Annual Wellness Visit Presentation

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eC Research A division of eCast Corporation Managing HealthCare with AWACS tm George Marmo Business Development Manager eC Research A division of eCast Corporation 1

Transcript of Annual Wellness Visit Presentation

Page 1: Annual Wellness Visit Presentation

eC Research A division of eCast Corporation

Managing HealthCare

with AWACStm

George Marmo

Business Development Manager

eC Research A division of eCast Corporation

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• AWACS takes advantage of new Medicare law

• Medicare patients get an Annual Wellness Visit (AWV)

• no copay and no deductible

• AWACS helps improve the quality of healthcare, reduces the cost of healthcare and rewards the physician

AWACS is a proprietary system known as “Annual Wellness and Care Surveil lance”

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• Provides long range plan of healthcare

• Identifies high-risk chronic illnesses

• Identifies patients who are failing in mental acuity

• Identifies patients who pose a safety risk

• Reduces accident and fall rate

• Reduces long term care and nursing home stays

AWACS Reduces Healthcare Costs

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* Performed by Practice

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* Performed by Practice

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Plan & Implement Train Staff Configure Systems Load Data

eCR AWACS Implementation Plan Page 1

eCR AWACS Implementation Plan

Greetings and welcome to the eC Research Annual Wellness and Care Surveillance (AWACS) program. Under AWACS, you can expect to achieve the following milestones:

You will greatly increase your quality of care for your patients You will reduce the overall cost of healthcare for your Medicare patient population You will increase your own revenue base

As you may know, the Medicare Annual Wellness Visit, which is the foundation of AWACS, is a program that is strongly encouraged by Medicare for all your Medicare patients every year. Congratulations! As an AWACS provider, you are demonstrating your professional concern for patient health and cost reduction measures. Now, here is an implementation plan for your AWACS system. Pre-Implementation Steps Date Due Completed/ Notes AWACS Contract Signed Business Associate Contract Signed NP Assigned Define Days of Week and Times for AWACS (See Note 1)

Define Staff Member names and roles (See Note 3)

Implementation Steps Date Due Due From/ Completed/ Notes Project Manager Assigned ESV Setup Assigned ESV Trainer Assigned Practice Data and Provider Data Captured .mdEmail service order completed and faxed to client

.mdEmail service order signed by client and faxed to eCR

Ledger of Medicare patients prepared by client and sent to eCR (See Note 2)

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The Wellness Visit consists of:• Past Medical History• List of Current Providers• Medications, Allergies and Immunizations• Social and Family History• Review of Systems (brief)• Physical Exam (brief)• Functional Capacity and Safety Evaluation• MCI/Cognitive Impairment Evaluation• PHQ-9 Potential for Depression Evaluation

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Physicians Report• Summary• Risk Factors• 5 Year Plan• Health Advice

Problem(s)

Allergy History

Medication History

Constitution

Vitals

Reason for Visit

Current Providers and Suppliers of Medical Care

Diet

Exercise and Activity Level

Functional Capacity

Safety

MCI/Cognitive

Mental State and Potential for Depression (PHQ-9)

New River Medical Center 1640 Bryan Station Road Ste 101 Lexington, KY 40505 P:859-259-0588 F:859-422-4357

Betty J Pendegrass 303 Willow Lane Glendale, KY 07343 Account Number: 56345 MRN:

Printed: 10/7/2011 Patient Name: Betty J Pendegrass

SSN: 555-00-2342 DOB: 09/12/1934 Age: 77

Rendering Provider: Joy Wilburn

DOS: October 6, 2011

The patient reports the following problems: obesity, forgetfulness, depression, sleep disorder, HTN, osteoarthritis and problems with cholesterol.

(Last Reviewed By: ) 10/06/2011 Other Pollen 10/06/2011 Medication penicillin G benzathine 1,200,000 units/2 mL intramuscular suspension

(Last Reviewed By: )

Date Medication Qty Dosage & Frequency Rfl 10/06/2011 hydrochlorothiazide 12.5 mg oral capsule cap 1 cap(s) orally once a day 0 10/06/2011 lisinopril 10 mg oral tablet tab 1 tab(s) orally once a day 0 10/06/2011 Synthroid 100 mcg (0.1 mg) oral tablet tab 1 tab(s) orally once a day 0

Complains of weight gain, fatigue, weakness and insomnia. Denies appetite.

Date Time LMP EDD Height (in)

Weight (lb)

BMI BP Resp. Pulse Temp. (°F)

O2 Sat. Head Cir. (cm)

Waist (in)

10/07/2011 08:36 AM 62 125 22.91 110/90 35

The purpose of this visit is the Medicare Annual Wellness Visit for the initial (first) annual wellness visit.

The patient's providers and suppliers of medical care are as follows: Tammy McChord (dentist), Wal Mart (drug store), Winchester (drug store) and Clark Regional (hospital).

The patient's diet consists of 1-2 servings of nuts or berries per week, 3 or more servings of fruit per week, 1-2 servings of fish per week, 3 or more servings of red meat per week, 3 or more servings of green, leafy vegetables per week, no servings of soda with sugar per week, 3 or more servings of fried food per week, 1-2 servings of saturated fat food per week, no cups of coffee per day, 1-2 cups of tea per day and 1 aspirin each day.

The patient's exercise and activity level consists of low exercise level, gardening, crossword or jigsaw puzzles, boating and fishing.

The patient was evaluated for his or her functional capacity. Pass/Fail results are as follows: sitting (passed), standing (failed), lifting (passed), carrying (passed), pushing (passed), pulling (passed), bending (passed), stooping (failed), squatting (failed), kneeling (failed), reaching (failed) and hand use (failed).

The patient's safety was evaluated. The evaluation shows that the patient's safety awareness is as follows: the patient currently uses handrails and understands the need to hold on to a handrail when walking or using stairs, the patient sometimes or frequently walks on slippery surfaces without the ability to stabilize (fails), the patient drives quite a lot even though it may pose a safety threat to him or her (fails), the patient locks his/her doors and windows and keeps lights on at night, the patient maintains steady contact with his/her family and the patient has a number of friends with whom s/he stays in contact.

The patient was assessed for MCI/Cognitive responses and the results are as follows: eye movement (passed), walking and balance (failed), sense of touch (passed), draw clock face with hands showing time (passed), name today's date and location (failed), ability to copy a design (failed), ability to follow a 3-step command (failed), remembering a list of 3 words (failed), ability to follow a written instruction (passed), ability to write a complete sentence (failed) and ability to count backwards from 100 by 5 (failed).

The patient reports that s/he is happy with his/her family life. The patient's outlook on life is negative. The patient appears to be moody,

Betty J Pendegrass-5634510/7/2011

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Risk Factors

Written screening schedule - 5 year Plan

Personalized Health Advice

uneasy, anxious with a depressed state of mind, sad, empty and in a ready state of tears. The patient appears to has a lack of interest in activities that used to be enjoyable. The patient reports that s/he has gained or lost weight recently. The patient reports that s/he has little to no appetite and does not enjoy eating food. The patient's sleeping patterns are abnormal and s/he has difficulty sleeping. The patient appears to be normal, calm, not agitated.. The patient reports that s/he is having trouble remembering and thinking things through lately and having difficulty remembering people, places and things and the details surrounding them. The patient is showing a reduction in his or her ability to move normally. The patient reports that he or she feels fatigued frequently and has a constant lack of energy. The patient feels good about him or herself and does not suffer any feelings of guilt. The patient's concentation is poor. The patient is able to make decisions freely. The patient does not have thoughts of death or suicide normally.

The patient's risk factors are shown in the following table.

RISK FACTOR LEVEL TREATMENT OPTIONS ASSOCIATED RISKS

Diabetes Moderate Continue monitoring lipids, BMI, waist. Retinopathy

CVD Severe Continue monitoring BP, cholesterol, BMI. Stroke/TIA

Stroke/TIA High Continue monitoring BP, aspirin intake.

Colorectal Cancer High Counsel patient on fatty red meat, fried food and saturated fat intake. Consider referral to Registered Dietician if warranted.

Osteoporosis/Arthritis Moderate Continue monitoring bone density. Consider calcium supplement.

Bone Loss

Depression High Continue monitoring early warning signs of depression.

Cognitive Impairment Severe Continue monitoring cognitive impairment. Consider referral to neurologist.

Functional Capacity and Safety

Severe Continue monitoring safety, driving habits, handrails and slippery surfaces.

The patient's written screening schedule and 5-year plan is as follows.

CATEGORY YEAR1 YEAR2 YEAR3 YEAR4 YEAR5

Office Visit

HbA1C Check if value GTR 7.0 else 6 months later. Goal is: 6.5

HbA1C Check if value GTR 7.0 else 6 months later. Goal is: 6.5

HbA1C Check if value GTR 7.0 else 6 months later. Goal is: 6.5

HbA1C Check if value GTR 7.0 else 6 months later. Goal is: 6.5

HbA1C Check if value GTR 7.0 else 6 months later. Goal is: 6.5

BP Every visit - goal: Systolic < 120 Diastolic < 80

Every visit - goal: Systolic < 120 Diastolic < 80

Every visit - goal: Systolic < 120 Diastolic < 80

Every visit - goal: Systolic < 120 Diastolic < 80

Every visit - goal: Systolic < 120 Diastolic < 80

Wt/BMI Every visit - goal: BMI 18-25

Every visit - goal: BMI 18-25

Every visit - goal: BMI 18-25

Every visit - goal: BMI 18-25

Every visit - goal: BMI 18-25

Standing Lab Orders

CBC, CMP, TSH, U/A, Microalbumin, HbA1C, Lipid Plus

CBC, CMP, TSH, U/A, Microalbumin, HbA1C, Lipid Plus

CBC, CMP, TSH, U/A, Microalbumin, HbA1C, Lipid Plus

CBC, CMP, TSH, U/A, Microalbumin, HbA1C, Lipid Plus

CBC, CMP, TSH, U/A, Microalbumin, HbA1C, Lipid Plus

Immunizations

Seasonal Flu Pneumovax (once after age 65) Tdap (every 10 years)

Seasonal Flu Seasonal Flu Seasonal Flu Seasonal Flu

Referrals

Gastroenterologist Registered Dietician Optometrist or Ophthalmologist Podiatrist

Registered Dietician Optometrist or Ophthalmologist Podiatrist

Registered Dietician Optometrist or Ophthalmologist Podiatrist

Registered Dietician Optometrist or Ophthalmologist Podiatrist

Registered Dietician Optometrist or Ophthalmologist Podiatrist

The patient's personalized health advice is as follows.

CATEGORY RECOMMENDATION ACCOMPLISH BY

• Food with saturated fats include meats, milk, eggs, butter and cheese. Talk to your provider about your intake of saturated fats. We suggest you reduce your intake of eggs and butter and order sandwiches without cheese and mayonaise. If you can reduce the saturated fat in your diet, your heart will love you for it and you'll lose inches off your waistline.

Betty J Pendegrass-5634510/7/2011

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Risk Factors

5-year Testing & Screening Plan

Health Advice

Medicare Mandatory Requirements

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The Report includes an assessment of Risk Factors:

• Diabetes II• CHD/CF• COPD• Depression• Cognitive Impairment• Functional Capacity• Safety

•Lung Cancer•Colon Cancer•Breast Cancer•Prostate Cancer

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• Please let your provider know that you are having difficulty sleeping at night. Remember to avoid large meals and caffeine before bedtime.

• You should discuss your fatigue and loss of energy with your provider as soon as possible.

Physical Strength

• Your age is 65 years or older. As you age your bones become brittle and you have muscle loss. Your provider can discuss ways that you can help strenthen bones and muscles.

As directed by your provider: ______________

• Your risk for arthritis is "moderate." Please talk to your provider about this as soon as possible.

• You had difficulty using your hands. Your provider will discuss this with you separately.

• You had difficulty kneeling. Your provider will discuss this with you separately.

• You had difficulty reaching over your head. Your provider will discuss this with you separately.

• You had difficulty squatting down. Your provider will discuss this with you separately.

• You had difficulty standing up. Your provider will discuss this with you separately.

• You had difficulty stooping. Your provider will discuss this with you separately.

• Exercises you should do every day include walking around the block twice, lifting 20 pounds 10 times and bending and stretching at the waist. If you are able, consider gardening, walking, bowling, golfing or other recreational activities 3 times per week to keep your muscles and bones strong.

• If you feel that your physical movements have become restricted lately, please let your provider know immediately.

• Your provider will discuss your reduction in physical movements with you and offer some further advice.

• Your risk of osteoporosis is "moderate." Please talk to your provider about ways you can prevent osteoporosis.

Referrals

• Your provider will talk with you about your reported high blood pressure problems and discuss options with you.

As directed by your provider: ______________

Joy Wilburn 10/07/2011 07:25 PM

Betty J Pendegrass-5634510/7/2011

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Your Electronic Signature

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• Very innovative strategy that reduces overall cost and increases the quality of healthcare

• Addresses the very heart of what CMS wants to provide which is “proactive” healthcare

• Rewards physicians and up running in less than 30 days

• Comes with certified “starter” EMR, works with any EMR and stores data in a Health Information Exchange

Summary

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George MarmoeC Research

Business Development Manager

(973) 524-5048

[email protected]