Making the Connection: Annual Wellness Visits and Care Coordination

Despite Annual Wellness Visits (AWV) being covered by Medicare since 2011, they remain misunderstood – and not only by the patients who might benefit most from them, but also by primary care providers.

In an upcoming webinar, “Building the Bridge between Annual Wellness and Care Coordination” on May 28, Faith Jones, Director of Care Coordination and Lean Consulting at HealthTechS3, will discuss the key elements of the AWV, its value to patients and providers, and how to build AWVs in one’s care coordination program.

What is an Annual Wellness Visit?

As a 2011 provision under the Affordable Care Act, Annual Wellness Visits were meant to review the patient’s health issues and develop a preventative plan for the full year.  The Annual Wellness Visit is a perfect resource to include as one of a family of Medicare Care Coordination services designed to bridge gaps in care among patients living with two or more chronic conditions—a population that figures especially large among Medicare beneficiaries. These gaps in care can result in increased hospital admissions and larger Medicare expenditures, thus making care coordination paramount.

“Right now, we have 10,000 baby boomers coming onto Medicare every day,” said Jones. “Yet, there’s still this misunderstanding about what Annual Wellness Visits are.”

The AWV is not an annual physical. Rather, it is a risk-identification visit. Typically lasting one hour, an AWV takes place between patients and nurses or health coaches and results in a personalized prevention plan for the coming year. This plan may include a review of the patient’s medical and family history, an up-to-date list of prescriptions, a screening schedule for appropriate preventive services, and various risk assessments to include depression, cognitive impairments, and safety concerns such as falls.

The Challenges to Adopting AWVs in Care Coordination

Since the Centers for Medicare & Medicaid Services (CMS) classifies AWV as a wellness service, AWV tends to sound like an afterthought compared to the more urgent care coordination programs Medicare covers, like Chronic Care Management and Advanced Care Planning.

“Primary care providers (PCP) often misunderstand the value of the Annual Wellness Visit, both to the patient and to their own practices,” Jones said. “And if the provider doesn’t get it, I guarantee the patient won’t get it.”

In addition to providers underestimating the value of AWVs, effective adoption and integration of AWVs in care coordination requires that they change their practices and worldviews, which is no easy feat.

“The funny thing is, for someone who’s not in healthcare, this makes perfect sense,” Jones said. “But changing how providers practice is tough. They have a hard time changing their worldview, and that’s essentially what we’re asking them to do.”

The Key Benefits of AWVs in Care Coordination Models

One of the key benefits of folding AWV into a care coordination program is that patients are less likely to feel confused or surprised when a specific screening or procedure is recommended. AWVs can also serve as a recruitment opportunity into the care coordination program.

“Sometimes I hear care coordinators tell me that after an Annual Wellness Visit, the patient will say, ‘Wow, that’s a lot of stuff to keep track of,’” Jones said. “But that’s when the nurse or health coach can say, ‘Well, we have a care coordination program to help you keep track of it all.’ There’s a natural flow there.”

The flow from an effective AWV to recruitment in a care coordination program can also go the other way. If a patient is already in a care coordination program, they are likely familiar with a team-based approach to their health care and may be more willing to participate in an AWV.

Ultimately, Jones said that taking the time to ensure that AWVs are folded into your care coordination program will lead to greater efficiency and patient satisfaction.

“In any chronic care management program, we talk about assisting patients with health promotion,” Jones said. “But if you’re not tying that to Annual Wellness Visits, you’re missing revenue. And when done right, patients love them.”

Telehealth Technology May Enable Increased Adoption of the AWV

The COVID-19 pandemic may actually provide a nudge toward AWVs being taken up by more providers and patients, as they can be easily done with a patient at home via telehealth technologies like videoconferencing and streaming media.

“One of the cool things I’m seeing lately is that some practices are using telehealth visits to communicate with their patients at home,” Jones said. “I’m hopeful that many people are taking advantage so that once the pandemic is over, we can lobby for telehealth Annual Wellness Visits to continue to be covered under Medicare with the patient at home.”

Join Us in “Building the Bridge between Annual Wellness and Care Coordination” on May 28.

If you are interested in building a more efficient care coordination program by using the Annual Wellness Visit elements, join us on this webinar to understand how to make the visit process valuable to the patient, provider, and your care coordination program. The webinar will provide valuable insights to providers who are eager to take a more team-based approach to their patients’ health and care coordination teams who are using telehealth in new ways due to COVID-19.

Visit to register for the “Building the Bridge between Annual Wellness and Care Coordination” webinar on May 28.