Annual Wellness Visits and Community Health’s Focus on Prevention

Carl Beckler, MD recently saw a returning patient, a former smoker, for an annual wellness visit (AWV) and recommended again that the patient have a one-time abdominal ultrasound to rule out an abdominal aortic aneurysm, a dangerous condition that occurs with smokers. “I had asked the patient during the previous AWVs for two or three years running, but the patient declined the test,” said the Community Health primary care provider. This time he again encouraged the patient to reconsider, and this time the patient agreed.

“The test revealed a six-centimeter abdominal aortic aneurysm which was then repaired with an endovascular graft,” Dr. Beckler said. “I would not have been able to pick this up on a physical exam, so this was instrumental in the health of this patient.” The patient has recovered and is doing well.

Many people have never heard of the “Medicare annual wellness visit” or AWV. It’s not your yearly physical, but the once-a-year checkup for Medicare patients where medical history, blood pressure, medications, immunizations and testing schedules are reviewed. The purpose of the annual wellness visit is to audit an individual’s wellness and develop a personalized prevention plan. It’s free for Medicare patients who have had supplemental coverage for the past year.

Annual wellness visits are among the several wellness initiatives that Community Health is spotlighting as part of the care management and value-based care initiatives that emphasize outcomes and prevention as the keys to healthy living.

“I have been doing AWVs on a regular basis for several years,” Dr. Becker said. “It is helpful, in that all aspects of health care management are addressed in a comprehensive and consistent manner to prevent missing treatable health problems.”

Dr. Beckler has been seeing patients at Community Health’s Mettowee practice since the facility opened a few decades ago. “I’ve got people I’ve taken care of for over 30 years,” Dr. Beckler said. “That’s pretty special.” He’s seen firsthand the benefits of preventive practices like the annual wellness visit.

Most people are so used to making appointments to see a primary care provider only when they are sick, or something feels wrong.

“Education, communication and prevention have become top priorities,” said Andrea Wicher, MSW, Community Health Director of Population Health and Quality. “Care management is a service that can address the need for increasing the focus on prevention by providing patient education, recognizing  social determinants of health and addressing complex care needs with preventive programs that can potentially head off health issues in the future,” she said.

Community Health providers have identified priority prevention programs as the basis for clinical responses to prevailing issues in the region that were highlighted in the most recent Community Health Needs Assessment. The three programs Community Health has focused on are:

• Medicare annual wellness visits
• Sepsis/UTI awareness
• Prediabetes/diabetes education

AWV is a free service offered through Medicare that focuses on prevention and is designed to keep people healthy, lower their risk of illness and injury and provide the support needed for a healthy quality of life. Medicare covers one free annual wellness visit each year for those enrolled in Medicare Part B for at least 12 months. There’s no co-payment or deductible for the visit.

Sepsis, the third leading cause of death in the US, is a life-threatening condition caused by the body’s response to an infection. Urinary tract infections, or UTIs, are common infections that are mostly preventable. If ignored or untreated, a UTI can lead to sepsis. UTI is one of the most common emergency department illnesses presented in Rutland County.

Diabetes, a condition that occurs when blood sugar or blood glucose is too high, was identified in the Community Health Assessment as affecting 13% of the population in Rutland County. Community Health supports an ongoing certified diabetes education program for those diagnosed with diabetes and by identifying those at risk for diabetes and educating about the signs of prediabetes.

Education, training and using technology are ways that Community Health is improving the delivery of preventive care services. Sharing data and a preventive care mindset with health care providers has elevated the impact of preventive care services, helped to identify gaps in care and supports value-based care with its focus on improving health care quality and outcomes.

Value-based care encourages and rewards the delivery of quality care in the form of treatments, early intervention and prevention while reducing the cost of health care. The Community Health Assessment identifies social determinants like access to food, housing and transportation as having a significant effect on health issues now and in the future. The report also zeroed in on conditions like diabetes and populations such as those over the age of 65 as being at risk.

Annual wellness visits are the perfect starting place to begin moving in the direction of transitioning from a fee-for-service culture to a value-based-care world.

Follow this series over the next three months, every Friday, as we discuss primary care, value-based care and Community Health’s role in providing high quality health care services that include support groups and educational programs. Find out more about Community Health’s preventive programs and watch for our follow up stories about diabetes education, Alzheimer’s support and behavioral health programs exclusive to Community Health.

Follow this series over the next three months, every Friday, as we discuss primary care, value-based care and Community Health’s role in providing high quality health care services that include support groups and educational programs. Find out more about Community Health’s preventive programs and watch for our follow up stories about diabetes education, Alzheimer’s support and behavioral health programs exclusive to Community Health.

Carl Beckler, MD was one of the original primary care providers when Community Health Mettowee was established as part of the Community Health federally qualified health center (FQHC) in 2004. 

Andrea Wicher, MSW, is Community Health’s Director of Population Health and Quality.

Community Health is Vermont’s largest Federally Qualified Health Center (FQHC), a network of primary care, pediatric, behavioral health, dental and pharmacy services with offices in Rutland, Brandon, Castleton, West Pawlet and Shoreham. Community Dental offices are located in Rutland and Shoreham; Community Kids Dental is in Rutland; Community Health Pediatrics is in Rutland and Behavioral Health services are available at all locations. Community Health Express Care Centers, open 7 days a week, are located at the Rutland and Castleton Community Health Centers. For more information about Community Health, check our website https://www.chcrr.org/.