Health Risk Assessment and Annual wellness visit Program

The Guardian Health Services Health Risk Assessment and Annual Wellness Program (HRA/AWV) targets two distinct populations—Medicare patients (original Medicare land patient’s enrolled in Medicare Advantage Plans) and Commercial patients. The goals the Program for both populations are to:

  • Remove barriers and provide an avenue for patients to receive recommended and potentially life-saving preventive services.
  • Establish a foundation and interactive environment to educate and support patients’ endorsement and commitment to disease prevention, early detection, and lifestyle modifications.
  • Provide a base for identifying potential medical risk adjustment and HCC coding and documentation opportunities.
  • Provide a base for identifying current and projected high health service utilization patients.
  • Provide an opportunity to identify high risk patients that may benefit from engagement in the GHS Chronic Care Management Program.

For Medicare patients, GHS offers an interactive proprietary Health Risk Assessment (HRA) Form that is uniquely designed to capture a wide range of self-reported subjective information from patients across thirteen (13) domains. The data captured on the HRA are automatically transmitted to the Guardian HIE  HRA/AWV dashboard in the patient’s Patient Master Chart (PMC). For each domain the patient is assigned a high, moderate, or low risk ranking based on a numeric algorithm in the Guardian platform, and a patient HRA Risk Profile is generated. For each of the high risk domains exhibited by a patient, the patient is provided brief information on actions they may take to deal with the risk in PDF format as well as access to applicable patient education materials posted in the Guardian Library.

The Commercial proprietary HRA form provides an avenue for identification of high risk patients for care management. The assessment domains and sub-domains of the GHS Commercial HRA include:

  • Patient Personal Information (demographics and contact Information)
  • General Physical Health Status (physical health rating; experienced pain; body/mass index; health conditions; medication use)
  • Use of Health Services
  • Preventive Health Screening Activities
  • Emotional Health Status
  • Lifestyle Behaviors (nutrition, smoking, alcohol and drug use, sleep, physical activity)
  • Readiness and Confidence to Engage in Positive Lifestyle Behaviors

For each of these domains and sub-domains, there is an algorithm built into Guardian to calculate a patient’s risk level (high risk, moderate risk, and low risk). The GHS AWV Encounter Form is more comprehensive than the Medicare and Commercial HRA’s and can be used for both Medicare patients and commercial patients. The use for Medicare patients is fully compliant with the requirements of the CMS Annual Wellness Visit Program. The interactive Encounter Form contains 14 distinct domains with over 160 data points ranging from general information to targeted assessments for medication adherence, ADLs, obesity, hypertension, risk for falls, depression, pain, tobacco use, alcohol abuse.

The interactive GHS HRAs and Encounter Form are interfaced with the Guardian IT platform, and automatically generate for each patient:

A Health Risk Assessment Profile. Targeted Patient Education Briefs made available through the Guardian Library. A comprehensive Personalized Preventive Care Plan (PPCP)

Each of the HRA/AWV documents created by the Guardian platform can be automatically integrated into an EMR as a PDF or filed as paper copy in a patient’s medical record as an audit proof permanent document. In addition, the information/data captured in the HRA/AWV process serves as a fundamental initial base for creating a Patient Master Chart (PMC) in the Guardian platform.

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