What components should be included in an Annual Wellness Visit (AWV) plan?

Medicare Annual Wellness Visit (AWV) Plan Components

The AWV plan must include a comprehensive health risk assessment, cognitive and depression screening, functional assessment, preventive service planning, and personalized prevention strategies based on identified risk factors. 1

Required Core Medical Assessment Components

Physical Measurements and Vital Signs

• Height, weight, BMI calculation, and blood pressure determination are mandatory components 1
• These measurements establish baseline data for ongoing health monitoring and risk stratification 1

Comprehensive Medical and Medication History

• Review family history of autoimmune disorders, complications, and common comorbidities including obesity, obstructive sleep apnea, and non-alcoholic fatty liver disease 1
• Assess medication-taking behavior, potential medication rationing, intolerance, and side effects 1
• This medication review is critical as polypharmacy is common in Medicare beneficiaries and directly impacts morbidity 1

Mandatory Cognitive and Mental Health Screening

Cognitive Assessment

• Detection of existing cognitive impairment using validated screening tools is federally mandated since 2011 2
• The Mini-Cog test (sensitivity 76%, specificity 89%) is recommended for identifying possible dementia 1
• The Alzheimer's Association algorithm includes review of Health Risk Assessment information, patient observation, unstructured queries, and structured cognitive assessment tools for both patients and informants 3
• Common pitfall: Despite the mandate, fewer than one-third of eligible patients receive structured cognitive assessment 2, and only 31% undergo formal cognitive testing even when AWV is completed 4

Depression Screening

• Use validated tools such as Patient Health Questionnaire-2 (PHQ-2) or Patient Health Questionnaire-9 (PHQ-9) 1
• Mental health screening is a critical component that should not be neglected 1

Functional Assessment

• Evaluate activities of daily living and mobility, particularly important for patients 65 years and older 1
• This assessment identifies patients requiring additional support services and impacts quality of life outcomes 1

Required Preventive Health Screenings

The AWV must address age-appropriate and sex-specific preventive services:

Cancer Screening

• Cervical cancer screening with Pap smear every 3 years, or cytology plus HPV testing every 5 years for women aged 30-65 1
• Clinical breast examination annually for women aged >19 years 1
• Mammography biennially for women aged 50-74 years 1
• BRCA risk assessment through family history evaluation with referral for genetic counseling if indicated 1

Metabolic and Cardiovascular Screening

• Lipid profile (total, LDL, HDL cholesterol and triglycerides) if not done within the past year 1
• Diabetes screening with A1C testing if not available within the past 3 months 1
• Bone health assessment including calcium, vitamin D, and phosphorous levels when appropriate 1

Social Determinants of Health and Behavioral Assessment

Social Risk Factors

• Assess food security, housing stability, transportation access, financial security, and community safety 1
• These social determinants directly impact health outcomes and must be documented to guide intervention planning 1

Substance Use and Lifestyle Behaviors

• Tobacco, alcohol, and substance use screening with appropriate counseling 1
• Physical activity and sleep behaviors assessment, including screening for obstructive sleep apnea 1
• Eating patterns and weight history review 1

Personalized Prevention Plan Development

The plan must be individualized based on screening results and include:

• Specific intervention strategies prioritized by risk level 1
• Referrals to health education and prevention counseling services as needed 1
• Advance care planning discussions including identification of surrogate decision makers 1
• For women at increased breast cancer risk, counseling about risk-reducing medications 1

Treatment Plan Communication

• Communicate treatment and follow-up plans interactively with patients and appropriate family members in collaboration with the primary healthcare provider 5
• Document measurable clinical findings and create a treatment plan that prioritizes goals and outlines intervention strategies for risk reduction 5

Critical Implementation Considerations

Documentation Requirements

• The plan should be created and shared with the beneficiary 2
• Document patient assessment information that reflects current status and guides development of prioritized goals with intervention strategies 5
• Avoid excessive copy-forward of prior notes without editing, as this propagates errors and reduces clinical utility 5

Common Pitfalls to Avoid

• Do not substitute brief physical examinations for the comprehensive preventive services required by Medicare 1
• Do not focus solely on physical health while neglecting behavioral and social aspects 1
• Recognize that cognitive screening remains underutilized despite the mandate, with significant disparities affecting Black and Hispanic populations who are less likely to receive AWV services 2
• PCPs report lacking time, education, and wrap-around support to properly conduct cognitive assessments 2

Practice Redesign Solutions

• Training other staff members to perform evaluations can reduce physician burden 2
• EHR-based tools combined with practice redesign approaches significantly increase AWV utilization (from 7% to 54% in one intervention study) and preventive services completion 6
• Virtual implementation of AWV interventions has proven successful even during high-demand periods 6