Date of Degree
Summer 2025
Document Type
DNP Scholarly Project
Academic Department
School of Nursing
Degree Type
Doctoral
Degree Name
Doctor of Nursing Practice
First Advisor
Dr. Amanda Graham, DNP, MSN, RN-BC, AMB-BC
Second Advisor
Dr. Melanie Brewer, DNSc, RN, FNP-BC, NEA-BC, FAANP
Abstract
Problem: Despite being a covered service designed to support individualized prevention planning, the Medicare Annual Wellness Visit (MAWV) remains underutilized at a rural Federally Qualified Health Center (FQHC). Barriers include low patient awareness, inconsistent outreach, and a reactive scheduling process that excludes patients without upcoming appointments. These issues limit the FQHC’s ability to meet preventive care goals and sustain performance in value-based reimbursement models.
Aim of the Project: This quality improvement project evaluates the impact of implementing a nurse navigator on MAWV completion. The intervention incorporates proactive scheduling and cohort engagement to address barriers related to awareness, access, and outreach.
Review of the Evidence: Evidence supporting nurse navigator roles in MAWV coordination is promising, though primarily based on observational studies and quality improvement (QI) initiatives. While the outcomes suggest improved access and engagement, further research is needed to validate these findings across diverse clinical settings. Nurse-led outreach and standardized workflows show potential to enhance preventive services in underserved populations.
Project Design: The project follows the Plan-Do-Study-Act (PDSA) model and the OhioHealth Change Management framework. Staff readiness assessments, stakeholder input, and workflow audits support implementation. Data are collected weekly and analyzed using Microsoft Excel to track trends and guide improvement.
Intervention: Over the course of ten weeks, a nurse navigator conducts patient pre-screening, provides individualized outreach, schedules visits, and coordinates follow-up care. Staff receive training on revised workflows, and weekly progress reports support monitoring. All activities adhere to the Health Insurance Portability and Accountability Act (HIPAA) compliance standards and prioritize equitable engagement.
Significant Findings/Outcomes: MAWV completion rates rise from 43% to 52%, resulting in 35 additional visits. Clinicians describe the increase as clinically meaningful, and a large effect size is observed. Staff workload remains stable, and billing projections indicate a potential net revenue gain. Outreach efficiency improves by 18%, missed appointments decline, and documentation accuracy improves. Patients report higher satisfaction, especially with communication and coordination of care.
Implications for Nursing: This nurse navigator-led model improves access to preventive care without increasing staff burden. It supports nursing goals of equity, care quality, and population health in FQHC settings.
Recommended Citation
Snyder, Nanette L., "The Impact of a Nurse Navigator on the Completion of Medicare Annual Wellness Visits" (2025). Doctor of Nursing Practice (DNP) Scholarly Project. 35.
https://fuse.franklin.edu/dnp-project/35
Rights
CC BY-NC-SA 4.0
