Health Assessments in Primary Care

Appendix 2:  Health Assessment Case Study


Family and preventive medicine residency program in Georgia. 20+ faculty clinicians, mostly part-time; 18+ resident physicians.

Getting Started (Week 1)

Practice leaders knew they needed to start consistently implementing the Annual Wellness Visit (AWV) for their Medicare-eligible patients. As the AWV clinician-champion noted, "The AWV was an easy way to increase our revenue and it was something we needed to do anyway for our patients. This was low-hanging fruit to continue the culture change in our practice toward becoming a patient-centered medical home." Unfortunately, in this large practice, clinicians, staff, and the off-site scheduling system were not completely ready.

First, they started with a small team meeting (two clinicians and staff) to talk about their general interests and priorities for health assessments for the practice. Next, the clinician-champion and a physician assistant read the How-to Guide to make sure they weren’t forgetting an important step.

Selecting a Health Assessment (Week 2)

After settling on the AWV as the focus for a new health assessment, they began looking at different options for the questions they might use. They looked to their professional societies (the American College of Physicians and the American Academy of Family Physicians) for sets of questions that were suitable for their practice and patients. They selected a set of questions and modified them somewhat for their specific needs and practice flow. The final draft resulted in a more user-friendly tool for the nurses, patients, and clinic workflow.

Planning and Integrating (Weeks 3-4)

There were a number of logistical hurdles to consider: How and when would patients complete the health assessment? What kind of visit would work to review the assessment? What would staff and clinicians need to know about the assessment and the new type of visit? Here’s how they approached this by type of personnel involved:

IT Specialist

  • Work with IT to develop lists of eligible patients to contact and schedule visits.
  • Create an "Annual Wellness Visit" in the scheduling system.
  • Develop a method to draw attention to AWV appointments when the schedule is printed so the clinic is properly prepared for the visit.


  • Mail patients paper copies of the health assessment to complete prior to their scheduled visit. They chose to mail these out 2 weeks in advance of the visit.
  • Work with the institution’s schedulers to develop a script to talk to patients about the AWV and how it’s different from an annual physical exam.
  • Work with the schedulers and staff to set the appropriate visit. 

Management and Leadership

  • Develop and deliver a one-hour formal training on the new AWV for faculty, residents, and staff. The slides developed for the training were also sent to staff by email for easy access and future reference.
  • Develop a protocol for staff to score the health assessment quickly at the office visit.
  • Share strategies for successful AWVs. 

Assessing and Refining (Weeks 5-6)

Once the initial processes were in place, the team continued to watch how the implementation went and how patients reacted. Because there was some ongoing confusion among patients (and a few clinicians) about the purpose of the AWV, the practice looked for a script they could use with patients. Again, they looked to their online resources at professional societies and found one they could start with. They had the schedulers and staff use the same script to send a consistent message to patients. Since then, they have tailored the script to suit their specific needs.

Because the practice also wanted to know what patients thought about the new health assessment, they surveyed a small sample of patients with a brief one-page survey. They learned that most patients completed the survey just fine. More importantly, they also learned that the health assessment helped remind some patients about behaviors and habits that affect their health.

Looking Ahead (7-8 Weeks and Beyond)

The practice knew that the new health assessment was basically working well. They also recognized that they would have to revisit the process in a few weeks to look at their data on who had completed their annual wellness visits to help them identify any gaps and make a few more improvements.


Page last reviewed September 2013
Page originally created September 2013
Internet Citation: Appendix 2:  Health Assessment Case Study. Content last reviewed September 2013. Agency for Healthcare Research and Quality, Rockville, MD.
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