Ambulatory Nurse Leaders: Developing Opportunities for Patient-Focused Care Navigation

In previous columns, we have discussed the need for nurses to assist ambulatory care patients with navigating the complexities not only of ambulatory care services, but also with knowing the options open to Medicare and Medicaid patients as a result of the health care reform law. The movement toward prevention and wellness care for Medicare patients begins with the Annual Medicare Wellness provision described in the Patient Protection and Affordable Care Act (PPACA).

According to a guide from the Centers for Medicare & Medicaid Services (CMS, 2011). "Medicare covers a onetime preventive visit within the first 12 months" for patients that have Medicare Part B. "This visit is called the ‘Welcome to Medicare’ preventive visit. It includes a review of medical and social history related to health, and education and counseling about preventive services, including certain screenings, shots, and referrals for other care, if needed" (p. 9).

Starting January 1, 2011, patients that have had Part B for longer than 12 months were able to get a yearly "wellness" visit to develop or update a personalized prevention plan based on current health and risk factors (CMS, 2011). This visit, which is covered once every 12 months, includes the following:

  • Review of medical and family history
  • A list of current providers and prescriptions
  • Height, weight, blood pressure, and other routine measurements
  • A screening schedule for appropriate preventive services
  • A list of risk factors and treatment options (p. 11)

The CMS guide also lists all the typical preventive screenings and how often they are done. It also notes that if a patient has Original Medicare and their physician accepts Medicare, there is no cost to the patient. This is a wonderful benefit that has the potential to enhance health and wellness for senior citizens on Medicare; however, access for the typical Medicare beneficiary, even when they know about this benefit, is challenging. While the Medicare patient who has a primary care provider, physician, or nurse practitioner may request these benefits, others who do not yet have a primary care provider will need to find one who is willing to do these assessments and establish the five-year plan for prevention.

After doing a quick review of health system Web sites in the Midwest, I am convinced that current sites are stuck in specialty care services. The term "prevention" is not commonplace. Health care in the U.S. has had a strong acute care focus in which the desired destination is diagnosis and disease treatment, and navigation within Web sites reflects this. To navigate or steer a course, one must know what and where the destination is.

Most sites are still asking patients to search for physicians by specialty, and primary care is not often listed. The more sophisticated patient may look under family or internal medicine for a primary care provider, but again, although the search started with family or internal medicine, physicians listed under these categories still list specialty areas of practice. (On one site, physicians listed under the category "prevention" had a specialty of emergency medicine.)

Physician groups today should be proactively offering the annual wellness visit, a comprehensive health risk assessment, and a personalized prevention plan, especially since it is funded by Medicare. Again, a quick search of health system Web sites in the Midwest yielded no results when searching for the terms "annual wellness visit," "comprehensive health risk assessment," and "creation of a personalized prevention plan." This begs the question: How can patients easily access such services in our current health system? We are already more than halfway through 2011; what can be done to assist our Medicare patients in ambulatory care?

Certainly a start is for ambulatory care nurses to let patients know that these benefits are available. Next, ambulatory nurse leaders need to be at the table proactively planning for the provision of such services. As a central part of their role, advanced practice nurses in ambulatory care settings should be developing opportunities for annual wellness visits with resultant comprehensive risk assessment and five-year plans for prevention.

Ambulatory nurse leaders should be working with informaticians so that documentation screens are available to reflect contributions of both ambulatory care staff nurses and advanced practice nurses to patient wellness, health promotion, and disease prevention. Ambulatory nurse leaders also need to work with personnel in the appointment scheduling systems to help operators be able to provide responsible answers to requests for annual wellness visits and risk assessments. And finally, nurse leaders should be involved in marketing meetings when materials and Web site content are developed so that these pieces include information on how to access annual wellness and prevention services.

Sheila A. Haas, PhD, RN, FAAN, is a Professor, Niehoff School of Nursing, Loyola University of Chicago, Chicago, IL. She can be reached at

Centers for Medicare and Medicaid Services. (2011). Your guide to Medicare’s preventive services. Baltimore, MD: U.S. Department of Health and Human Services.