How the Annual Wellness Visit and Community Health Integration Work Together

The Medicare Annual Wellness Visit (AWV) and Community Health Integration (CHI) are two separate but complementary Medicare-covered services. Understanding how they work together can help you get the most out of your preventive care.

The AWV: Identifying risks and barriers

The Annual Wellness Visit is a preventive visit where a clinician reviews your overall health, identifies risks, and creates a personalized prevention plan. During the AWV, the clinician may learn about everyday barriers that are interfering with your healthcare, such as:

• Difficulty getting to appointments
• Medication costs that make treatment hard to follow
• Food access challenges
• Housing or utility problems
• Social isolation
• Difficulty understanding medical instructions

These are the kinds of unmet social or environmental circumstances that CHI is designed to address.

The CHI connection: Ongoing care coordination

An AWV can serve as the CHI initiating visit when:

1. The AWV is performed by the practitioner who will bill for the CHI services.
2. The practitioner identifies an unmet upstream driver during the visit.
3. The upstream driver may prevent the patient from carrying out the recommended personalized prevention plan.
4. All other applicable requirements are satisfied.

However, the AWV does not automatically make every patient eligible for CHI. The clinician must determine that the unmet circumstance significantly limits their ability to diagnose or treat the medical problem addressed during the visit.

The patient pathway

Here is how the process typically works:

• Step 1: You call Medcare during business hours. Our team explains your options and helps verify Medicare eligibility.
• Step 2: You are connected to a licensed clinician by phone or secure video.
• Step 3: The clinician conducts your Annual Wellness Visit, including a health risk assessment and personalized prevention plan.
• Step 4: During the visit, the clinician may learn that transportation, food access, medication costs, or other circumstances are interfering with your healthcare.
• Step 5: The clinician decides whether the unmet need meets Medicare's requirements for medically necessary CHI.
• Step 6: If CHI is recommended, you receive an explanation of the service, cost sharing, voluntary participation, and the one-practitioner-per-month rule. Consent is documented.
• Step 7: Qualified personnel provide ongoing care coordination, education, and community resource navigation under the practitioner's supervision.
• Step 8: The CHI worker tracks progress, documents activities, communicates with the practitioner, and updates your plan based on your needs.

Why the combination is valuable

The AWV helps identify risks and create a personalized prevention plan. CHI can help address the real-life barriers that prevent you from carrying out that plan.

For example, the AWV might identify that you need follow-up appointments with a specialist. The clinician then learns that you lack transportation. The clinician determines that the transportation barrier significantly interferes with treatment. With your consent, CHI personnel help you navigate transportation resources and follow up. Your practitioner remains involved and evaluates whether the barrier is improving.

The value of this approach is that healthcare does not stop when the clinical visit ends. It recognizes that a treatment plan may not work when the patient cannot obtain medication, attend appointments, understand instructions, access nutritious food, or safely manage care at home.