UTILIZATION OF PRECEDE-PROCEED MODEL IN EVALUATING A NURSE PRACTITIONER-RUN GROUP MEDICARE ANNUAL WELLNESS VISIT

The purpose of this DNP project was to perform a process evaluation of a quality improvement project, nurse practitioner-led group Medicare Annual Wellness Visit (AWV), using the PRECEDE-PROCEED Model. The Affordable Care Act (ACA) became a law in the United States in 2011. Under the ACA, Center for Medicaid and Medicare Services (CMS) ceased payment for annual physical examinations. Instead, CMS will reimburse for Annual Wellness Visits (AWV) with personalized preventive plan services (PPPS) without cost sharing to patients effective January 1, 2012. Health plans foresaw an increased demand for AWV with PPPS by large numbers of new insurance enrollees. A large health maintenance organization anticipated access problems and proactively determined that group Medicare AWV might avert access problems. Senior (65+) Kaiser Permanente (KP) Health Plan members covered by Medicare Part B were the target population for group visits. Group AWVs were implemented in the ambulatory care clinic at KP Medical Center in Panorama City, California. This center serves a moderately diverse patient population with a large percentage of Latinos and Filipinos. The PRECEED-PROCEDE MODEL was used in the evaluation of the planning, implementation, and outcomes of these nurse practitioner-led group visits. Findings indicate that although the steps of the PRECEDE-PROCEED model had been followed, patient input and involvement was not solicited in the initial phase. Three screening tests, iv (i.e., Timed Up and Go Test, Patient Health Questionnaire-9, and Clock Drawing Test) were chosen at the regional level as quality indicators for the AWVs. Since 2013, completion rates of these screening tests have been higher in patients seen in group AWVs versus individual AWVs; Panorama City typically had higher completion rates of these indicators, as compared to 12 other medical centers within the region, attributable to the group AWVs. During this period, documented patient evaluation for group AWVs showed high patient satisfaction with anecdotes of improved patient care experiences. Cost calculations indicate that cost savings occur when groups have at least six patients. Other cost savings estimated come from potential prevention of fall injuries among high risk patients referred to physical therapy for gait, balance, and muscle strength training.