Moving Upstream Using the Annual Wellness Visit
As we move from a volume-based system of care to a value-based system of care, we need to make a fundamental shift in how we care for patients. That means, instead of just treating the sick, we need to get better at preventing sickness from happening in the first place. This will involve elements of practice redesign and learning to use novel approaches in how we care for patients.
The Annual Wellness Visit (AWV) is an excellent example of a novel approach by taking a comprehensive look at all your patients’ needs for the upcoming year. The visit can build trust between the patient and the care team, identify risks that contribute to deteriorating health, and guide future interventions and efforts. Physicians can perform these, but they can also lean on their teams for help. Working together upstream, teams will quickly realize the benefits to both patients and their care teams as patients live longer and healthier lives.
We have developed a playbook for AWVs that offers ideas and workflows for how to make these visits work for your practice. Feel free to reach out to the care management team for more ideas about which workflows are best for your team.
C3 has a centralized team of nurse care managers to provide support to our practices. Recently, Champions Family Medical practice manager Rich Lane let us know how helpful one of our care managers had been with one of their more complicated patients. The team had reached out to this patient and enrolled them in our longitudinal care management program. The patient had a complex medical history, with multiple hospitalizations and ED visits in the previous 6 months. The care manager discovered that the patient’s family felt overwhelmed by the care required, and they were often unable to provide transportation to all the follow-up medical appointments. As a result, the patient was ending up back in the ER or hospital. The care manager worked with the home health care RN to apply for a Medicaid waiver, which would allow them to pay for additional assistance with everyday care needs. She was also able to communicate with the home health team so they could reinforce the importance of follow-up visits with the patient’s PCP. The care manager communicated with all members of the care team, including the PCP, and created a seamless experience and the best possible outcome for the patient and family.
Family Clinic of Fort Collins joined the ACO in late 2021 as an Epic Community Connect practice. As a network practice, they have access to a dashboard tool that helps them keep track of their performance in the value-based care quality measures. The office manager reached out to the C3 network engagement team to better understand the dashboard. She wanted to know how they could use it to improve the care they were providing to their patients. The practice transformation coordinators were able to help her use the dashboard tool to identify patients who were due for preventative screenings or follow-up visits for chronic issues. The clinic used these lists as part of an outreach process so that these patients could be scheduled with their PCPs. The network engagement team was excited to be able to help the practice better utilize the tools at their disposal.