The Case for Utilizing RNs in Medicare Annual Wellness Visits

Age-friendly health care and the 4Ms in RN-led annual wellness visits

BACKGROUND

Medicare annual wellness visits (AWVs) are prevention-focused healthcare visits free to Medicare recipients. These visits focus on health maintenance, health risk assessment, prevention of illness, and maintaining independence, all of which are within the scope of registered nurse (RN) practice as well as aligned with what matters, medication, mentation, and mobility - the 4Ms - of age-friendly health care. The objective of this pilot study was to evaluate the implementation of the 4Ms in the context of RN-led Medicare AWVs in a primary care practice.

METHODS

In a primary care practice with approximately 2500 patients, including approximately 571 of whom were enrolled in Medicare, RN-led Medicare AWVs were implemented, incorporating the 4Ms framework. During this time, data were collected on the effect of the AWV on access to care-conceptualized here as the number of visits available as well as the type of clinician open to staff these visits. Data collection also included patient responses to the 4Ms question "what matters most?"

RESULTS

Overall, the RN-led visits were successful and beneficial to the practice. Each RN-led visit allowed for 2 additional acute or monitoring visits per provider (nurse practitioner, MD) per day, increasing patient access to their primary care providers. Inclusion of the 4Ms questions facilitated discussion around overall mental and emotional well-being, life stressors, quality of life, and goals of care.

CONCLUSION

RN-led Medicare AWVs incorporating the 4Ms framework enhances the role of RNs in primary care by focusing on a health promotion role, utilizing RNs to their full scope of practice. RN-led AWVs increase provider availability for acute and chronic care appointments, as well as foster conversations around quality of life, as well as mental and emotional well-being.

Team-Based Approach to Successful Annual Wellness Visits

OBJECTIVE

The purpose of this study was to implement a 2-phase approach to rapidly increase the number of annual wellness visits (AWVs) and build a sustainable model at 3 study units (Mayo Clinic in Rochester, Minnesota, and clinics in 2 regions of Mayo Clinic Health System), which collectively serve approximately 80 000 patients who qualify for an AWV annually.

METHODS

In the rapid improvement phase, beginning in July 2022, goals at the facilities were reoriented to prioritize AWVs, educate staff on existing AWV resources, and create low-effort workflows so that AWVs could be incorporated into existing patient appointments. Staff at all 3 study units worked independently and iterated quickly. In the second phase, all study units collaborated to design and implement a best-practice solution while they leveraged the engagement and lessons learned from the first phase and invested in additional system elements and change management to codify long-term success.

RESULTS

The number of AWVs completed monthly increased in each study unit. In the rapid improvement phase, the number of AWVs increased but then plateaued (or decreased at some study units). In April 2023, the final scheduled outreach automation and visit tools were implemented, and the number of AWVs was sustained or increased, while outreach and scheduling times were decreased. The number of completed AWVs increased from 1148 across all study units in the first 6 months of 2022 to 14 061 during the first 6 months of 2023.

CONCLUSIONS

The lessons learned from this project can be applied to other health systems that want to provide more patients with AWVs while improving operational efficiency. The keys are to have a clear vision of a successful outcome, engage all stakeholders, and iterate quickly to find what works best for the organization.

Implementing a Fall Prevention Initiative in Nurse-Facilitated Annual Wellness Visits: A Quality Improvement Project

BACKGROUND

Falls are the leading cause of injury-related death and disability in community-dwelling older adults.

LOCAL PROBLEM

Evidence-based fall prevention activities in primary care, including nurse-facilitated wellness visits, have been limited. Barriers including patient engagement and adherence exist.

METHOD

A quality improvement project integrating components of the Centers for Disease Control and Prevention's Stopping Elder Accidents, Deaths & Injury (STEADI) was introduced by registered nurses during older adult annual wellness visits.

INTERVENTION

Nurses assessed risk and implemented patient-centered fall prevention plans including follow-up.

RESULTS

A total of 522 patients were screened, with 21% (n = 111) having increased fall risk. Of these, 78% (n = 87) engaged in home safety, gait, strength, and balance assessments and the majority (n = 83; 95%) participated in fall prevention plans of care. At 2-week follow-up, patients' self-reported adherence was 74% for gait/strength/balance and 67% for home safety.

CONCLUSION

An expanded primary care team model shows promise for promoting fall prevention behaviors.

Creating a Primary Care Track in Prelicensure Nursing Education

BACKGROUND

RNs practicing in primary care (PC) increase access to health care and contribute to better patient outcomes and cost savings, yet undergraduate nursing education traditionally focuses on disease-oriented care. This article describes a curricular track for infusing PC prelicensure programs.

METHOD

PC content is threaded across four semesters with targeted assignments and clinical experiences. Providing clinical immersion experiences with practicing RNs as preceptors in community and PC settings is a key component of this initiative.

RESULTS

Student feedback has been favorable. Students stated they gained insight to the role of RNs in PC through class assignments and clinical rotations. Graduating seniors were offered employment in PC settings where they completed their practicum clinical rotations.

CONCLUSION

The PC track contributes to building a nursing workforce to meet health care demands and promote health equity. Nurse educators interested in infusing PC content throughout the curriculum can adapt this model for all student populations. [J Nurs Educ. 2023;62(3):171-174.].

Effects of Medicare wellness visits on health promotion outcomes

BACKGROUND

The American older adult population has the highest historical prevalence of chronic disease and underuses wellness visit benefits. Little is known about how Medicare wellness visits (MWVs) affect health outcomes.

PURPOSE

The aim of this retrospective case-control study was to examine how MWVs affect health outcomes by measuring two kinds of data for case and control groups at baseline versus 15 months: (1) the differences in blood pressure, fasting lipids, and glucose levels and (2) the completion frequencies for seven screenings and vaccinations.

METHODOLOGY

Informed by Pender's Health Promotion Model, this design used purposively matched samples from a large American Midwestern Medicare population active between January 2013 and January 2016, with a total sample size of 252, consisting of the case group ( N = 120) and control group ( N = 132). The case and control group samples were matched according to gender, age, marital status, Charlson index scores, smoking status, and pharmaceutical classes. The two groups, case (MWV recipients) and matched control (MWV nonrecipients), were compared at different time points using a doubly multivariate repeated-measures analysis procedure. Descriptive statistics were computed to compare completion frequencies between groups.

RESULTS

A doubly repeated multivariate analysis of variance (MANOVA) and descriptive statistics revealed significant differences between the case and control group for three of the four health outcomes. The case group had increased completion frequencies in pneumococcal vaccination.

CONCLUSIONS

Additional research controlling for more variables is warranted to better understand MWV efficacy on health outcomes.

IMPLICATIONS

Primary care providers need to study how MWVs affect longitudinal health outcomes.

Implementing Enhanced Primary Care Registered Nurse Reimbursement in Rural Health Clinics: A Policy Analysis

Rural Health Clinics (RHCs) were created in 1977 to address the high health care needs, limited provider access, and poor health outcomes of rural Americans. Although innovative at their inception, the provider-centric model of RHC cost-based reimbursement structures has not evolved, leaving limited opportunities for change; many have failed. Comprehensive, proactive change is needed. Registered nurses (RNs) working at the top of their practice scope are a neglected clinical resource that can improve access, quality, value, and satisfaction for rural patient communities. RHC reimbursement policy must evolve to sustain and support this significant RN role. RNs have demonstrated value in care continuity and disease management, but there is little research on the utilization of RNs using their enhanced skill set in RHCs. Using the Bardach and Patashnik's eight steps of policy analysis, the authors will describe the background and regulations of RHCs, identify current barriers to improving the health of America's rural residents, and then provide evidence to support a new policy option according to the Quadruple Aim framework. The result is a sustainable policy recommendation designed to best serve rural communities.

Are Medicare wellness visits improving outcomes?

BACKGROUND

As the largest and unhealthiest population in American history enrolls as Medicare beneficiaries, it is vital for primary care providers to understand how to maximize Medicare wellness provisions. The Baby Boomer population has been documented to have the highest chronic disease prevalence related to preventable lifestyle behaviors. Perpetual unhealthy lifestyle behaviors associated with chronic disease prevalence are detrimental to life quality and the American Medicare resource structure. Since 2011, the Affordable Care Act provisions have included free wellness visits designed to prevent disease for Medicare beneficiaries, who continue to grossly underuse these services.

OBJECTIVES

This systematic review was conducted to evaluate the quality, level, and strength of evidence regarding Medicare wellness service efficacy on related health outcomes.

DATA SOURCES

The methodology adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for selection of 21 research-based articles included in the analysis. Results from the 21 eligible studies revealed low research quality and vigor; therefore, lacking causality and generalizability of medicare wellness visit (MWV) efficacy on health promotion outcomes.

CONCLUSIONS

The evidence is focused on how MWVs are affecting preventive care utilization instead of patient health outcomes. In the interest of reducing chronic disease prevalence and the economic burden on our health care system, it is important to understand how these services affect health promotion outcomes.

IMPLICATIONS FOR PRACTICE

The results of this systematic literature review substantiate the need for primary care providers to study MWV efficacy on health promotion outcomes for the Medicare population.