electronic health records, administrative data) and brief patient reports. Detect any cognitive impairment Not collected on the MOHR. Cognitive impairment data may be collected from existing data (electronic health records, administrative data) and brief patient reports. Establish a written screening schedule, based on: • Age-appropriate preventive services that Medicare covers • Recommendations from the USPSTF and the ACIP • The HRA, health status, and screening history • Risk factors and conditions (including mental health, treatment options) Patient responses to all items (except height and weight) are scored and categorized as being of “no concern,” “some concern,” or “high concern.” Patients are asked if they are ready to change and/or discuss topics of some or high concern with their clinician. MOHR then provides patients a summary, containing feedback that identifies any health behavior or mental health risks, paired with the healthy goal, initial steps to make improvements, and a worksheet to start creating specific, measurable, achievable, realistic, and timely (SMART) goals, with a follow-up plan after the visit. Clinicians receive a summary of any positive screens prior to the visit. Personalized health advice, referrals: • Fall prevention • Nutrition • Physical activity • Tobacco-use cessation • Weight loss Patient responses to all items (except height and weight) are scored and categorized as being of “no concern,” “some concern,” or “high concern.” Patients are asked if they are ready to change and/or discuss topics of some or high concern with their clinician. MOHR then provides patients a summary containing feedback that identifies any health behavior or mental health risks paired with the healthy goal, initial steps to make improvements, and a worksheet to start creating specific, measurable, achievable, realistic, and timely (SMART) goals, with a follow-up plan after the visit. Clinicians receive a summary of any positive screens prior to the visit. Advance Care Planning Services (may include an Advance Care Directive) Not collected on the MOHR. Advance Care Directives may be collected from existing data (electronic health records, written patient records, administrative data). Note: ACIP = Advisory Committee on Immunization Practices; ADL = activities of daily living; AWV = Annual Wellness Visit; BMI = body mass index; BRFSS = Behavioral Risk Factor Surveillance System; EHR = electronic health record; HRA = health risk assessment; MOHR = My Own Health Record; NIDA = National Institute on Drug Abuse; QOL = quality of life; USPSTF = United States Preventive Services Task Force; YRBSS = Youth Risk Behavior Surveillance System. aThe initial AWV is offered after first 12 months as a Medicare Part B beneficiary, with annual updates. All of the components are repeated annually, with height measured only at the initial AWV. bMOHR available from: http://myownhealthreport.org/. The measures were selected if evidence-based, valid, brief, actionable with rapid clinical utility, and feasible in real-world and low-resource settings. cEating patterns, physical activity, sleep, and smoking/tobacco use measures from Framingham health behaviors. dPatient responses to all items (except height and weight) are scored as being of “no concern,” “some concern,” or “high concern.” View Large Table 1. Components of the Annual Wellness Visita and the MOHR Measures and Processesb AWV Component MOHR Domains MOHR Items and Processesc,d HRA: • Demographic data • Self-assessment of health status • Psychosocial risks, behavioral risks, and ADLs, including, but not limited to: dressing, bathing, and walking • Instrumental ADLs, including but not limited to: shopping, housekeeping, managing own medications, and handling finances. Socio-Demographics Gender, race/ethnicity, educational level, marital status, country of birth, occupation, veteran status, speak English/need interpreter Overall health status 1 item: BRFSS Questionnaire Stress 1 item: Distress Thermometer (Roth et al., 1998) Substance abuse 1 item: NIDA Quick Screen (Smith, Schmidt, Allensworth-Davies, & Saitz, 2010) Risky drinking 1 item: Alcohol Use Screener (Smith, Schmidt, Allensworth-Davies, & Saitz, 2009) Smoking/tobacco use 2 items: Tobacco Use Screener (Adapted from YRBSS Questionnaire) Sleep 2 items: (a) adapted from BRFSS; (b) Neuro-QOL (item PQSLP04) Physical activity 2 items: the Exercise Vital Sign (Sallis, 2011) Eating patterns 3 items: modified from Starting the Conversation (adapted from Paxton, Strycker, Toobert, Ammerman, and Glasgow, 2011) List current providers and suppliers Collected separately, on EHR Review medical/family history Collected separately, on EHR Review potential risk factors for depression Anxiety and Depression 4 items: Patient Health Questionnaire—Depression and Anxiety (Kroenke, Spitzer, Williams, & Löwe, 2009) Review functional ability and level of safety: • ADLs • Fall risk • Hearing impairment • Home safety Not collected on the MOHR. May be collected from existing data (electronic health records, administrative data) and brief patient reports. Assess: • Height, weight, BMI (or waist circumference, if appropriate), and blood pressure • Other routine measurements, as deemed appropriate based on medical and family history Height and Weight BMI collected on the MOHR. Biometric and other measures may be collected from existing data (electronic health records, administrative data) and brief patient reports. Detect any cognitive impairment Not collected on the MOHR. Cognitive impairment data may be collected from existing data (electronic health records, administrative data) and brief patient reports. Establish a written screening schedule, based on: • Age-appropriate preventive services that Medicare covers • Recommendations from the USPSTF and the ACIP • The HRA, health status, and screening history • Risk factors and conditions (including mental health, treatment options) Patient responses to all items (except height and weight) are scored and categorized as being of “no concern,” “some concern,” or “high concern.” Patients are asked if they are ready to change and/or discuss topics of some or high concern with their clinician. MOHR then provides patients a summary, containing feedback that identifies any health behavior or mental health risks, paired with the healthy goal, initial steps to make improvements, and a worksheet to start creating specific, measurable, achievable, realistic, and timely (SMART) goals, with a follow-up plan after the visit. Clinicians receive a summary of any positive screens prior to the visit. Personalized health advice, referrals: • Fall prevention • Nutrition • Physical activity • Tobacco-use cessation • Weight loss Patient responses to all items (except height and weight) are scored and categorized as being of “no concern,” “some concern,” or “high concern.” Patients are asked if they are ready to change and/or discuss topics of some or high concern with their clinician. MOHR then provides patients a summary containing feedback that identifies any health behavior or mental health risks paired with the healthy goal, initial steps to make improvements, and a worksheet to start creating specific, measurable, achievable, realistic, and timely (SMART) goals, with a follow-up plan after the visit. Clinicians receive a summary of any positive screens prior to the visit. Advance Care Planning Services (may include an Advance Care Directive) Not collected on the MOHR. Advance Care Directives may be collected from existing data (electronic health records, written patient records, administrative data). AWV Component MOHR Domains MOHR Items and Processesc,d HRA: • Demographic data • Self-assessment of health status • Psychosocial risks, behavioral risks, and ADLs, including, but not limited to: dressing, bathing, and walking • Instrumental ADLs, including but not limited to: shopping, housekeeping, managing own medications, and handling finances. Socio-Demographics Gender, race/ethnicity, educational level, marital status, country of birth, occupation, veteran status, speak English/need interpreter Overall health status 1 item: BRFSS Questionnaire Stress 1 item: Distress Thermometer (Roth et al., 1998) Substance abuse 1 item: NIDA Quick Screen (Smith, Schmidt, Allensworth-Davies, & Saitz, 2010) Risky drinking 1 item: Alcohol Use Screener (Smith, Schmidt, Allensworth-Davies, & Saitz, 2009) Smoking/tobacco use 2 items: Tobacco Use Screener (Adapted from YRBSS Questionnaire) Sleep 2 items: (a) adapted from BRFSS; (b) Neuro-QOL (item PQSLP04) Physical activity 2 items: the Exercise Vital Sign (Sallis, 2011) Eating patterns 3 items: modified from Starting the Conversation (adapted from Paxton, Strycker, Toobert, Ammerman, and Glasgow, 2011) List current providers and suppliers Collected separately, on EHR Review medical/family history Collected separately, on EHR Review potential risk factors for depression Anxiety and Depression 4 items: Patient Health Questionnaire—Depression and Anxiety (Kroenke, Spitzer, Williams, & Löwe, 2009) Review functional ability and level of safety: • ADLs • Fall risk • Hearing impairment • Home safety Not collected on the MOHR. May be collected from existing data (electronic health records, administrative data) and brief patient reports. Assess: • Height, weight, BMI (or waist circumference, if appropriate), and blood pressure • Other routine measurements, as deemed appropriate based on medical and family history Height and Weight BMI collected on the MOHR. Biometric and other measures may be collected from existing data (electronic health records, administrative data) and brief patient reports. Detect any cognitive impairment Not collected on the MOHR. Cognitive impairment data may be collected from existing data (electronic health records, administrative data) and brief patient reports. Establish a written screening schedule, based on: • Age-appropriate preventive services that Medicare covers • Recommendations from the USPSTF and the ACIP • The HRA, health status, and screening history • Risk factors and conditions (including mental health, treatment options) Patient responses to all items (except height and weight) are scored and categorized as being of “no concern,” “some concern,” or “high concern.” Patients are asked if they are ready to change and/or discuss topics of some or high concern with their clinician. MOHR then provides patients a summary, containing feedback that identifies any health behavior or mental health risks, paired with the healthy goal, initial steps to make improvements, and a worksheet to start creating specific, measurable, achievable, realistic, and timely (SMART) goals, with a follow-up plan after the visit. Clinicians receive a summary of any positive screens prior to the visit. Personalized health advice, referrals: • Fall prevention • Nutrition • Physical activity • Tobacco-use cessation • Weight loss Patient responses to all items (except height and weight) are scored and categorized as being of “no concern,” “some concern,” or “high concern.” Patients are asked if they are ready to change and/or discuss topics of some or high concern with their clinician. MOHR then provides patients a summary containing feedback that identifies any health behavior or mental health risks paired with the healthy goal, initial steps to make improvements, and a worksheet to start creating specific, measurable, achievable, realistic, and timely (SMART) goals, with a follow-up plan after the visit. Clinicians receive a summary of any positive screens prior to the visit. Advance Care Planning Services (may include an Advance Care Directive) Not collected on the MOHR. Advance Care Directives may be collected from existing data (electronic health records, written patient records, administrative data). Note: ACIP = Advisory Committee on Immunization Practices; ADL = activities of daily living; AWV = Annual Wellness Visit; BMI = body mass index; BRFSS = Behavioral Risk Factor Surveillance System; EHR = electronic health record; HRA = health risk assessment; MOHR = My Own Health Record; NIDA = National Institute on Drug Abuse; QOL = quality of life; USPSTF = United States Preventive Services Task Force; YRBSS = Youth Risk Behavior Surveillance System. aThe initial AWV is offered after first 12 months as a Medicare Part B beneficiary, with annual updates. All of the components are repeated annually, with height measured only at the initial AWV. bMOHR available from: http://myownhealthreport.org/. The measures were selected if evidence-based, valid, brief, actionable with rapid clinical utility, and feasible in real-world and low-resource settings. cEating patterns, physical activity, sleep, and smoking/tobacco use measures from Framingham health behaviors. dPatient responses to all items (except height and weight) are scored as being of “no concern,” “some concern,” or “high concern.” View Large The electronic version of MOHR provides a score and categorizes patients’ responses as being of “no concern,” “some concern,” or “high concern.” For responses with some or high concern, patients are asked if they are ready to change and/or discuss the topic with their clinician (Glasgow & Goldstein, 2008; Glasgow, Davis, Funnell, & Beck, 2003; Krist et al., 2008; Whitlock, Orleans, Pender, & Allan, 2002). MOHR provides patients a summary containing motivational feedback, initial improvement steps, and space to create 3 “SMART” goals (i.e., goals that are specific, measurable, achievable, realistic, and timely; Croteau & Ryan, 2013; O’Neill, 2000). A clinician summary is automatically shared with the practice, to be uploaded into the electronic health record (sample SMART goals and feedback reports for patients and the practice team are found in Glasgow et al., 2014; Gorin & Krist, 2013). The MOHR Pragmatic Trial The implementation of the MOHR tool was systematically evaluated within a practice-level, cluster-randomized, pragmatic-implementation study. The design was purposefully pragmatic, allowing local tailoring of implementation to ensure that findings reflected real-life practice. The general methods, measures, and intervention components are described elsewhere (Krist et al., 2013). The MOHR study coordinator recruited eight nationally-distributed academic partners that manage practice-based research networks or participate in the Cancer Prevention and Control Research Networks, resulting in 18 intervention and control practices (see Figure 1). Nine practice pairs were randomized with allocation concealment to implement MOHR (early implementation) or to provide usual care with a delayed option to implement MOHR (delayed implementation). The randomized, delayed intervention sites did not receive either the MOHR assessment and feedback tool or explicit goal-setting support; they provided a control for temporal trends and local context (Estabrooks et al., 2012). Intervention practices were encouraged and helped to adapt their implementation workflow to fit local needs. The MOHR content and research data collection activities were standardized. Figure 1. View largeDownload slide My Own Health Record sites. Figure 1. View largeDownload slide My Own Health Record sites. MOHR practices varied with respect to size, ownership, health-system affiliation, geographic location, and patient socio-demographics (Balasubramanian et al., 2017; Glasgow et al., 2014). At baseline, no practice systematically offered a health risk assessment, instead relying on clinicians to ask about health behaviors and psychosocial issues as part of care. In addition to the descriptive data collected from the MOHR tool, qualitative data were also collected from site records, field and learning collaborative notes, and practice interviews (see Balasubramanian et al., 2017). Data on resource use were also collected from nine of the participating practices (see Ritzwoller (2018) for details). The primary outcomes of the study were assessed via patient surveys of patients' health behavior and psychosocial domains. The primary MOHR outcomes were whether patients set goals or action plans with their clinicians; and whether they arranged any follow-up contact regarding their plans. MOHR Study Results As previously reported (Glasgow et al., 2014), most practices approached (60%) agreed to adopt MOHR. Overall, the reach was 49.6%. Patient assistance (via a call center, office, or research staff) increased the overall reach. The reach was significantly higher when the MOHR was completed by staff, rather than by patients (71.2% vs 30.2%, p < .001). Fielding the MOHR increased staff and clinician time by an average of 28 minutes per visit. Contextual factors influencing MOHR implementation and patient reach included factors both internal and external to the practice. These factors included: practice staff capacity for implementation; practice information system capacity; external resources to support quality improvement; community linkages; and implementation strategy fit with patient populations (Balasubramanian et al., 2017). Costs per patient completing MOHR ranged from $10.25 to $54.50, depending on the strategy used. Phone-based strategies were the lowest cost. Strategies requiring large amounts of personnel (Doctor of Medicine [MD], Registered Nurse [RN], Medical Assistant [MA]) time with minimal information technology support were associated with the highest costs. Regarding the major MOHR outcome of goal setting, compared to patients from control practices, intervention practices reported greater screening rates for each of the eight behaviors and mental health risks (range of differences, 5.3%–15.8%, p<.001; see Table 2; Krist et al., 2016). Compared to controls, intervention patients felt clinicians cared more for them and showed more interest in their concerns. Patient-centered health risk assessments improved screening and goal setting. Table 2. My Own Health Record Findings on Outcomea Topic Intervention Control p-value Eating/Diet 48.2% 31.5% <0.001 Physical activity 46.3% 33.5% <0.001 Tobacco/smoking 17.2% 14.8% Alcohol use 15.1% 10.8% <0.01 Drug use 12.3% 10.3% Stress level 27.3% 19.2% <0.001 Anxiety/depressionb 28.9% 20.7% <0.001 Sleep 27.7% 22.1% <0.01 Topic Intervention Control p-value Eating/Diet 48.2% 31.5% <0.001 Physical activity 46.3% 33.5% <0.001 Tobacco/smoking 17.2% 14.8% Alcohol use 15.1% 10.8% <0.01 Drug use 12.3% 10.3% Stress level 27.3% 19.2% <0.001 Anxiety/depressionb 28.9% 20.7% <0.001 Sleep 27.7% 22.1% <0.01 Note:aFrom the Patient Experience Survey that was mailed to eligible patients, and described in Krist et al. (2013). The table describes the most common risks (from Krist et al., 2016). bMost ready to change (Krist et al., 2014; Phillips et al., 2014). View Large Table 2. My Own Health Record Findings on Outcomea Topic Intervention Control p-value Eating/Diet 48.2% 31.5% <0.001 Physical activity 46.3% 33.5% <0.001 Tobacco/smoking 17.2% 14.8% Alcohol use 15.1% 10.8% <0.01 Drug use 12.3% 10.3% Stress level 27.3% 19.2% <0.001 Anxiety/depressionb 28.9% 20.7% <0.001 Sleep 27.7% 22.1% <0.01 Topic Intervention Control p-value Eating/Diet 48.2% 31.5% <0.001 Physical activity 46.3% 33.5% <0.001 Tobacco/smoking 17.2% 14.8% Alcohol use 15.1% 10.8% <0.01 Drug use 12.3% 10.3% Stress level 27.3% 19.2% <0.001 Anxiety/depressionb 28.9% 20.7% <0.001 Sleep 27.7% 22.1% <0.01 Note:aFrom the Patient Experience Survey that was mailed to eligible patients, and described in Krist et al. (2013). The table describes the most common risks (from Krist et al., 2016). bMost ready to change (Krist et al., 2014; Phillips et al., 2014). View Large The Use of the MOHR for the AWV among Older Adults Table 1 displays the components of the AWV that are measured by the MOHR tool. While the MOHR was designed for adults in primary-care practices, it also offers particular advantages to assessing the older adult in this setting. The implementation of MOHR included components that facilitate a positive interchange with older adults, including; supportive technology, education, framing of the HRA, and conversation-strengthening resources (e.g., “change talk,” Nagykaldi et al., 2017). The MOHR tool is well-evaluated, incorporating psychometrically-sound measures. Some of the measures, for example of depression with the Patient Health Questionnaire-2 (PHQ2), are widely used with older adults. While the AWV recommends the use of community resources for fall prevention, nutrition, physical activity promotion, and tobacco-use cessation, the MOHR systematically assesses these behaviors, at multiple levels. The MOHR also assesses other key community-level factors, such as neighborhood safety, homelessness, and transportation, and family- or group-level factors, such as partner safety, food insecurity, and social isolation, that are not systematically addressed in the AWV. Dental health is measured in the MOHR, but is not addressed in the AWV. Further, the MOHR has been systematically tested in diverse, national primary-care practices, using mixed methods. So many of the implementation factors that are discussed further forthwith are better understood; this knowledge facilitates translation to other settings. The sites in which the MOHR was tested varied, from having 2–49% Medicare enrollees; in fact, the highest reach for MOHR uptake was observed in the site with the greatest enrollment of Medicare beneficiaries, suggesting generalizability to older adult populations. Yet MOHR is not uniquely designed as a single assessment tool for the older adult, so requires supplemental data to fully describe the health risks and prevention needs of this population. MOHR does not include systematic measures of cognitive decline, activities of daily living (e.g., dressing, bathing, and walking), Instrumental activities of daily living (including shopping, housekeeping, managing own medications, and handling finances), or characteristics related to fall prevention. Other conditions of older adults, such as hearing and vision changes, are also not assessed in the MOHR. The family and medical history are collected separately from the MOHR (see Table 1). Only the AWV includes a discussion of advance care planning and the opportunity to complete an advance directive. The Context for MOHR Implementation in the AWV As discussed previously, practices’ unique local contexts are important to consider for successful implementation of the MOHR in an AWV. As no practices were able to sustain the complete MOHR assessment without adaptation after study completion, the MOHR study authors identified facilitators and barriers to understand the implementation process (Balasubramanian et al., 2017). Practices that are part of larger health systems may have additional system resources, such as patient portals or care coordinators to assist with MOHR completion, while smaller, independent practices may lack such resources and staff capacity (Balasubramanian et al., 2017). The automated creation of patient and provider reports to assist with goal setting adds value to the clinician-patient discussion during the annual wellness visit, but can add significant time to the clinic visit (Krist et al., 2014). It is likely that with sustained use of the MOHR, practices may be able to identify more efficient ways to implement it within the AWV. Practices’ patient panel mix can also impact efficient and effective implementation. For instance, achieving high rates of follow-up after goal setting is difficult for practices with transient, less-stable patient populations with high levels of no-shows. Also, use of patient portals and other time- and resource-efficient methods of conducting a health risk assessment may not be feasible in practices with large proportions of low-literacy patients. These patients may need practice-staff assistance in completing the MOHR, further adding time and resources (Balasubramanian et al., 2017). Finally, it is important for the practice to strengthen its connections to community resources, such as mental/behavioral health counseling services, smoking cessation resources, and access to safe spaces for physical activity, so that patients who are ready to change their problem behaviors can get the help they need (Etz et al., 2008; Krist et al., 2013; Krist et al., 2014). Team Structure, the MOHR, and the AWV The structure and organization of a practice is key to implementing a service, such as the AWV, and a new tool, such as the MOHR. A typical primary-care practice is organized around front- and back-office functions, directed by a physician or a group of physicians and a practice manager. The front office is comprised of people whose roles directly interface with the patient, whether in-person at a visit, by phone, by email, or through patient portals. Examples of such roles are the receptionist, billing assistant, and care coordinator. The back office is typically comprised of individuals who provide direct patient care, and include clinicians, medical assistants, and nurses. Within this typical organizational structure, the AWV is inherently physician-centric and almost entirely conducted by the physician. Ganguli, Souza, McWilliams, and Mehrotra (2017) found that most AWVs (90.7%, 95% confidence interval 90.7–90.8%) were performed by primary-care physicians. The patient-centered medical home initiative brought teams and team-based care to primary-care practice, because of emerging evidence that implementing team-based care can enhance care delivery and health-care outcomes (Schottenfeld et al., 2016). Using a team-based approach in primary care creates an opportunity to effectively conduct an AWV that includes a comprehensive HRA, focused on identifying psychosocial and behavioral risks; social determinants of health; and physical and biomedical risk factors, with the goal of prevention and wellness (Krist et al., 2016; Krist et al., 2013). In the MOHR study, primary-care practices often leveraged such a team-based approach to increase the reach of the MOHR (Krist et al., 2013; Krist et al., 2014). These ranged from MAs administering the MOHR while placing patients in rooms, a practice staff member administering it by phone to patients prior to their AWV, or administering it via patient portals and asking patients to complete the HRA prior to their visits (Balasubramanian et al., 2017; Krist et al., 2014). Standardized patient and provider reports were automatically generated and printed to aid goal setting and action planning during the AWV (Krist et al., 2013). These approaches extended the typical roles played by office assistants, who, after adequate training, were able to successfully administer the MOHR, thus creating opportunities and time during the clinician-patient encounter to discuss problem behaviors and risks and create action plans to address them on an ongoing basis (Krist et al., 2014). In addition to staff training, clinicians would also benefit from continuing medical education in addressing sensitive topics, such as substance use and depression, through brief, motivational techniques. This level of concrete goal setting and action planning is often difficult to achieve in an AWV that does not leverage the primary-care practice team in assisting patients to complete a thorough health risk assessment (Krist et al., 2016). Implications for Practice, Policy, and Research Administering a patient-centered HRA like MOHR in the AWV within diverse primary-care settings will identify a significant number of unhealthy behaviors and mental health needs, allowing patients and clinicians to better set goals that will improve health. The MOHR reach of about 50% of patients compared favorably with HRAs in large health systems and with incentives in worksite settings (22.4% and 40% – 64%, respectively; Krist et al., 2014). Patients reported significantly greater goal-setting with providers in MOHR sites than in the controls. This is particularly important, as the implementation of the AWV has thus far been both limited among eligible Medicare beneficiaries (15.6% in 2014) and uneven within this population (Ganguli et al., 2017). But practices will need more support to implement and sustain systematic and generalizable HRA assessments in the AWV among diverse older adult patient groups over time (Krist et al., 2014). More support for the application of existing and novel technology approaches, in particular, could enhance dissemination of the AWV, by increasing patients’ responses, reducing staff time, and increasing the portability of health risk findings and referrals from the AWV (e.g., embedding an AWV “smart set” in the electronic health record to electronically generate HRA responses for a provider to view prior to the visit). Some of these approaches are already in use in integrated healthcare systems, but could be enriched for use with follow-up referrals and counseling and could be expanded to other primary-care practices (Ritzwoller, 2018; John F Steiner, December 2, 2018, personal communication, February, 2018). Indeed, effectiveness of the AWV in improving outcomes lies in systematic assessments of health risks, goal setting, and comprehensive follow-up. From a policy perspective, better integration of primary care with mental health and health behavior is needed to address the modifiable risks, notably depression, that will likely be identified as the AWV—with the required HRA—is more widely implemented among older adults. Further, if Medicaid health homes were expanded to include Medicare beneficiaries, these could integrate and coordinate all primary, acute, behavioral health, and long-term services and supports to treat the whole person (Bartels, Gill, & Naslund, 2015). MOHR could be an important tool to systematically assess risks and tailor health promotion counseling to older adults. Additional study of how to routinely support the use of health risk assessments in primary care, as well as how to deliver follow-up counseling to patients ready to make changes in the context of the AWV, is needed. Evidence-based tools are necessary to systematically assess the processes and outcomes of the AWV, so that the findings are robust and may be applied across the population. Ultimately, research on the AWV could be embedded in the process of care, alongside technology, incentives, and organizational culture, to lead to continuous, practice-based improvement and innovation (Selker et al., 2011). Acknowledgements The authors thank Jessica D. Austin, MPH, UTHealth School of Public Health in Dallas, Department of Health Promotion Behavioral Science, for her editorial help. References Anderson , D. R. , & Staufacker , M. J . ( 1996 ). The impact of worksite-based health risk appraisal on health-related outcomes: a review of the literature . American Journal of Health Promotion 10 , 499 – 508 . doi: https://doi.org/10.4278/0890-1171-10.6.499 Google Scholar Crossref Search ADS PubMed Balasubramanian , B. A. , Heurtin-Roberts , S. , Krasny , S. , Rohweder , C. L. , Fair , K. , Olmos-Ochoa , T. 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Medicare Health Promotion and Disease Prevention Efforts Over 50 YearsKaskie,, Brian;Dreissen,, Julia
doi: 10.1093/ppar/pry055pmid: N/A
Annual Wellness Visit, Medicare Welcome Visit, Vaccination, Disease Prevention, Health Promotion, Older Adults In 1961, at the first White House Conference on Aging, Robert Havinghurst (1961) declared that the process of growing old should not be defined by an inevitable decline consisting of disease, disability, and death. Alternatively, old age should be viewed as a time of continued development and new experiences, and he summarized these sentiments by declaring that growing old was not just about adding “years to our lives” but “adding life to our years.” In 1986, 25 years later, the first international conference on health promotion and disease prevention took place in Ottawa, Canada (World Health Organization, 2016). There, health promotion and disease prevention was defined: “health promotion is a process of enabling people to increase control over, and to improve, their health.” Since then, vaccinations and screenings have become the cornerstones of health promotion and disease prevention efforts. With the likelihood of infectious disease increasing with age, vaccinations have become a primary means for preventing illness among older Americans and reducing associated health costs, including emergency room visits and pneumonia (Weinberger, 2017). Pneumonia’s rates of incidence and mortality are highest among older Americans relative to all other age groups and pneumonia is one of the top 10 most common reasons for older adult hospitalization (American Thoracic Society, 2015). Said disease burden for this population is inherently with associated health costs rendered by the aforementioned hospitalizations. And, while cancer remains a leading cause of death in the United States, as of 2016 approximately 15.5 million American people can boast survivor-status, (National Cancer Institute, 2015) arguably because positive screenings led to early detection and effective cancer treatment. As discussed elsewhere in this issue, the Medicare program historically has done little beyond recommending routine vaccinations and screenings and, instead, reimburses hospitals and physicians for providing services deemed “medically necessary” (Hill, 2012) in part by the American Medical Association via setting physician fee schedules (American Medical Association, 2017). Yet, as more individual Medicare beneficiaries demanded services to prevent or delay the onset of disease and disability and as overall expenditures continued to outpace inflation, the Medicare program recognized the need to do more, especially as it became increasingly evident that older adults could experience the significant benefit from health promotion and disease prevention and as such efforts offered great potential to curb program expenditures (McGinnis and Foege, 1993). On the basis of the comprehensive assessments conducted with the most complex patients (e.g., Program of All-Inclusive Care for the Elderly; Peikes, Peterson, Brown, Graff, & Lynch, 2012), Medicare created a platform for all beneficiaries to become more engaged in their own care and to facilitate access to recommended vaccinations and screenings. In 2005, Medicare established “Welcome to Medicare” (WTM) and, in 2011, Medicare established the annual wellness visit (AWV). As might be expected, these platforms were deliberately designed to increase the involvement of Medicare beneficiaries in promotion and prevention efforts and, coincidentally, contribute to decreasing their overall program expenditures. Medicare supports these platforms (WTM & AWVs) by targeting policies toward beneficiaries, providers, and the health systems in which they are embedded. For example, as cost-sharing is a significant impediment to the use of preventive services, Medicare beneficiaries can obtain all of their approved vaccinations and screenings at no cost. The Centers for Medicare and Medicaid Services (CMS) also allows state Medicaid programs (in which several Medicare beneficiaries are enrolled as “dual eligibles”) to have community health workers and other unlicensed medical providers offer preventive services. In addition, CMS offers state Medicaid programs a one percentage point increase in their federal matching rate if they provide immunizations and screenings rated as grade “A” or “B” by the U.S. Preventive Services Task Force (Gates, Ranji, & Synder, 2014). The Center for Medicare and Medicaid Innovation provides grant awards to 10 states that explicitly propose to enhance and expand patient engagement, health promotion, and disease prevention (Centers for Medicare and Medicaid Services, 2018). Current Platform Performance Ganguli (2017) charted a slow and steady increase in the percentage of Medicare beneficiaries who completed an AWV, moving from 8% in 2011 to 16% in 2014. Camacho, Yao, and Anderson (2017) added that AMVs contributed to increased use of vaccinations and screenings. In 2016, the Centers for Disease Control and Prevention estimated that two of every three Medicare beneficiaries received flu vaccinations, and others reported that as many as four out of ten Medicare beneficiaries had completed recommended screenings. While these uptakes certainly are remarkable, Tipineri and her colleagues (this issue) discussed how rates vary significantly by education, race, and geographic region. It also is worth noting that more than 86% of the 79,416 Americans who died of the flu in 2017 were over the age of 65 (Centers for Disease Control and Prevention, 2018) and more than half of the 600,000 estimated cancer deaths in the United States were related to preventable causes, some of which could have been identified with proper screening (Centers for Disease Control and Prevention, 2018). Considering how WTM and AWVs offer clear and certain benefits to beneficiaries, it surely seems the platforms should be expanded. Yet, such an expansion should also offer clear and certain reductions in corresponding program expenditures. Shoring Up the Platform Medicare could expand and enhance the WTM and AWV platforms by addressing: (a) beneficiaries themselves, (b) providers, and (c) the health systems in which beneficiaries and providers are embedded. For example, many beneficiaries simply are not aware of the WTM and AWV visits, and some are confused by the different vaccination efforts offered through Parts B and D (Ganguli, 2017; Ng, Jensen, & Fritz, 2017). Mass media campaigns using brief and recurring messages could increase awareness of these platforms, given the success of such campaigns at increasing physical activity and tobacco cessation (Community Preventive Services Task Force, 2001b), and Medicare could increase support for existing public education campaigns, such as “Share the news, share the health” meant to encourage the utilization of preventative services available to beneficiaries without cost sharing by educating said beneficiaries as well as their providers and caregivers on the newly expanded services (United States Government Accountability Office, 2012). Moreover, public education efforts could be targeted specifically toward dually-eligible beneficiaries over 85, who are the most likely to benefit from these preventive services but the least likely to know about and use them (Tipineri et al, this issue). Public education efforts also could be embedded within Medicare’s existing Seniors Health Insurance Information Program, as well as be targeted to the informal caregivers of older Medicare beneficiaries (AARP, n.d.). In addition, more Medicare Advantage (MA) plans and state Medicaid programs may consider offering incentives to increase beneficiary participation in health promotion and disease prevention. For example, Idaho’s Preventative Health Assistance Benefits offer credit points and reduced premiums to individuals who receive up-to-date vaccinations; the Healthy Indiana Plan offers financial incentives to Medicaid beneficiaries who complete appropriate preventive services (Vleet & Rudowitz, 2014). Medicare Providers Ganguli (2017) reported that a majority of the AWVs were conducted by less than 5% of qualified Medicare providers. He also observed that more than half of qualified Medicare providers did not engage in any preventive efforts, though this should not be surprising, as many providers are medical specialists who may not consider such services as part of their scope of practice. One way to address the lack of engagement would be to increase financial incentives to provide WTM, AWVs, and the related vaccinations and screenings. For example, by increasing provider reimbursements, the Department of Veterans Affairs (2011) increased the influenza vaccination rate from 83.4% to 90.5% and the pneumococcal vaccination rate from 66.5% to 75.6%. It is worth noting that the Department of Veterans Affairs (2014) also found the increased payments were offset, as related hospitalization rates decreased by as much as 50%. With the increasing deployment of alternative payment models and their associated quality metrics, Medicare would seem to have several ready-made opportunities to directly incentivize WTM and AWV completion. As an alternative, Simpson (this issue) suggested that nurse practitioners could be increasingly deployed to offer preventive services. It also might be worth considering how to expand the role of non-traditional Medicare providers. For example, CMS recently created regulations that support those states that allow unlicensed practitioners to deliver preventive services (Paying for Senior Care, 2018). Perhaps the national network of case managers and other non-medical providers embedded in the nation’s 620 Area Agencies on Aging could be called upon to offer WTM and AWVs (American Society on Aging, 2018). Health Systems The GAO (2012) and others (Sloan, Acquah, Lee, & Sangvai, 2012; Tao, 2018) have reported that beneficiaries enrolled in some type of MA plan were significantly more likely to encourage preventive care use, compared to those enrolled in a health plan that relied on fee-for-service reimbursements. More recently, Camacho, Yao, and Anderson (2017) observed significant differences across MA plans, and found that AWVs were more likely to be provided within those plans that conducted patient education and outreach; developed clinical guidelines and offered financial incentives to providers; and used monitoring and feedback software to evaluate system-wide performance. Yet, the Medicare Payment Advisory Commission (2016) has raised a cautionary flag about the continued expansion of these platforms within MA plans. In particular, some MA plans appear to conduct health risk assessments as a way to alter individual risk adjustments upward, and such efforts may, in part, explain why the average beneficiary payments to MA plans continue to exceed the average payments for beneficiaries embedded within systems that rely on fee-for-service reimbursement. Moreover, Medicare Payment Advisory Commission suggested that these upward payment adjustments are made without any assurance that services are being provided for the condition identified through the AWV. Camacho, Yao, and Anderson (2017) noted how Medicare providers have used the AWVs to establish a medical need for diagnostics and treatments considered to be of low value. So, even though MA plans have done particularly well to expand the platform, some appear motivated to use WTM and AWV visits as way to create “medical need” for diagnostic and treatment services that increase provider reimbursements. How such service substitutions (and corresponding expenditures) contribute to lowering overall Medicare expenditures remains unclear. Besides making a more concerted effort to monitor such MA plan practices (Medicare Payment Advisory Commission, 2018), Medicare could expand efforts to engage other service delivery systems that have no reason to alter risk adjustments or induce demand for low-value services. For example, the Area Agencies on Aging could be engaged to provide preventive care by partnering with the Vote & Vax program, which offers influenza vaccinations at polling places on and around election days (Vote and Vax, 2008). Moreover, Medicare could increase support for Accountable Health Communities and Community Transformation Grants, which encourage collaborative efforts among supportive service providers and community services supporting the health-related social needs of Medicare and Medicaid beneficiaries (Centers for Medicare and Medicaid Services, 2018). The Center for Medicare and Medicaid Innovation also could expand efforts to involve other independent service delivery systems, such as the YMCA, an organization with a century-long commitment to wellness and no obvious financial conflicts with local healthcare-delivery systems (Alva, Hoerger, Jeyaraman, Amico, & Rojas-Smith, 2017). Concluding Remarks The Medicare program has taken 50 years to get to this point. Considering this pace, it seems like an act of Congress is needed to expand the wellness platform in a more timely and efficient manner. Alas, most members of Congress who also are health-care professionals identify themselves as specialists and, as such, may be less concerned with policy advancements that fall outside of their scope of practice; they also may not support policies patently designed to reduce the demand for specialty health-care services. It is less clear how many members of Congress recognize that the prevention platform offers some Medicare providers an unprecedented opportunity to identify a countless number of conditions that can be linked to a “medical need” and, ultimately used to increase diagnostic testing and the provision of long-term, pharmaceutical treatments. Meanwhile, CMS can look to increase WTM and AWVs within those states with a higher percentage of dual eligibles; CMS can advance payment reforms that deter upward risk adjustments and low-value healthcare; and CMS could increase opportunities for other service systems to expand and enhance the platform in such a way that benefits continue to be experienced by older adults, while expected decreases in expenditures become more clear and certain. References Alva , M. L., Hoerger , T. J., Jeyaraman , R., Amico , P., & Rojas-Smith , L (2017) . Impact of the YMCA of the USA diabetes prevention program on medicare spending and utilization . 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