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.

Demographics and replantation

We reviewed demographic data on 761 patients who had one or more amputated parts replanted at Duke University Medical Center between 1972 and 1984 to learn more about the population that sustained amputation and replantation. Ninety-four percent were from North Carolina and its border states. Persons between ages 21 and 30 years were the most frequently injured. Eighty-five percent of patients were men. Seventy-eight percent of amputations occurred between 6:00 AM and 6:00 PM. No significant difference in the number of replantations was noted at various months of the year. Fifty-eight percent of amputations were job related, and laceration was the most frequent type of amputation. Time between injury and operation averaged 5 hours 50 minutes. Average operating time was 6 1/2 hours. Thumbs were replanted most frequently, the index and small finger least frequently. Length of hospital stay averaged 9 days. Time out of work averaged 3 months. This data suggest that efforts directed toward employee education, safety, and prevention of injury on the job have the potential of decreasing the largest single cause of amputations in the upper extremities of patients in our area of the United States.

Correction of post-traumatic flexion contracture of the elbow by anterior capsulotomy

Despite prolonged conservative therapy, including splinting, bracing, and supervised exercise programs, significant flexion contracture of the elbow after local trauma may remain both a functional and a cosmetic impairment. We studied the cases of fifteen patients who underwent a relatively limited surgical procedure consisting of anterior capsulotomy of the elbow without tenotomy of the biceps tendon or myotomy of the brachialis muscle. The mean preoperative flexion deformity of 48 degrees was reduced to a mean postoperative deformity of 19 degrees (a 61 per cent improvement). Two groups of patients were identified. Eleven patients who did not have significant preoperative evidence of intra-articular degenerative (post-traumatic) changes in the joint achieved a 65 per cent improvement in extension, with one patient having continued pain with vigorous activity. Four patients who had significant preoperative post-traumatic arthrosis achieved a 50 per cent improvement in extension; however, three of these four patients continued to have significant pain. Limited anterior capsulotomy is a safe and effective means of decreasing post-traumatic flexion contracture of the elbow in properly selected patients. Better overall results are obtained in elbows without significant post-traumatic arthrosis.