What information should be provided to patients during a Medicare annual wellness visit?

Medicare Annual Wellness Visit: Patient Information Summary

Patients should receive a comprehensive assessment covering medical history, preventive screenings, functional and cognitive evaluation, mental health screening, social determinants of health, and a personalized prevention plan with specific follow-up recommendations. 1, 2

Core Medical Assessment

Medical and Medication History Review

• Update complete medical history including family history of diabetes, autoimmune disorders, cardiovascular disease, and cancer 3, 1
• Review all current medications, assess medication-taking behavior, identify potential medication rationing due to cost, and evaluate for side effects or intolerances 1, 2
• Document use of complementary and alternative medicines 3
• Review vaccination history and administer age-appropriate immunizations including annual influenza vaccine and pneumococcal vaccination (PPSV23) 3, 2

Physical Measurements and Vital Signs

• Measure height, weight, and calculate BMI 3, 1, 2
• Obtain blood pressure measurement at every visit 3, 1, 4
• Perform orthostatic blood pressure measurements when indicated 3

Cognitive and Mental Health Screening

Cognitive Assessment

• Screen for cognitive impairment using validated tools such as the Mini-Cog test (sensitivity 76%, specificity 89% for dementia detection) 1, 2
• This screening is Medicare-required even if the patient appears cognitively intact, as early detection facilitates care planning 2

Mental Health Evaluation

• Screen for depression using Patient Health Questionnaire-2 (PHQ-2) or Patient Health Questionnaire-9 (PHQ-9) 1, 4
• Screen for anxiety and disordered eating patterns when appropriate 1, 2, 4

Functional Assessment

Activities of Daily Living

• Evaluate functional performance and ability to perform daily tasks, household chores, and work responsibilities 1, 2, 4
• Assess mobility, balance, and history of falls 3
• Screen for difficulties standing from a chair or completing routine activities 3
• This assessment is particularly critical for patients ≥65 years to identify geriatric syndromes 2, 5

Preventive Health Screenings

Cancer Screening

• Cervical cancer: Pap smear every 3 years, or cytology plus HPV testing every 5 years for women aged 30-65 1
• Breast cancer: Annual clinical breast examination and biennial mammography for women aged 50-74 1
• Colorectal cancer: Initiate or update screening beginning at age 45 2
• Prostate cancer: Discuss screening for men using shared decision-making 2

Cardiovascular and Metabolic Screening

• Complete blood count (CBC) with differential 2, 4
• Comprehensive metabolic panel (CMP) to assess kidney and liver function 2, 4
• Lipid profile (total cholesterol, LDL, HDL, triglycerides) if not done within the past year 1, 4
• Hemoglobin A1C for diabetes screening if not available within past 3 months 1, 4
• Urinalysis with albumin-to-creatinine ratio 4

Additional Age-Appropriate Screening

• Thyroid-stimulating hormone (TSH) testing, particularly for women and older adults 4
• Bone densitometry for postmenopausal women and men ≥50 years 4
• Calcium, vitamin D, and phosphorous levels when appropriate 1
• Abdominal ultrasonography once for men aged 65-75 who have ever smoked 4

Social Determinants of Health Assessment

Environmental and Social Factors

• Screen for food security and access to healthy foods 3, 1
• Assess housing stability and homelessness risk 3, 1
• Evaluate transportation access to medical appointments 3, 1
• Identify financial security concerns including ability to afford medications and copays 3, 1
• Assess community safety 3, 1
• Evaluate support from family members and social network 3

Lifestyle and Behavioral Assessment

• Screen tobacco, alcohol, and substance use with appropriate counseling 3, 1, 4
• Assess physical activity levels and barriers to exercise, including access to safe exercise facilities 3, 1, 4, 6
• Review eating patterns, weight history, and dietary habits 3, 1, 4
• Evaluate sleep behaviors and screen for obstructive sleep apnea 3, 1, 4

Personalized Prevention Plan Development

Individualized Health Planning

• Develop a personalized prevention plan based on identified risk factors, screening results, and patient goals 1, 4
• Provide health education and counseling on diet, physical activity, tobacco cessation, and alcohol use 2, 4
• Make referrals to specialists, registered dietitians, certified diabetes educators, or other health professionals as needed 3, 1
• Address patient-centered outcomes including improvement in physical activity, adoption of healthy balanced diet, and weight loss 6

Advance Care Planning

• Identify surrogate decision maker and discuss advance care planning 3, 1, 2
• Document healthcare proxy, living will, and end-of-life preferences 2

Patient-Centered Communication

Goal Setting and Shared Decision-Making

• Discuss what matters most to the patient regarding health goals and treatment preferences 3
• Address patient concerns that may affect ability to follow treatment plans, including work demands, family responsibilities, and emotional stressors 3
• Identify barriers to care such as difficulty understanding medical information, challenges keeping appointments, or inability to afford medications 3, 6
• Encourage patients to share information about topics that might not typically come up during visits but affect health outcomes 3

Common Pitfalls to Avoid

• Do not skip cognitive screening even if the patient appears cognitally intact, as Medicare specifically requires this assessment 2
• Do not overlook functional assessment in patients ≥65 years, as this identifies critical geriatric syndromes 2
• Do not substitute brief physical examinations for the comprehensive preventive services required by Medicare 1
• Do not neglect mental health screening, which is a critical component often missed 1
• Do not focus solely on physical health while neglecting behavioral and social determinants that influence adherence and outcomes 1, 6