Annual Wellness Visits January 25, 2011

Guidelines Review medical/family history List current providers and suppliers Measure ht, wt, BMI, BP ,etc Detect cognitive impairment Review risk factors for depression Review functional ability and safety (based on obs or questionnaire) Establish written screening schedule for next 5-10 yrs Furnish personalized health advice to individual with appropriate referrals to health education, etc

Patient Completes Self-Assessment Interim Approach Patient Completes Self-Assessment PHQ-2 Fall Risk Assessment IADLs Hearing/Vision/Incontinence List of all health care and equipment providers Tablet or Written ROS MA Usual check list Vital signs including height and weight

Doctor WorkFlow Review any presenting complaints or changes. Review active problems Brief review of PMH, PSH, FH, SH correct and respond if needed. Medication reconciliation (of course!) Review answers to patient self-assessment form. Assess identified risks further and make plans if needed(see below for order set). Review BPAs and HM -- update HM as appropriate. Do an exam (this is appropriate to patient needs – comprehensive only if you are billing Preventative rather than AWV)

Smart Text documentation template Smart Set Smart Text documentation template Documents that the above was done Section for doctor to select risks that were identified and plan that was done (fall, hearing, depression, smoking, etc …) Orders PT Hearing assessment ??? Patient Information for AVS Default in HM with due dates Smart List – doctor chooses risks and plans for them Patient education materials doc can choose – next slide

Patient Education Materials Fall avoidance Depression Incontinence Cholesterol Hypertension Hypertensive Meds Confusion Dementia