Improving Patient-clinician Conversations During Annual Wellness Visits

Zsolt J. Nagykaldi, PhD; Ami Dave, MS3; Connor J. Kristof, MS3; Tanya N. Watts, MS4; Sravanthi Utpala, MD; Elizabeth Wickersham, MD


J Am Board Fam Med. 2017;30(2):161-169. 

In This Article

Abstract and Introduction


Background: Health risk assessments (HRAs) have been implemented and studied for decades in various settings, but little is known about the effect of introducing HRAs on the dynamics and content of patient-clinician conversations during Medicare Annual Wellness Visits (AWVs) and whether the effective use of HRAs requires additional training and resources.

Methods: We used Conversation Analysis techniques to analyze 40 AWVs conducted in an academic family medicine residency practice. After a 3-month baseline period, a low-intensity intervention was implemented to explore improvements in the dynamics and content of conversations. Short exit interviews with patients and clinicians were evaluated by standard content analytic techniques.

Results: Six overarching themes emerged that described the dynamics of AWV conversations. Patients and clinicians sub-optimally utilized the HRA report and missed many opportunities for promoting behavior change. However, a low-intensity, multi-component intervention significantly decreased the proportion of clinician talk time per visit by 9% (P < .001), while it increased the proportion of patient talk time by 7% (P < .001), robustly increased the number and duration of "change talk" by 639% (P = .0007), increased the number of patient cut-ins by 237% (P = .04) and tended to increase the number and duration of clinician "advice talk" (P = .065). Patients felt more informed, empowered, and motivated by the HRA-enhanced wellness visit. Clinicians found that the process helped them construct a more effective visit agenda and it facilitated the convergence of patient goals with evidence-based recommendations.

Conclusions: Our study suggests that HRAs introduced without proper framing, education, and additional resources may not allow patients and clinicians to leverage AWVs for effective health planning and improvement. A targeted, low-intensity intervention may help patients and clinicians improve the quality of HRA-guided health conversations during AWVs.


The Patient Protection and Affordable Care Act of 2010 (ACA) instituted annual wellness visits (AWVs) and implemented a new payment structure for Medicare AWVs.[1] Payment for AWVs has been tied to addressing specific clinical content and implementing a health risk assessment (HRA) that covers 34 required elements, including demographics, health status, psychosocial and behavioral risk factors, activities/instrumental activities of daily living, and the development of a personalized health plan.[2] When the ACA incorporated systematic financial support for longitudinal health planning and prevention in AWVs, it created a long-awaited opportunity for primary care practices to more effectively align their mission (improving the health and well-being of a community) with the sustainability of their organization. Although payment for Medicare AWVs is a step in the right direction, much work needs to be done to identify and test effective approaches to implementing AWVs in community settings.

There are many gaps in our knowledge pertaining to the role and effective participation of patients in AWVs, the types and specific content of HRAs that may improve process and health outcomes, how AWVs should be structured, what resources and education clinicians and practice staff might need to make AWVs effective, how patients can be empowered to meaningfully participate, what personalized wellness plans should include and how these plans can be communicated to others, how wellness plans and care goals can be documented in a problem-oriented medical record, how practices can efficiently and appropriately respond to complex behavioral health needs emerging from AWVs, and how systematic patient follow-up can be provided to reach the goals set in AWVs. In this pilot study, which was part of a medical student research experience program, our team aimed to bridge some of these gaps by observing, analyzing, and improving HRA-based health planning conversations in primary care settings.