Date of Graduation

Summer 8-9-2022

Document Access

Restricted Project/Capstone - USF access only

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


Kaiser cohort MSN capstone

First Advisor

Cathy Coleman


Problem: While Annual Wellness Visits (AWVs) are widely accepted as beneficial and necessary, they remain underutilized. This writer intended to increase the number of AWVs scheduled with primary care physicians (PCPs) with the help of eConsults. Many seniors are still not utilizing AWVs, perhaps because they perceive them to be minimally valuable or too difficult to access. Social and behavioral determinants of health may be contributors to many members not utilizing this copay free provision. A global aim and additional outcome for this project included creation of a template for future QI projects within the year at a clinic in Northern California.

Context: A health check-up, also known as an AWV, was introduced by Medicare within the Affordable Care Act (ACA). The Center for Medicare & Medicaid Services (CMS) viewed the provision of an AWV as a valuable means for health providers to be reimbursed for care. Furthermore, increasing AWVs can minimize the high costs of chronic illness and disabilities, leading to positive economic impacts. Health screenings, which can cover function, cognition, and depression, help guide treatments and formulate individualized prevention plans.

Interventions: By June 30, 2022, patients eligible for yearly wellness visits would schedule appointments using eConsult, with 2% improvement at a clinic in Northern California. Patients were offered appointments with their PCPs when they were physically present on campus. This in reach effort to schedule patients using the eConsult scheduling system aimed to improve operational efficiency.

Measures: The outcome measure was increased scheduling of AWVs with PCPs using the eConsult application. A process measure added efficiency to the work of achieving AWV for our members.

Results: Twenty-nine patients were scheduled and seen by their PCPs within this project, achieving a 19% success rate. The in-reach method did not show successful results, and edits were made to the interventions. The post intervention employee questionnaire showed satisfaction within the group about involvement on the effort to increase AWV scheduled, and with >95% attendance to the huddles.

Conclusion: The investment of time and team building, and the introduction of improved methodologies/tools produced more motivated and knowledgeable staff members. By creating a nonthreatening work environment, a culture of continuous learning, and outcomes management strategies, this CNL student mobilized frontline microsystem teams to improve both patient and organizational outcomes. This QI project allowed the team to tackle the operational, clinical, and financial realities of care delivery while striving to successfully increase timely scheduling of outpatient AWVs using eConsult, an electronic decision support tool.

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