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Service Delivery Innovation Profile

Physician Practices Use Software-Facilitated System to Complete Medicare Annual Wellness Visit, Improving Preventive Care and Generating High Satisfaction


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Snapshot

Summary

Primary care physician practices use a comprehensive system (facilitated by software) to encourage Medicare patients to schedule the Annual Wellness Visit and to facilitate completion of and billing for required components of that visit in an efficient manner, with the visit typically taking just 20 minutes. The system also identifies and addresses needed preventive and screening services, with patients receiving them during the same visit or leaving with referrals or a followup appointment for them. Patients also receive a printed screening and immunization schedule and personalized prevention plan to address identified risk factors. The program has improved the provision of needed preventive services and generated high levels of satisfaction among both physicians and patients. A future analysis will evaluate its impact on health outcomes.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the average number of needed preventive services provided to patients as a result of the visit, along with anecdotal reports from patients and physicians participating in the program.
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Developing Organizations

Senior Wellness Solutions
Dr. Averel Snyder and Steven Zuckerman designed the software system used to facilitate the Annual Wellness Visit through the company, Senior Wellness Solutions.end do

Use By Other Organizations

The software is currently being used by 8 organizations that collectively have 14 care sites and care for approximately 10,000 Medicare patients. These organizations include five community-based primary care practices, two large independent practice associations, and a large university health system.

Date First Implemented

2012
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Patient Population

Age > Aged adult (80 + years); Vulnerable Populations > Frail elderly; Insurance Status > Medicare; Age > Senior adult (65-79 years)end pp

Problem Addressed

Many older adults do not receive recommended, evidence-based care, including preventive services, chronic disease management, and management of common geriatric conditions. As a result, these seniors may experience a decline in physical and functional status, leading to expensive emergency department (ED) or inpatient care. Although Medicare now covers Annual Wellness Visits in which some of these services are provided free of charge and other care gaps can be identified and addressed, few beneficiaries have such visits.
  • Failure to provide evidence-based care to seniors: A review of more than 345,000 Medicare beneficiaries found that they received indicated care less than two-thirds of the time for 16 of 40 indicators studied.1 A recent survey found that only a small percentage of older adults (7 percent) receive all preventive services recommended by the Centers for Medicare and Medicaid Services (CMS), with 52 percent receiving none or 1, and most (76 percent) receiving less than one-half.2
  • Negative impact on health and costs: The failure to receive timely, evidence-based care can have a negative impact on physical and mental health and functional status, leading to increased morbidity and mortality among seniors and the need for expensive inpatient and ED care.3
  • Few taking advantage of Annual Wellness Visit: As of January 1, 2011, Medicare covers an Annual Wellness Visit for all beneficiaries as a Part B benefit; this visit is intended to identify and in many cases provide some of the evidence-based services that seniors should receive. However, the number of beneficiaries taking advantage of this benefit has fallen dramatically short of CMS expectations, with only 6.5 percent having had a visit thus far, and 68 percent of older adults reporting that they have not heard about the benefit.2 Barriers include confusion over what the visit entails, the lengthy time required (up to 1 hour) to complete it, and the perceived inadequacy of the reimbursement rate ($170) among providers.
  • Unrealized potential of systems to facilitate visit: Systems for primary care practices that make the visit quicker and easier to complete could improve uptake, but very few practices have access to such support.

What They Did

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Description of the Innovative Activity

Primary care practices use a comprehensive system (facilitated by software) to encourage Medicare patients to schedule the Annual Wellness Visit and to facilitate completion of and billing for required components of that visit in an efficient manner, with the visit typically taking just 20 minutes. The system also helps practices identify and address needed preventive and screening services, with patients receiving them during the same visit or leaving with referrals or a followup appointment for them. Patients also receive a printed screening and immunization schedule and personalized prevention plan to address identified risk factors. Key program elements are outlined below:
  • Proactive encouragement to schedule visit: Posters in the office describe the Annual Wellness Visit and encourage Medicare patients to schedule it. In addition, clinicians and other office staff seeing Medicare patients for acute problems suggest that they schedule the visit before leaving the office (at checkout). Those who do schedule the visit receive an appointment card that includes instructions for online completion of a health risk assessment (see below for more information). In addition to these in-office efforts, office staff can use a master list to proactively contact Medicare patients and invite them to schedule a wellness visit.
  • Screenshot of the health risk assessment.

    Figure 1: The health risk assessment gathers basic information about the patient’s medical and family history. Click the image to enlarge. Image courtesy of Averel Snyder. Used with permission.

  • Health risk assessment, with information entered into software: Patients must complete a health risk assessment as part of the Annual Wellness Visit (see Figure 1). Patients able to use the Internet can complete it online before the visit. For others, office staff ask patients questions to gather the requisite information needed at the start of the visit, and then input it into the software. Information gathered includes a basic medical and family history, including past medical and surgical encounters (e.g., hospitalizations, illnesses, operations, allergies, injuries, treatments); use of medications and supplements; and family medical events, including diseases that may be hereditary. The patient also provides a list of other providers regularly involved in his/her care.
    • Software-facilitated provision of required care: During the visit, physicians and/or nonphysician providers use templates within the software to ensure that all CMS-required components occur. The templates guide them in performing required tasks and entering findings in real time into designated fields (including free-text entry in comment fields). Templates appear on successive screens that reflect the major components of the Annual Wellness Visit, with the process generally taking about 20 minutes, as outlined below:
      • Evaluation of general health indicators: The provider measures the patient’s blood pressure, height, weight, and waist circumference; calculates body mass index; and completes any other measurements deemed appropriate based on medical and family history.
      • Assessment of cognitive impairment: The provider conducts a cognitive assessment, including word recall and clock draw tests.
      • Depression screening: The provider reviews the patient’s potential risk factors for depression, including current or past experience with the disease and/or other mood disorders.
      • Review of functional ability and safety: The provider asks questions related to activities of daily living, hearing impairment, risk of falling, and safety (such as seat belt use), and conducts a gait and balance assessment via the “Get Up and Go” test (in which the patient rises from a chair, walks 10 feet, and returns to the chair).
    • Written prevention plan that identifies needed care: When all templates are completed, the system generates a screening and immunization schedule and personalized prevention plan (which includes a list of risk factors and strategies and/or treatments for addressing them) based on evidence-based clinical algorithms embedded in the software, as outlined below:
        Screenshot of the recommended tests/screening page.

        Figure 2: The software generates a personalized list of necessary screenings and other tests. Click the image to enlarge. Image courtesy of Averel Snyder. Used with permission.

      • Screening and immunization schedule: A personalized schedule lists necessary screening and immunizations for the next 5 to 10 years based on guidelines from CMS, the United States Preventive Services Task Force, and the Advisory Committee of Immunization Practices (see Figure 2). The schedule also reviews the patient’s health status and screening history and lists age-appropriate preventive services covered by Medicare, such as cancer screenings (for breast, prostate, cervical, and colon cancer), bone density testing, glucose testing, and pneumococcal and influenza vaccinations.
      • Personalized prevention plan: A personalized 8 to 10 page prevention plan provides general health advice, lists the patient’s risk factors and conditions (such as high blood pressure, metabolic syndrome, or risk of falling), and reviews treatment options and interventions to address those risks. For example, the plan might note the patient’s blood pressure, list cardiovascular complications of high blood pressure, and outline potential medical therapies and modifiable lifestyle factors. The plan also provides needed referrals for further testing and/or health education and counseling. Patients with Internet access also can access a personal portal with unlimited educational resources.
    • Proactive addressing of identified gaps: Whenever possible, the practice provides needed services (e.g., immunizations) during the visit. For services that cannot be offered right away, the practice generates the requisite referral (e.g., for a colonoscopy or mammography) and/or schedules the patient for a followup, problem-oriented examination.
    • Documentation and billing: The provider uses the software to produce a “superbill” that the practice can use to seek reimbursement of the Annual Wellness Visit and any other covered medical services provided (according to their existing process for bill submission). In addition, documentation of the visit can be exported to the practice’s electronic health record.

    Context of the Innovation

    Senior Wellness Solutions is a health information technology (HIT) company staffed by a team of multidisciplinary physicians and HIT experts. The impetus for this program came from Dr. Averel Snyder, a cardiac surgeon and certified geriatrics fitness trainer who works for the company. After reading reports that only a small percentage of Medicare beneficiaries had received the Annual Wellness Visit (due in part to its complexity and lengthy time requirements), he convened a group of physicians from multiple specialties and computer programmers to design a Web-based software program based on clinical algorithms that would allow providers (including those who are not physicians) to conduct and bill for the visit efficiently. After conducting a focus group with 30 older adults and pilot-testing the software in a physician office, the company began offering it to practices nationwide.

    Did It Work?

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    Results

    The program has improved the provision of needed preventive services and generated high levels of satisfaction among both physicians and patients. A future analysis will evaluate its impact on health outcomes.
    • Improved provision of preventive services: An evaluation of the first 130 patients found that the typical patient received 3.5 needed preventive services as a result of the visit. A subsequent evaluation of 420 patients found that, on average, each patient received 3.75 needed preventive services.
    • High physician and patient satisfaction: Both physicians and patients rate the program quite highly. Physicians often cite its benefits to quality of care and their ability to provide a timely, efficient Medicare Annual Wellness Visit. Patients also express satisfaction with quality of care, with some remarking to their doctors that this visit ranked as the best and most comprehensive visit they had ever experienced.
    • Future analysis of impact on health outcomes: A planned analysis will evaluate the program's impact on health outcomes over time, such as blood glucose, blood pressure, cholesterol, and weight.

    Evidence Rating (What is this?)

    Suggestive: The evidence consists of post-implementation data on the average number of needed preventive services provided to patients as a result of the visit, along with anecdotal reports from patients and physicians participating in the program.

    How They Did It

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    Planning and Development Process

    Primary care practices take the following steps in adopting this type of system:
    • Obtaining software: Practices interested in adopting this type of program will likely need to purchase external software to facilitate the efficient provision of Annual Wellness Visits. Practices working with Senior Wellness Solutions obtain a code to access the Web-based software, along with personalized visit scheduling cards and waiting room posters describing the visit.
    • Incorporating visits into workflow: Adopting practices need to decide how the scheduling process should work and which providers should conduct various aspects of the visit based on their existing workflows and processes.
    • Onsite live training and other support: Adopting practices will likely need real-world training and support during the implementation phase. Those working with Senior Wellness Solutions receive training during 6 to 10 initial Annual Wellness Visits over a 2-day period. During these visits, a clinical team composed of a physician and physician assistant participates in the visits and teach practice-based providers how to use the software to guide the visit. Providers also receive a written training manual and can participate in a series of training webinars and/or view a video training manual.

    Resources Used and Skills Needed

    • Staffing: In some practices, physicians and other staff can incorporate the Annual Wellness Visits into their existing schedules, while others may need to hire dedicated nonphysician clinicians to conduct them. Typically, 1 dedicated nonphysician provider can provide services to 3,000 Medicare beneficiaries.
    • Costs: Costs vary by practice and include salaries and benefits for those conducting the visits. Other costs include a laptop computer with Internet access for each provider, along with printing costs associated with the personalized prevention plans and schedules. Practices working with Senior Wellness Solutions remit a $25 per visit fee to the company, payable after Medicare reimbursement is received. Visit reimbursement typically exceeds the program's total cost to the practice.
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    Funding Sources

    Centers for Medicare and Medicaid Services; Senior Wellness Solutions
    Senior Wellness Solutions funded the development of the software. CMS reimburses practices for the Annual Wellness Visit.end fs

    Tools and Other Resources

    Guidelines for preventive care for seniors are available from the following sources:

    Adoption Considerations

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    Getting Started with This Innovation

    • Emphasize impact on quality and cost effectiveness to win support: In large physician practices and organizations, physician champions can obtain buy-in from colleagues by emphasizing the program's impact on the provision of recommended care, its positive return on investment, and its ability to help practices participate more effectively in the many accountable care organization and patient-centered medical home initiatives currently underway.
    • Ensure adequate staffing: Practices must have adequate capacity (either physicians or nonphysicians) to conduct the additional visits.
    • Develop reliable scheduling systems: Practices should consider how best to schedule all Medicare beneficiaries for Annual Wellness Visits. At a minimum, practices should likely set up systems to proactively schedule patients as they check out after an acute care visit. Practices should also consider whether to generate a list of all Medicare patients and assign a staff member to contact them to schedule a visit.

    Sustaining This Innovation

    • Continue scheduling visits each year: By definition, the Annual Wellness Visit should occur each year. Practices can ensure that it does by continuing to proactively schedule patients over time using the scheduling processes chosen by practice leaders.

    Use By Other Organizations

    The software is currently being used by 8 organizations that collectively have 14 care sites and care for approximately 10,000 Medicare patients. These organizations include five community-based primary care practices, two large independent practice associations, and a large university health system.

    More Information

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    Contact the Innovator

    Averel Snyder, MD
    Chief Medical Officer
    Senior Wellness Solutions
    5369 Brooke Farm Drive
    Atlanta, GA 30338
    (404) 210-5993
    E-mail: snyder@seniorwellness365.com

    Innovator Disclosures

    Dr. Snyder is a principal of Senior Wellness Solutions and has a financial interest in the company, which benefits financially from the adoption of this program by physician practices.

    References/Related Articles

    A video depicting the use of the software is available at http://www.youtube.com/watch?v=rVdS2-9HqJ4&hd=1.

    Department of Health and Human Services, Centers for Medicare and Medicaid Services. The Guide to Medicare Preventive Services, (4th ed). Washington, DC: Department of Health and Human Services, Centers for Medicare and Medicaid Services, 2011.

    Goetzel RZ, Staley P, Ogden L, et al. A Framework for Patient-Centered Health Risk Assessments: Providing Health Promotion and Disease Prevention Services to Medicare Beneficiaries. Washington, DC: Centers for Disease Control and Prevention. Office of the Associate Director for Policy, 2001. Available at: http://www.cdc.gov/policy/ohsc/HRA/FrameworkForHRA.pdf.

    Department of Health and Human Services, Agency for Healthcare Research and Quality. The Guide to Clinical Preventive Services 2010-2011: Recommendations of the U.S. Preventive Services Task Force. Washington, DC: Department of Health and Human Services, Agency for Healthcare Research and Quality. Available at: http://www.ahrq.gov/clinicpocketgd.pdf.

    Centers for Disease Control and Prevention, Administration on Aging, Agency for Healthcare Research and Quality, and Centers for Medicare and Medicaid Services. Enhancing Use of Clinical Preventive Services Among Older AdultsClosing the Gap, 2011. Available at: http://www.cdc.gov/features/preventiveservices
    /clinical_preventive_services_closing_the_gap_report.pdf
    .

    Footnotes

    1 Asch SM, Sloss EM, Hogan C, et al. Measuring underuse of necessary care among elderly Medicare beneficiaries using inpatient and outpatient claims. JAMA. 2000;284(18):2325-33. [PubMed]
    2 John A. Hartford Foundation. National Poll: Low Cost, Lifesaving Services Missing From Most Older Patients’ Health Care. Press Release. April 24, 2012. Available at: http://www.businesswire.com/news/home/20120423006487/en/National-Poll-Cost-Lifesaving-Services-Missing-Older.
    3 Counsell SR, Callahan CM, Butttar AB, et al. Geriatric Resources for Assessment and Care of Elders (GRACE): a new model of primary care for low-income seniors. J Am Geriatr Soc. 2006;54(7):1136-41. [PubMed]
    Comment on this Innovation

    Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

    Original publication: December 05, 2012.
    Original publication indicates the date the profile was first posted to the Innovations Exchange.

    Last updated: June 18, 2014.
    Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.