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  • 1.  Annual Wellness Visits

    Posted 01-03-2025 09:13

    Hello!
    Would anyone be willing to share their nursing workflow for AWV's?  We would like to have our nurses start performing these visits in 2025 and looking to gain some insight from others that have successfully implemented AWV for nursing.  Thanks in advance!!



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    Cicely Overton MSN RN, AMB-BC
    Director of Nursing and Clinical Practice
    Eskenazi Health Center-Primary Care
    Indianapolis IN
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  • 2.  RE: Annual Wellness Visits

    Posted 01-06-2025 08:24
      |   view attached

    Good morning,

    I have uploaded what our teams use to manage AWVs. I hope it is helpful.



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    Kimberley Sipos
    Sentara Health Care
    Virginia Bch VA
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    Original Message


  • 3.  RE: Annual Wellness Visits

    Posted 06-12-2025 14:16

    This playbook is incredible!

    Thank you! have there been any updates since the original post? What barriers are you finding? 



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    Angela Bowers RN
    RN Supervisor
    Portage WI
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    Original Message


  • 4.  RE: Annual Wellness Visits

    Posted 06-13-2025 08:18

    Good Morning, Thank you for sharing. We have been implementing RN-led AMW visits and I would state our barriers are staffing shortages pulling the RN away from the work, some patient reluctance and otherwise the opportunity to perform HCC review. Has anyone taught their nurses how to pend up the documentation to satisfy HCC coding for risk attribution? 

    Happy to jump on a call and learn from others. 



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    Sarah C. Overton MSN, RN
    Chief Nursing Officer/VP Clinical Services OSF MultiSpecialty Services
    800 NE Glen Oak Ave
    Peoria, Il 61603
    p. (309)683-7253 c. (309)264-7670 f. (309)624-2834
    "Serving with the greatest care and love"

    www.osfhealthcare.org
    ------------------------------

    Original Message


  • 5.  RE: Annual Wellness Visits

    Posted 09-17-2025 14:45

    We are doing something similar to this-patients with identified HCC gaps are contacted, the nurses assesses one week before pt comes to clinic to see provider, provider asks "any changes from when you spoke to the nurse?" and documents MEAT criteria. Finding patients are much engaged if we can talk them into seeing the RN virtually first, and providers are saving loads of time, AND we are capturing those HCC gaps!



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    Angela Bowers RN
    RN Supervisor
    Portage WI
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    Original Message


  • 6.  RE: Annual Wellness Visits

    Posted 06-13-2025 17:53

    Thank you so much for sharing this information. We are currently working on this in our system. 



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    JULIE KLOEPPEL
    MetroHealth Medical Center
    Avon OH
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    Original Message


  • 7.  RE: Annual Wellness Visits

    Posted 06-20-2025 08:48

    Hey Cicely. Kim already shared our workflow but I wanted to reach out to the rest of the folks who DO have this implemented and ask if you have any difficulty billing RN led AWVs at Provider Based Billing (PBB) locations, if so have you been able to reach any resolutions? Thanks for any insight.

    Naomi Ramshur, RN, BSN, MBA

    Director of Quality and Clinical Operations

    Complex Care Solutions

    Sentara Ambulatory Services Division

    Office: 757-339-4629 Mobile: 757-339-4629

    Email: nxramshu@sentara.com

    1330 Sentara Park 4th floor Virginia Beach, VA 23464



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    Naomi Ramshur
    Director of Quality and Clinical Operations
    Chesapeake VA
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    Original Message


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