Hattiesburg Clinic offers a Quality Management program for Medicare patients. Quality Management stemmed from an initiative of the Centers for Medicare & Medicaid Services (CMS) to help ensure Medicare patients have access to preventive and chronic medical care. The Quality Management program includes two services: Annual Wellness Visits (AWV) and Chronic Care Management.
Annual Wellness Visit (AWV)
The Annual Wellness Visit (AWV) is designed to promote health, detect illness, and focus on early disease detection and prevention. Rather than a physical examination, each AWV is a one-on-one session with a skilled registered nurse to review patients’ health. During the typical 30-45 minute visit, a nurse will work with patients to complete an assessment and develop a personalized prevention plan in order to manage his/her health. Each AWV will include, but is not limited to, the following services:
- Gathering typical measurements such as height, weight, blood pressure and body-mass index
- Reviewing the patient’s medical and family history
- Compiling a list of current providers, suppliers, and medications
- Completing a personal risk assessment
- Reviewing functional ability and level of safety
- Identifying any cognitive impairment
- Conducting depression screenings
- Developing a schedule for Medicare’s screening and preventive services the patient qualifies for over the next 5 to 10 years
- Discussing personalized health advice.
If any problems are identified, the primary care physician will schedule a separate visit to see the patient within a few days. All AWVs will be billed to Medicare and are no cost to the patient.
Chronic Care Management
Medicare patients with two or more ongoing medical problems may be eligible for the Chronic Care Management program. After enrolling, patients will be assigned a Case Manager Nurse. This registered nurse will assist in the many aspects of the patient’s health and contact the patient at least once a month to discuss any concerns or needs. Case Manager Nurses will remind patients stay up to date with scheduled services such as lab workups, radiology films, and follow-up appointments that are part of treating the patient’s chronic medical conditions. Please refer to the list below for a comprehensive list of the services provided through this program. Case Manager Nurses will:
- Ensure patients receive appointments with their primary care provider (PCP) or designated team member when needed
- Help facilitate any referral appointments to specialists
- Oversee follow-ups with the patient’s PCP and appropriate specialists after any hospitalization
- Educate patients and/or family members regarding the patient’s diagnoses
- Teach patients about taking medication and assess any barriers they have in obtaining or taking each medication as prescribed
- Teach symptom recognition and steps to help with management of chronic conditions at home
- Coordinate preventative services such as vaccinations, and screening for certain forms of cancer
- Confirm patients are getting all necessary lab work monitored in a timely manner
- Work with the providers to develop a Care Plan that outlines the patient’s individual needs and goals for each chronic medical condition
- Contact patients at least once a month via phone call or patient portal to evaluate their general condition, making sure patients are doing well in between visits with their PCP and other providers.
To participate in this program, a service consent form must be completed. This form can be found here. Please complete this form and discuss this service with your provider at your next office visit. Please note: Chronic Care Management services will be billed to Medicare, but standard deductible rates may still apply. If patients do not have secondary insurance, a co-pay of approximately $8.00 will be required each month.