Clock iconAugust 7, 2021

How an Outreach Team is Making a Difference to Support AWV Initiative

CommonSpirit Health Accountable Care Organizations have been focused on annual wellness visits (AWVs) as an enterprise-wide initiative, successfully increasing the number of Medicare beneficiaries who receive them, but there’s still room for improvement. Ranae Forbes, Director of Clinical Program Support at Dignity Health Medical Foundation, has identified an outreach strategy that’s driving AWVs while lightening the workload for clinicians.

The Value of AWVs

AWVs are a critical pathway to identifying high-risk patients and helping them to develop personalized prevention plans to prevent illnesses. They also serve as a valuable tool to ensure appropriate quality gaps are closed.

Medicare Part B patients are eligible for one free annual wellness visit every 12 months, and ensuring that patients receive them can help improve their quality of life and lower their health care costs. Studies show a 5.7% reduction in adjusted total health care costs and up to 79% greater performance on certain clinical quality measures. Patients who get an AWV also are more likely to receive recommended preventive clinical services like screenings for fall risk, colorectal cancer and breast cancer, as well as depression screening and follow-up, and tobacco screening and cessation.

Streamlining the Process

While AWVs provide numerous benefits, the time associated with conducting the AWV in an already busy practice environment has been a challenge in increasing the volume of AWVs provided to patients. Forbes’ new outreach team is stepping in to provide support by contacting patients to schedule their AWV and document answers on the AWV questionnaires in advance of their visit.

“We’re a centralized outreach team, and we’re contacting patients all over the state,” she says. “We’re getting answers to as many of those questions as possible during our pre-visit phone calls so that when the patient comes in, the medical assistant only needs to confirm there are no changes needed.”

Making Steady Progress

The data is already reflecting an increase in AWVs in their market for both Medicare FFS and Medicare Advantage beneficiaries. DHMF provided 9,498 AWVs in 2020, or 17% of the eligible population, which is an increase from 6,779 in 2019, or 12%. They are targeting to reach 15,500 patients in 2021 and are well on track. Halfway through the year, they are at 7,700 patients with completed AWVs.

“I think we’re capturing a lot of patients who otherwise would not come in the door, and we’re really having an impact on their health,” Forbes says.

Secrets to Success

What can other markets learn from DHMF’s success? Forbes offers a few key recommendations.

  1. Create a playbook in partnership with clinics, where a maximum number of appointments per day or week is agreed on so that clinicians and staff are not overwhelmed by a flood of appointments.
  2. Assign staff/a team to complete the pre-appointment questionnaires. Completing as much documentation as possible on the pre-visit phone calls lightens the workload of the providers and streamlines the AWV process.
  3. Ensure the patient hasn’t already completed their AWV for the year. The visits are covered only once a year, so make sure the pursuit lists are up to date and confirm with the patients their last AWV visit was at least 11 months prior.

“Seeing our patients annually is key to ensuring that their health is being monitored,” Forbes says. “In this 65+ population, 51% have a chronic condition. So unless we ensure we’re capturing them annually, we may miss those chronic conditions and that could really impact their health.”

If you’d like to learn more about DHMF Outreach Program, please contact Ranae Forbes at For general questions about the AWV initiative at CommonSpirit Health, please reach out to Dr. Melissa Gerdes at



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  1. Helena Moon says:

    Great work! Thanks for sharing your strategy and great to hear you are able to expand the reach to additional patients!

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