Closing the gap: improving the percentage of Annual Wellness Visits among Medicare patients
Only 1.7% of Mayo Clinic internal medicine, Rochester, Minnesota, USA, patients eligible for an AWV had one performed in the last year. Cause-and-effect analysis revealed an inadequate process for identifying AWV eligible patients, a need for a standardized processes for ordering AWVs, insufficient patient communication, and confusion about eligibility and covered services. Further analysis found provider ambivalence to the promotion of AWVs, inadequate training on how to order, perform, document and bill an AWV and nursing shortages also compounded this issue. At baseline, 10,575 Medicare patients were identified as eligible for an AWV. Using the electronic medical record (EMR), the patient population was narrowed to 3,422 who were considered most in need. Criteria to determine the population most in need were that they (1) had not been seen in internal medicine since before 2020, (2) were between 65 and 85 years old and (3) were covered by Medicare or Medicare Advantage. By using this narrowed criteria, we could first reach out to those patients most in need of healthcare in whom preventative screening was lacking. Using a Suppliers, Inputs, Process, Outputs, Customers plus Requirement—a tool used to organize the process methodology, stakeholders were identified, and information gathering included internal medicine leadership, schedulers, nursing and providers. Stakeholder feedback was organized using an Ishikawa cause-and-effect diagram (fishbone tool) to determine possible interventions. Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guidelines were used to report findings. 

We aimed to increase the percentage of AWVs among Medicare patients by 1% (approximately 34 AWVs), from 1.7% to 2.7% in 3 months. 

With eligible, high-risk patients identified, a standardized approach was created where an AWV appointment was ordered, and a message explaining the benefit of the appointment was sent by the patient portal (which is integrated with the EMR). Age, gender, primary care provider, date last seen in internal medicine, gap score (a measure of overdue health maintenance needs with a gap score greater than 1 representing a patient who had 1 or more health maintenance items due), patient portal activity and date of sent message were all documented for those contacted. During our intervention, we also discussed the importance of AWVs with nurses and providers through care team huddles, email and presentation at department meetings and encouraged them to schedule and complete AWVs for eligible patients. 

The Medicare eligible patient AWV completion preintervention and postintervention was determined and revealed a 3.8% completion postintervention . Female patients comprised 60% of the total internal medicine patient population and 74% of the AWV patient population. The mean age of patients due for an AWV was 72. Age distribution analysis revealed that patients within the 65–74 age group were more likely to have an AWV completed than those less than 65 or older than 75. The majority of patients due for an AWV had the patient portal (89%), had a gap score of less than 1 (88%) and had not been seen since April 2020. 

AWVs have the potential to improve patient–provider communication and relationships, ensure preventative health measures are up to date, and allow screening and assessment for risks and medical conditions that can improve patient outcomes. This intervention showed improved AWV rates during the 3-month study and will continue to improve AWV completion rates for Medicare patients in internal medicine in the future. Our results showed a higher AWV completion rate in women, patients between 65 and 74, those who used the patient portal, and those who had not been seen in primary care within a 3-year window. By reaching younger Medicare patients and those who had not been seen recently we were able to capture patients in greatest need whom also would still benefit from preventative screening and early intervention. This intervention could be applied to other areas of primary care and other health systems that have the ability to calculate health maintenance gaps and have an EMR with an integrated patient portal. Study limitations include that outside factors may have also led to patients completing an AWV including but not limited to Medicare enrollment information, public advertising campaigns and information from family and friends. However, the lessons learned from this quality improvement project include the importance of educating all patients and providers on the value of AWVs, the need for a systematic process for sending messages and ordering AWVs, and the need to capture the work we provide as a healthcare team. 10.1136/bmjoq-2023-002554.supp1 Supplementary data 

