How to Increase Annual Wellness Visits & Close Gaps in Care

Value-Based Care

October 27, 2023
A doctor is working with a nurse side by side - looking at a ipad that will help them with outreach to patients.

Key Takeaways

  • Only 10-25% of a practice’s patients schedule annual wellness visits. Organizations must embrace proactive outreach to achieve preventive care targets.
  • With current staffing challenges, a digital communication platform is required to scale outreach and succeed in improving annual wellness visits (AWV) and closing gaps in care.
  • To optimize performance, use an agile, data-driven approach that monitors and optimizes annual wellness visits completed, the success of digital outreach and patient satisfaction.

As much as 75% of healthcare is reactive. This is consistent with wellness visits where data shows that only 10-25% of patients schedule an annual wellness visit. Physicians use wellness visits to address most gaps in care, so managing only patient-initiated visits are unlikely to achieve performance targets.

45% of US deaths have been attributed to modifiable risk factors. Routine health screening is key to reducing healthcare burdens. To prioritize preventive health, Medicare has incentivized practices to incorporate the AWV. This provides opportunities for accountable care organizations (ACOs) to increase revenue while providing this service to patients.

Despite the importance, only 8% of people obtain all recommended screenings, per the National Institutes of Health. Patients don’t schedule recommended screenings for many reasons, including:

  • Patients are not aware that an annual wellness visit is 100% covered
  • Limited understanding of the benefits of preventive health
  • Difficulty translating standard preventive health recommendations into a personal action plan
  • Social determinant concerns that place barriers to care
  • A lack of time

We cannot rely on patients scheduling a wellness visit to close gaps in care. This blog lays out the benefits, approach and real client results of proactive digital patient engagement.

Increasing Annual Wellness Visits - Benefits to the practice

  • Conducting annual wellness visits reinforces the beneficiary assignment to practice
  • The yearly check-up updates HCC conditions. These conditions affect the amount of money paid for the visit and the patient's overall care.
  • Increases practice revenue.
  • Improves gaps in care performance - Why should all organizations, regardless of reimbursement model focus on value-based care requirements? Value based care is growing.  Per a McKinsey analysis, the number of patients cared for in value-based arrangements is expected to double in the next 5 years. This is driven partially by a CMS goal to get 100% of Medicare recipients in value-based care by 2030.
  • Increases patient satisfaction and loyalty – More than ever, you need a strategy to retain patients. Primary care providers (PCPs) are experiencing a tsunami of change as alternative care delivery models upend the traditional healthcare landscape. Amazon, Walgreens, CVC Health, Target, Google, Dollar General, and other retailers are fast becoming dominant competitors, offering ambulatory healthcare services more conveniently at a lower cost. These nontraditional players see opportunities to rapidly expand and potentially capture as much as a third of the U.S. primary care market by 2030.
  • Reduces staff burden - Many organizations who are focusing on closing gaps in care now are using analytics to generate lists of patients to call. Staffing shortages and use of contract labor and over time is expected to continue. Shifting to proactive digital patient outreach reduces staff time on the phone, giving them more time to address patients in the clinic.

Increasing Annual Wellness Visits - Benefits to the patient

  • Identifies and addresses conditions early when complete recovery or management can reduce disease progression, disability and death.
  • Strengthens physician-patient relationships – Patients truly appreciate evidence that their physician is focused on their health. Here is one example of a patient comment received by a QliqSOFT client upon receiving proactive outreach.
“It [feels like you are] showing more concern [about] the patient and with everything happening in the world with COVID I’m happy [you]'re showing concern.”
Patient comment
  • Engages and empowers the patient – Provide patient education on the importance and timing of annual wellness visits. Use terms they understand to explain the importance of the wellness visit and make it easy to schedule the visit.
A nurse reviewing x-ray results with a patient inside of a clinic.

How to use digital patient engagement to increase annual wellness visits

Adopting proactive outreach requires changes to clinic workflow. These reason for the outreach needs to be explained to the team. The team needs to be involved in defining the new workflows and incorporate them into the day-to-day practice of the clinic. 

This blog assumes that the patient engagement platform technology is in place and focuses on how to use it. If you are newly implementing a patient engagement platform, check out this blog post that provides guidance for a successful implementation.

Baseline current performance

Most organizations today have both analytic dashboards that provide baseline performance and EHRs capable of generating lists of patients due for care. 

Set goals

You want to set three types of goals:

1.     Actual annual wellness visits completed: If you have incentive metrics, this is a good place to start. This is your outcome measure

2.     Outreach success: These are your process measures that help you identify and refine your outreach approach, if needed. There are several measures to include:

  • Valid mobile phone numbers
  • Patient open rates
  • Patient response rates – sometimes organizations are discouraged by a lower response rate. We have seen response rates from 25-95%. Performance depends on the quality of phone numbers and how the program is communicated to patients. Even a 25% increase in patient responses has the potential to double your performance over the 10-25% of patients who are proactively scheduling visits.

3.   Patient satisfaction – you can do this with either a separate satisfaction survey or add an option at the end of the secure patient outreach that asks them to rate their experience and provides the option to talk to a person.

Define ownership

  • Who will be responsible for tracking and trending metrics?
  • How often will this be done?
  • Who will the information be shared with? Don’t forget to include front office staff who may have direct patient feedback to share.

Define your approach

Use analytics or EHR lists to identify patients – depending on your system capabilities and budget, you may manually load lists into the digital communication platform, or you may integrate the analytics and digital communication systems to fully automate outreach.

Use a digital communication platform

Campaign automation allows for the organization to schedule patient messaging on a defined cadence. It also enables the administrator to tell the system how to respond if a patient does not initially respond to email or SMS outreach, such as to wait x number of days before sending another message. This automation is critical to reduce staff burden and scale outreach.

A infographic on how to gain patient trust in digital outreach - Educate Your Patients & Involve Your Staff, Apply Your Organization’s Branding, Track Adoption and Optimize Outreach, Enable the Patient To Escalate to a Live Agent.

Reduce barriers to digital engagement 

Trust – create an email or SMS message that reinforces to the patient that the sender is known, and it is safe to click on the link. Consider using MMS, which allows for the addition of a familiar logo. For best practices on building patient trust read this.

Appless – Most people hate to be forced to download an app to do business with a company. Appless interactions reduce barriers to action.

Personalization – use a digital communication platform that allows you to provide patient details to mass personalize the message. For example, calling the patient by name, mentioning the name of the clinic and the doctor when communicating the need for the annual wellness visit makes it feel more like a personal invitation to engage.

Woman is comfortably filling out a form on her iphone at home.

Screen and address Social Determinant of Health (SDoH) barriers  

In a recent gaps in care initiative, one QliqSOFT client screened for a series of topics where they could provide assistance. 36% of patients asked for help with scheduling and care coordination and 58% identified a need for SDoH assistance that, once provided, enabled them to close their gap in care need. 

Make scheduling easy  

Offer self-scheduling. If you cannot or do not want to offer self-scheduling use a platform that supports escalating to a live agent to assist with scheduling digitally. The agent and patient can securely text to schedule the appointment, reducing call volume for staff and unwelcome phone wait times for patients


As with any initiative, it is important to review results and look for ways to optimize performance. Review data in team meetings, solicit input from the team and review patient feedback to determine where and how to adjust all aspects of the program to increase performance.

Increasing annual wellness visits is a key to succeeding with value-based care. A patient engagement platform combined with an agile approach to increasing outreach are critical to success.

The Author
Bobbi Weber

Bobbi is a lifelong learner who is passionate about enabling healthcare transformation. She has 20+ years of healthcare experience in care delivery, consulting, healthcare IT, and market strategy.

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