Sentara Medical Group uses a unique team approach to provide wraparound care for seniors, providing hope and help.

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Giving Hope and Help: Annual Wellness Visits Offer Big Picture Coordination for Seniors

Using a team approach, Sentara Medical Group is now offering a unique way of wraparound care for seniors. People over 65 are eligible for a free one hour consultation under MediCare Advantage with a nurse practitioner, a registered nurse and a medical assistant.

Since June 2017, nurse practitioner Donna Forrest has been working with a team that travels to primary care practices around southeastern Virginia to see patients and their loved ones.

"It's all coordinated with their doctor, who isn't present during the appointment but gets all of our notes. We collect information from any specialists, as well as from the patient, try to get ahead of any problems and address them," she said.

Even though this benefit has been available for years, Forrest said it's been slow taking off.

"This is a comprehensive appointment, not a routine physical or a visit to address a chronic condition. We completely review a patient's health and needs, in depth for about an hour. We review medical history, medications and prevention, so it's not a quick visit," she said.

But patients who commit to coming in for the conversation think it's worthwhile. The care team looks at a number of things, including social support systems, at home fall risks, depression and alcohol use, as well as any family health risks that might indicate a need for screening.

"Nearly everyone says it was so helpful and that they understand their health so much better," she said.

Forrest said there have been a few surprise lessons along the way. "Patients don't understand condition as much as we thought or why they are taking certain medications. Sometimes they get a test at the doctor's office and don't follow up for the results. They may have reading challenges or math challenges that make following instructions more difficult," she said.

These wellness visits aren't just for the patient, they are often combined appointments for spouses, adult children, grandchildren or other caregivers, such as neighbors, to attend. This way, information can be shared, and caregivers can lean on the professionals for advice and expertise. Patients leave with a plan for care.

"We don't just say 'You need a mammogram,' we schedule the mammogram appointment for them at the closest location. We might give the first pneumonia shot today, and schedule and remind them to come for the follow-up," Forrest said.

Although the Sentara program is unique in how it's offered, the benefit is for anyone enrolled in Medicare. Forrest said that nationally, only about 16-18 percent of eligible Medicare recipients are taking advantage of this benefit – Sentara Medical Group's goal is to reach 80 percent of their patients.

"We like to see them as soon as they turn 65! It gives us an accurate picture of their health and meet their needs. We don't want to wait for problems," she said.

Other benefits of this visit are that it can help with health care coordination if you see more than one doctor and can help point out areas where a patient might need more explanation, such as what will happen if they don't take their medication or why they need to cut back on alcohol because it's affecting their sleep.

"Our goal is to provide the best care we can to our senior patients to keep them independent and healthy as long as possible. Aging is inevitable, but there are solutions that can offer hope and care," Forrest said.

Donna Forrest is a Nurse Practitioner and the Chief Coordinator for Advanced Practice Clinicians for Senior Health Services at Sentara Medical Group.