Value-Based Care Starts with the AWV
Reach every eligible patient. Act on what you learn. Prepare for value-based payment.
The Medicare Annual Wellness Visit (AWV) provides an opportunity to identify health risks, close preventive care gaps, and develop personalized care plans. We help Rural Health Clinics increase AWV completion rates, strengthen documentation, and translate findings into coordinated follow-up care, building the foundation for improved quality performance and participation in Medicare Advantage and ACO arrangements.
AWV Completion
Eligibility tracking, outreach, and scheduling that reach most eligible patients each year.
Team-Based Visit Design
Pre-visit planning and clear roles so every required element is captured.
Follow-Through & Contract Readiness
Screenings, referrals, and care management enrollment that build value-based performance.
Completion Rate Determines the Value.
An AWV is a planning visit, not a physical exam. Its value comes from reaching most eligible patients each year and acting on what the visit finds: screenings scheduled, conditions documented, and high-risk patients enrolled in care management.
Wintergreen helps clinics answer the core question: what share of your eligible Medicare patients complete an AWV each year, and does what you learn lead to follow-up care? From there, we build the outreach, visit workflow, and follow-through that value-based payment rewards.
Is Your Clinic Ready for Value-Based Payment?
- What share of your eligible Medicare patients complete an AWV each year?
- Do you know who is due for an initial or subsequent AWV, and who is still in the IPPE window?
- Are risk assessments and care gaps ready before the patient arrives?
- Do AWV findings reach the care management team and lead to scheduled follow-up?
- Can your completion and gap data support Medicare Advantage and ACO discussions?
Completion Builds the Panel-Wide View.
The share of eligible patients who complete an AWV each year decides how much of your panel’s risk and care gaps you can see.
Most risk and care gaps stay unknown.
Enough data to target outreach and care management.
A panel-wide view that supports value-based contracts.
Illustrative panel of 1,500 eligible Medicare patients. Completion targets should reflect your own baseline.
How Each AWV Element Supports Value-Based Care
| AWV Element | Value-Based Use |
|---|---|
| Health risk assessment | Risk stratification and care management enrollment. |
| Screening schedule | Closing preventive and quality measure gaps. |
| Conditions and providers | Accurate documentation for risk-adjusted contracts. |
| Cognitive and depression review | Referrals to behavioral health integration. |
| Advance care planning | Care aligned with patient preferences (optional). |
Six Gates, Taken in Order.
A strong AWV program moves every eligible patient through the same sequence, from knowing who is due to reporting what was done after the visit.
Eligibility Tracking
Know who is due for an initial or subsequent AWV, and who is still in the IPPE window.
Pre-Visit Planning
Collect the health risk assessment and gap list before the patient arrives.
Team Roles
Clinical staff complete elements under supervision; the provider reviews and plans.
Documentation
Every required element recorded, with a written screening schedule for the patient.
Patient Communication
The AWV has no cost sharing, but problem-focused care the same day may.
Follow-Through
Screenings scheduled, referrals made, and completion reported monthly.
Five Ways to Build Your AWV Program.
Practical steps that raise completion and make sure every visit leads to a care plan.
Outreach
A registry of due patients with reminder calls and scheduling.
Pre-Visit Planning
Risk assessments and care gaps ready before the visit.
Team-Based Visits
Nurses and care staff carry the structured elements.
Care Management Link
Patients flagged for CCM, PCM, or BHI are enrolled.
Contract Readiness
Use completion and gap data in Medicare Advantage and ACO discussions.
What We See Most Often
- Visits run as a checklist with no follow-up.
- Eligibility not checked, leading to denials.
- Patients surprised by charges for added services.
- Findings never reach the care management team.
Measure First. Then Expand AWVs.
We treat each AWV as the start of a care plan. The follow-through, not the visit alone, is what prepares the clinic for value-based payment.
Measure
Establish your current AWV completion rate across eligible Medicare patients.
Build
Put outreach and pre-visit planning in place before adding volume.
Connect
Link findings to screenings, referrals, and care management enrollment.
Leverage
Report completion monthly and use the data in Medicare Advantage and ACO discussions.
Better Visibility. Value-Based Readiness.
When most eligible patients complete an AWV each year and every visit leads to follow-up care, clinics see their panel’s risk clearly, close care gaps, and come to value-based contract discussions with the data to support them.
A Panel-Wide View of Risk
Health risk assessments and documented conditions that support risk stratification and accurate risk adjustment.
Closed Care Gaps
Screenings scheduled and referrals made, improving preventive and quality measure performance.
Contract-Ready Data
Completion and gap data that strengthen Medicare Advantage and ACO discussions.
Sources: 42 CFR 410.15 (Annual Wellness Visit); CMS MLN, Medicare Wellness Visits. Figures current as of November 2026. Examples illustrative.
Is Your Clinic Ready for Value-Based Care?
Low AWV completion and visits without follow-through leave risk and care gaps unknown, just as value-based payment depends on them.
Connect with Wintergreen to talk through an AWV and value-based care strategy at your clinic, from measuring completion to building the outreach and follow-through that prepare you for value-based contracts.
Nicole Thorell
RN, MSN, FNP‑C
Principal | Wintergreen
