Background Summary: In the United States, 45% of all adults have one or more chronic diseases and, 60% of adults over 65 have two or more chronic conditions. The Medicare Annual Wellness Visit (MAWV), a once per year prevention-based visit, combined with a Health Risk Assessment (HRA), will increase the percentage of patients screened for preventable/modifiable conditions including depression, cancer, hypertension, substance use disorders, and cognitive impairments. The new protocol design was to close gaps in patient care and provide personalized health goals for the next twelve months. In 2020 the Community Health Clinic (CHC) accurately completed only two MAWVs. Implementing a protocol was based on CHCs’ high percentage of patients over 65 plus the higher health risks associated with rural communities. EBP Framework: The EBP model used was the Stevens Star Model of Knowledge Transformation was combined with the theoretical framework of Nola Pender’s Health Promotion Model (HPM). The two together help evaluate current, relevant issues in the primary care setting to formulate logical solutions. The Stevens Star Model provided the structure, whereas the HPM helped focus on health and not disease. The use of these two models ensured the project and change remained evidence-based. Methods: The project was designed around two interventions, the new MAWV protocol, and the educating intervention. The success of the first intervention was based on the number of MAWVs scheduled and complete. The Lunch-n-Learn education intervention’s effectiveness was based on the participants’ Pre/Post-surveys quantifying their level of confidence plus a chart audit for each completed MAWV in 2020 and 2021. Findings/Results: The completion rate of MAWVs increased by 350% compared to the same time period during 2020, along with 28 MAWVs scheduled during the first quarter. The Level of Confidence Survey increased by 134%, and the chart audit revealed that post-intervention chart accuracy was 85.7% compared to 22.2% accuracy in 2020. Conclusion/Recommendations: For future implementation, the workflow associated with each portion of the health risk assessment (HRA) needs to be established and part of the original role out. The recommendation is for CHC to increase the number of completed MAWVs for patients 65 and older. The increase will increase the early identification of chronic diseases, increase preventive services, and increase the number of patients who receive follow-up care.
