Chronic Care Staffing (CCS): Health Risk Assessments and Annual Wellness Visits: How to Use Them for Better Patient Outcomes

Story by Connor Danielowski / February 28, 2025

Introduction

Chronic conditions place a significant strain on the healthcare system and impact patient well-being. Health Risk Assessments (HRAs) and Annual Wellness Visits (AWVs) serve as a powerful tool in addressing this challenge by providing healthcare providers with comprehensive patient insights. These assessments are particularly valuable in chronic care management, enabling early risk detection and personalized intervention strategies.

According to the CDC, chronic diseases and mental health conditions account for 90% of the $4.1 trillion spent annually on healthcare. HRA’s/AWV’s can help.

What is a Health Risk Assessment (HRA)?

A Health Risk Assessment (HRA) is a structured questionnaire designed to evaluate a patient’s overall health. It includes questions about medical history, lifestyle choices, and social determinants of health (SDOH). By gathering self-reported data, HRAs help healthcare providers assess risk factors that may not be immediately apparent during a routine visit.

What is the Importance of HRAs in Chronic Care Management?

1. Early Identification of Health Risks

HRAs allow providers to identify risk factors before they develop into chronic conditions. Information from these assessments enable preventive care measures, reducing hospitalizations and improving long-term health outcomes.

2. Personalized Patient Care Plans

By leveraging HRA data, healthcare providers can develop customized health plans that address individual patient needs. This personalized approach enhances engagement and empowers patients to take an active role in managing their health.

3. Reducing Healthcare Costs

Preventive interventions based on HRA insights shift healthcare resources away from costly treatments toward cost-effective preventive care. Medicare data shows that HRAs incorporated into Annual Wellness Visits (AWVs) lead to nearly a 6% reduction in total healthcare costs per patient per year.

HRAs and Annual Wellness Visits (AWVs)

1. Medicare Requirements for HRAs

HRAs are a mandatory component of Medicare AWVs and must include:

• Identification of chronic diseases and risk factors.
• Review of medical history, family history, and medication adherence.
• Assessment of social and behavioral risk factors.

2. Key Components of an Effective HRA

An HRA should address the following areas:

• Medical History: Past illnesses, surgeries, and chronic conditions.
• Family History: Genetic predispositions to diseases.
• Lifestyle & Behavioral Risks: Smoking, alcohol use, physical activity, diet, and mental health.
• Functional & Social Determinants of Health: Daily living abilities, housing stability, transportation access.
• Falls Risk & Depression Screening: Identifying mobility concerns and mental health challenges.

3. How to Administer HRAs for Maximum Efficiency

To streamline the process and improve participation:

• Using CCS’ Care Management team:
  • Our clinical team calls the patient and completes the HRA in the Practice EMR. 
  • Allows patients to complete assessments in the comfort of their home.
  • CCS then schedules the patient for their face to face meeting with their Provider. Appointment.
  • Patients time in the office is reduced 
  • Provider has more time to see other patients

Enhancing Patient Outcomes with HRA Data

1. Proactive Health Management

HRAs enable proactive intervention strategies, such as recommending lifestyle changes or scheduling necessary screenings based on identified risk factors.

2. Improved Patient Engagement

Patients who actively participate in HRAs gain better awareness of their health risks, leading to higher adherence to treatment plans and healthier lifestyle choices.

3. Data-Driven Decision Making

HRA insights empower providers to make informed decisions regarding patient care, leading to enhanced clinical outcomes and operational efficiency.

Why Your Practice needs HRA’s/AWV’s

AWV’s play a critical role in chronic care management by providing a comprehensive view of patient health. By capturing HRAs into Annual Wellness Visits and leveraging their data effectively, healthcare providers can significantly improve patient outcomes, enhance preventive care, and reduce overall healthcare costs. 

Contact Chronic Care Staffing to learn more about how we can help increase your HRA/AWV visits.

Connor Danielowski

Chief Operating Officer, Chronic Care Staffing

Connor Danielowski is the Chief Operating Officer at Chronic Care Staffing, where he leads operations, strategy, and growth initiatives focused on delivering high-impact virtual care solutions. He brings a unique blend of clinical service knowledge and financial expertise to help healthcare organizations implement and scale Chronic Care Management (CCM), Remote Patient Monitoring (RPM), and other virtual care management services.

Connor began his career in investment banking and private equity, where he focused on investing in healthcare businesses and working closely with management teams to drive revenue growth and profitability. This experience shaped his hands-on, results-oriented approach to healthcare operations today.

He holds a degree in Accounting from Washington & Lee University and brings both analytical rigor and a patient-first mindset to his role. In addition to his work at Chronic Care Staffing, Connor serves on the development board for the MUSC College of Nursing. He lives in Charleston, SC, with his wife and son.

Categories: Chronic Care Management News

Tags: CCS, Chronic Care Staffing