Incorporation of Medicare Annual Wellness Visits into the Routine Clinical Care of Nursing Home Residents

Abstract

The Medicare Annual Wellness Visit (AWV) was developed to improve preventative care for adults aged 65 and older. Although the AWV was originally designed for office-based healthcare settings, Geriatric Medicine healthcare professionals have adapted the AWV to be used as part of routine clinical practice in caring for older adults residing in the nursing home (NH).1 Previously, NH residence was a perceived barrier for utilization of the AWV, but, incorporation of the AWV for Medicare beneficiaries in this care setting can help providers improve care delivery and healthcare outcomes. An AWV for NH residents was developed at Saint Louis University (SLU) as part of the Geriatrics Workforce Enhancement Program (GWEP). With the assistance of facility staff to identify eligible patients, we have incorporated these annual visits into routine NH clinical practice in addition to the typical regulatory visits. The purpose of this article is to report the results of the AWV delivered to NH residents by members of the SLU interprofessional healthcare team. The study included eligible NH residents enrolled in Medicare under the care of the SLU Geriatric practice group from 2016 to 2017. Data were collected for the AWV included: age, gender, number of comorbidities, number of prescription medications, hospitalizations in past 12 months, hearing impairment, vision impairment, falls in past year, smoker, advance directive, pain self-rating score, Patient Health Questionnaire-9 (PHQ-9) score, Rapid Geriatric Assessment (RGA, which includes FRAIL scale, SARC-F scale, Simplified Nutritional Assessment Questionnaire [SNAQ], and Rapid Cognitive Screen [RCS]), and FRAIL-NH.2-10 A standardized data collection form was created to assist with the collection and documentation of AWV data in NH residents and is included as a Supplementary Figure S1. Two suburban academic for-profit NHs were included in the study. NH residents (N = 247) completed a baseline AWV (n = 197 in year 1 and n = 50 in year 2). A majority were female (n = 177, 71.7%) and aged 74 and older (n = 172, 69.7%). Residents had 7.78 ± 2 comorbid conditions and used 9.55 ± 3.9 medications at baseline. PHQ-9 identified mild depression among 27% (n = 62) and moderate or moderately severe depression among 11% (n = 25) persons at baseline. Frailty (76% FRAIL; 47% FRAIL-NH), sarcopenia (SARC-F 84%), risk of weight loss (SNAQ 46%), and cognitive dysfunction (RCS, MCI 12% and dementia 76%) were prevalent among residents (N = 247) at baseline. Hospitalization data were available for 19% of the baseline cohort, of which nearly half (48%) had at least one hospitalization in the last year. Baseline and 1-year follow-up AWVs were completed by 91 of 247 residents (37%) (Table 1). Residents' (N = 91) comorbid conditions increased from 7.8 ± 1 at baseline to 10.3 ± 3 at follow-up (P < .001), and medication use from 9.6 ± 4 at baseline to 10.9 ± 5 at follow-up (P < .001). PHQ-9 (4.2 ± 4, 4.0 ± 5) and pain (1.1 ± 2, 1.0 ± 3) scores were equivalent at baseline and follow-up, respectively (P > .50). RGA scores were changed (worse) at follow-up for frailty (FRAIL), sarcopenia (SARC-F), and cognition (RCS) (P < .001) and unchanged for nutrition (SNAQ) (P = .946). FRAIL-NH scores were increased at follow-up as well (P < .001). Hospitalization rates from the year between AWV were recorded on 89 residents (98%) on follow-up and 36 residents (40%) had at least one hospitalization in the past year. The purpose of this study is to contribute to the current body of literature that describes the screening tools, implementation and results of the Medicare AWV. To the best of our knowledge, no one has specifically analyzed the delivery of Medicare AWV in NH. This descriptive/observational study shows that it is feasible to incorporate the AWV into the NH via the interprofessional healthcare team through using established MDS data and brief, validated questionnaires. This study demonstrated areas of concern and unmet patient needs in the NH population highlighted by the AWV. Unsurprisingly, this specific cohort of Medicare patients had multiple chronic medical problems, polypharmacy, and sensory deficits (vision and hearing impairment). Personalized prevention plans created from the results of AWV in our NH led to full medication reviews, enhanced end of life discussions, physical and occupational therapy consultations, acquisition of appropriate durable medical equipment, and recommendations to obtain hearing or visual aids. Creation of these personalized prevention plans also led to additional opportunities for NH interprofessional team engagement around important health prevention topics, such as immunization administration, falls prevention, and advanced care planning. Future studies should aim to enroll greater numbers of participants over longer observational periods and should look at the impact of the implementation of personalized prevention plans created from AWV on patient- and facility-level outcomes, as well as cost and treatment burden. We acknowledge Kathleen Leonard for her administrative support throughout the project. The authors of this submission have no conflicts of interest to disclose. All authors meet criteria for authorship as stated in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals. Study concept and design: John Morley. Acquisition of data: Christina Traber. Analysis and interpretation of data: Theodore Malmstrom, Milta Little. Drafting of manuscript: Milta Little. Critical revision of the manuscript for important intellectual content: Angela. Sanford, John Morley, Theodore Malmstrom. This work is supported by a Health Resources and Services Administration (HRSA) Geriatrics Workforce Enhancement Program (GWEP) grant (U1QHP28716). The funding source had no role in the design of this study and did not have any role during its execution, analyses, interpretation of the data, or decision to submit results. Supplementary Figure S1: Nursing home Annual Wellness Visit standardized data collection form. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Topics & Concepts