Article Sections
AWV Assessments into a Patient Care Plan
Select information from a patient’s Annual Well Visit (AWV) will automatically be pulled and incorporated into their patient care plan.
The sections of information included in an AWV includes:
Medical History
Hospitalizations and Surgical History
Providers and Suppliers
Medications and Allergies
Social History
Mental Health
Lifestyle
Functional Status and Support
Home Safety
Life Planning
Preventive Services
Completed by
Care Coordination Programs
NOTE: Not all information and patient answers from the AWV will be pulled into the care plan.
NOTE: Please reach out to your Customer Success Manager to enable this feature.
An AWV assessment can be completed through the ‘Wellness’ tab on a patient’s file.
From the ‘Wellness’ tab, select the ‘AWV’ tab and then choose the Annual Wellness Visit assessment.
Note: If this is the first time performing an AWV assessment for a patient or you need to perform another AWV within the first year period of a patient’s first AWV, then you may need to choose the ‘IAWV’ assessment option which stands for ‘Initial Annual Wellness Visit.’
If the patient already has taken an IAWV, then the user may select the ‘Subsequent AWV Exam.’
NOTE: The modal contains language explaining and giving caution to selecting the right exam type. Selecting the incorrect exam type for a patient may lead to billing issues and claims not going through.
Patient answers within the AWV assessment may trigger automation of care plan items to be generated within a patient’s profile under their ‘Summary of Care’ tab and “Care Management’ tab.
The following examples below will highlight some of the possible automation options that have been built into the ThoroughCare software.
During the assessment, if a patient is asked “Do you have any problems taking medications as prescribed?” and the user completing the assessment documents their answer as “Yes” then the software will automatically add the ‘Medication Adherence Issues’ care plan item to the patient’s file.
In the same scenario, if a patient is asked the following questions:
“Do you have any difficulty picking up your medications such as paying for them or having transportation to obtain them?” and the patient answers “Yes.”
“Is your support system adequate and meeting your needs?” and the patient answers “No.”
“Do you have hearing aids?” and the patient answers “Yes, but they are inadequate.”
“If you were unable to get up following a fall, do you have a way to call for emergency help?” and the patient answers “No.”
Then the ‘Lack of Resources and/or Support” care plan item is automatically populated to the patient’s file.
If during an AWV the patient is asked:
“Have you ever felt you should cut down on your drinking?” and the patient answers “Yes”
“Have people annoyed you by criticizing your drinking?” and the patient answers “Yes.”
“Have you ever felt bad or guilty about your drinking?” and the patient answers “Yes.”
“Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?” and the patient answers “Yes.”
Then the ‘Alcoholism’ care plan item is automatically populated to the patient’s file.
When a patient is asked “Do you smoke or use nicotine products?” during their AWV and they respond with “Yes”:
Then the ‘Nicotine Dependence’ care plan item is automatically populated to the patient file.
During the AWV, if a patient is asked “Do you have any problems with pain?” and they respond with “Yes, my pain is currently unmanaged.”
Then the ‘Chronic Pain’ care plan item is automatically populated to the patient.
When a patient’s AWV exam asks them “In a typical week, how many days do you eat a balanced diet of fruit, vegetables, protein, and whole grains?” and the patient responds with the answer of “1-2 days” or '"Never":
Then the “Diet Adherence Issues” care plan item is automatically populated to the patient.
If in the AWV a patient is asked “On average, do you exercise at least 30 minutes a day, 5 days a week?” and they answer with “No”:
Then the “Physical Inactivity” care plan item is automatically populated to the patient.
Should a patient get asked, “On average, how many hours of sleep are you able to get each night?” and they answer with “4 hours,” “3 hours,” “2 hours,” “1 hour,” or “Less than 1 hour”:
Then the “Sleep Disturbance” care plan item is automatically populated to the patient.
When a user documents a patient’s AWV, and the assessment asks the patient:
“Have you fallen in the past year?” and the patient answers “Yes”
“Do you feel unsteady when standing or walking?” and the patient answers “Yes”
“Do you worry about falling?” and the patient answers “Yes”
Then the “Fall Risk” care plan item is automatically populated to the patient.
When a user documents a patient’s AWV, and the patient is asked:
“Are the walkways in your home clear of cords, furniture, clutter?” and the patient answers “No.”
“Do your stairways have handrails?” and the patient answers “No.”
“Do you have difficulty getting in and out of the bath or shower or have concerns of falling while bathing?” and the patient answers “Yes.”
“Do you have adequate lighting throughout the house including areas of transitions like hallways or stairways?” and the patient answers “No.”
“Do you have functioning smoke detectors in your home that you perform routine maintenance on such as changing the batteries?” and the patient answers “No.”
Then the “Unsafe Living Conditions” care plan item is automatically populated to the patient.
If in an AWV a patient is asked “Do you have any of the following life planning documents in place?” and the patient responds with “I do not have life planning documents in place”:
Then the “Gaps in Care” care plan item is automatically populated to the patient.
Utilizing the Automation of AWV Patient Problems
Care plan items are automatically populated to patient files through the provided patient answers in their AWV assessment.
These care plan items will be added as ‘Problems’ under the ‘Summary of Care’ tab and 'Care Management' tab (under enrolled programs associated) in a patient file.
The status of the ‘Problems’ will be listed as ‘Suggested’ since they were just populated through AWV automation.
These automatically generated patient problem cards can be interacted with like a manually added problem card in that they may be clicked on, and a user can see suggested goals, barriers, and interventions attached to the problem.
A user may also search and add other care plan items to these problems aside from the suggested items.
In the example below, a user may then navigate to the 'Care Management' tab and under the 'Problems' tab below it they will find the same Care Plan items in the 'Suggested' state.
To access other helpful ThoroughCare articles in the Knowledge Base or to get help from the ThoroughCare Support team members, click the ‘i’ icon in the top right corner of the software next to the user name and use the appropriate link.