Abstract
Background: The Medicare Annual Wellness Visit (AWV) has high potential value depending on its implementation and clinical setting. We studied the perceived value of the AWV in a residency clinic providing care for underserved patients.
Methods: Qualitative interviews with both physicians and patients with deidentified transcription and immersion-crystallization analysis.
Results: Physicians and patients identified the following learning points: 1) preparing patients for the AWV; 2) aligning expectations and agenda; and 3) optimizing the value of the AWV given patients’ competing demands.
Discussion: The Medicare AWV is a promising tool but needs thoughtful implementation to make it valuable in underserved trainee settings.
- Access to Care
- Annual Wellness Visit
- Geriatrics
- Medicare
- Qualitative Research
- Resident Run Clinic
- Vulnerable Populations
Introduction
The Medicare Annual Wellness Visit (AWV) is a health maintenance visit for US Medicare recipients that focuses on topics relevant to older adults.1,2 It has 4 main areas:3 1) reviewing the health history (documenting and facilitating communication with other physicians seeing the patient), 2) assessment of functional and cognitive status, using office-based screening tests, 3) patient-centered discussion of age-specific screening recommendations, and 4) discussion of advance care planning. Primary care practices have used care teams variably implementing the AWV;4⇓⇓⇓–8 large database analyses show benefits when implemented,9,10 though not always cost savings.11 AWV uptake has been less among patients reporting lower income, and Black, and Latinx patients.12⇓–14 Even when implemented, it is unclear whether the visit is universally experienced as helpful.
In 2020, we began implementing AWVs in a busy academic family medicine clinic in the northeastern US with 2 objectives: to use the AWV to teach geriatric visits,15 and to explore its implementation with patients and residents. The clinic’s population is medically underserved16 due to low income, limited English proficiency, limited transportation/access to health care, and low health literacy. Our research question was: What is the current patient and resident experience of the AWV and how can it be more effective?
Methods
Setting
The clinic physicians (10 faculty and 36 family medicine residents) serve 12,000 active patients, with 600+ visits per week, over 30,000 visits annually. Approximately 25% of the patients are Medicare recipients and eligible for an AWV; approximately a third have limited English proficiency, and about half report income at/below the federal poverty level. Patients have high rates of unstable housing and unmet behavioral health needs. Before the AWV, a medical assistant administers a questionnaire for health history/functional status screening; the physician uses the 30-minute AWV to review responses, discussing preventive screening, functional status, mental health, and advance care planning with the patient.
Sample and Recruitment
The study was approved by the Kent Hospital Institutional Review Board. Residents were emailed if they had conducted one or more AWVs. For patients, a question was added to the end of the AWV questionnaire asking if they would agree to be contacted by a researcher for an interview.
Data Collection
This was a qualitative study; family medicine resident physicians and clinic patients engaged in an individual, semistructured recorded interview with a coauthor (REG) by phone or Zoom. All interviews were professionally transcribed; for patient interviews, notes were also taken on content. Interview guides with predominantly open-ended questions were created based on the literature about AWV components and processes, and our multidisciplinary team’s experience in teaching and conducting AWVs (Figure 1).
Data Analysis
We used the immersion/crystallization method of qualitative data analysis.17 Transcripts, notes, and recordings were systematically reviewed for content and themes, documenting commonalities and differences among and between residents and patients. Emerging findings were discussed by members of the faculty study team until final interpretation was achieved.
Results
Participants
Thirteen family medicine residents and twelve patients were interviewed (see Table 1), at which point our preliminary analyses indicated that both code and meaning saturation18 had been reached.
Participant Characteristics
Topical Categories
Three elements emerged from data analyses regarding uptake and understanding of the AWV: 1) lack of patient preparation for the AWV, 2) agenda-setting and misalignment of expectations, and 3) appreciation of the meaning and value of the AWV to patients in light of potential competing demands.
Lack of Patient Preparation for the AWV
There were few patient-generated requests for the AWV in the practice before their initiation. The majority of patients were called on the telephone and told they would be scheduled for an AWV as their next visit and that it would be ‘like a physical.’ In some cases, they were scheduled with a physician who was not their PCP. Patients had little understanding of the visit’s purpose and most were unable to describe in interviews how it was different from their usual appointments. Patients demonstrated this lack of understanding by wanting to address acute issues during the visit; residents expressed frustration about keeping the patient focused on the requisite elements of the AWV.
I noticed it was a bit different, but not that different. (patient)
The patient was not really clear why she was here. (resident)
Agenda-Setting
Residents expressed chagrin when patients tried to bring up new problems or questions they wanted addressed, while trying to get through the specific agenda of the AWV. Patients were unprepared for some of the discussions, especially around goals of care or advanced care planning (ACP), and could not or would not participate fully.
I did not give him no answers on that [ACP] because I did not have any answers. I told him I’d be thinking about all that. Because that needs to be addressed, but we did not come to a conclusion while I was there. (patient)
I did not quite understand it so I did not know what to say. I did not know how to respond so I just did not do anything. (patient)
Residents also reflected on the ACP discussion, sometimes characterizing the patients as not caring about the topic, but often acknowledging that the patient cared but was unprepared to engage in that discussion.
One thing I noticed with a lot of… patients in the community that we serve - that they do not have a health care proxy. They do not have a power of attorney or a living will. Their response is like, “Well, I am fine. I do not need all that.” Like, “I do not need to think about what would happen if I got really sick 'cause I am feeling great.” That is a part of the medical wellness visit that I think patients are not adequately—they are not necessarily prepared that they are going to have to be thinking about those questions. (resident)
Appreciation of the AWV in Light of Competing Demands
Several patients perceived the AWV as a valuable addition to their health care. However, many were not able to understand the value of the visit, possibly due to competing priorities in their lives.
Oh, I do not know [what we discussed], I was numb because I just lost [my] husband. (patient)
I could read the article [explaining the visit]… and my brain…[to] absorb it and understand it… So [I] need time. (patient)
Discussion
The Medicare AWV has had modest uptake in primary care19; its overall benefit11 is still unclear. Previous studies advocated increasing the uptake of AWVs in underserved populations – with the implicit assumption that performing the AWV alone would be of benefit.20
However, the expressed views of patients and trainees about its meaning and utility did not support this idea in the present study. Participants reflected that the AWV was a visit that the patient had not asked for, did not really understand, and was unable to fully participate in, which diminished its effectiveness and relevance. This finding resonates with other studies suggesting that, as a ‘one size fits all’ approach. the AWV may not effectively address disparities.21
While the implementation experience can be variable, we were struck by the potential for competing priorities among patients experiencing life stressors other than those addressed in the AWV. This finding suggests that the elements of the AWV are sensitive to social determinants of health (SDOH), a concept that has been discussed relative to value-based care generally, but not with regard to the AWV.22
It is likely that the benefit of the AWV depends on patients’ preparation and activation23⇓⇓–26 in anticipation of the visit. While some older adults are proactive about aging, health care, and planning for medical uncertainty, others may have competing life stressors (including SDOH) such that they cannot engage in this kind of planning without significant coaching/support from the physician. Our findings also suggest that patients less ready for the visit tended to characterize it as less valuable or helpful.
Like all health care innovations, the AWV will be revised and updated in response to feedback from patients and physician. We suggest further study regarding optimal patient involvement in the AWV, and in the meantime offer these learning points.
– Better previsit education of target population (not relying on written materials in English, and considering modalities broadly including videos, radio and television ads, or other forms of communication). Similar educational modalities have been used in other settings, notably to improve27 chronic disease outcomes.
– Clearly communicate the purpose of visit (during and after the experience) in a patient-centered way. In addition consider handing out postvisit education materials or following up to emphasize important points about what was addressed.28
– Adopt a stages-of-change model for talking about advanced care planning, changing the goal that it could be fully addressed and acted on in a single prevention-focused visit.29 This adaptation would increase the chance of a meaningful outcome.
Future study of the AWV should focus not only on improving its uptake in varied patient populations, but also on changing aspects of the way it is performed to make it a more meaningful activity, and 1 that is more responsive to social determinants of health.
Interview guide.
Notes
This article was externally peer reviewed.
Funding: This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $750,000 with 0% financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.
Conflict of interest: None.
To see this article online, please go to: http://jabfm.org/content/38/2/360.full.
- Received for publication June 2, 2024.
- Revision received June 16, 2024.
- Revision received August 25, 2024.
- Revision received September 5, 2024.
- Revision received October 9, 2024.
- Accepted for publication October 14, 2024.
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