Legacy Health Partners - News & Updates
Delivering value and improving health
Driving Wellness Forward – Annual Wellness Visits as Our Path to Value
A message from Dr. Albert Chaffin, LHP Medical Director
This year, Legacy Health Partners is seeing exciting momentum in Annual Wellness Visits (AWVs). Thanks to expanded support from Legacy Medical Group pharmacists and nurses, our network doubled the number of AWVs completed from 2024 to 2025. This surge in preventive visits means more patients are getting comprehensive check-ups and care plans – a win for patient health and a testament to teamwork across clinicians, pharmacists, and nurses. Early outcomes are encouraging, but they also reveal how much opportunity remains. AWV completion rates hovered around 15–17% last year, against a 50% benchmark set by major Medicare value-based programs. In other words, we’re making progress, yet we have a significant gap to close to meet our targets.
Why does this matter? AWVs are not just check-the-box exercises, they are linchpins of value-based care success. Research shows that patients who complete an AWV incur about 6% lower healthcare costs per year, on average. AWVs also drive better outcomes by boosting preventive screenings (from cancer screenings to depression checks) and improving chronic disease metrics. In our value-based arrangements, AWV performance is often directly tied to incentives and shared savings. In fact, some of our largest programs require at least 50% of eligible patients to have an AWV in a year to fully earn savings or quality bonuses. We’ve already felt this pressure, and the upside, of strong AWV performance.
It’s important to note that this effort extends beyond LHP contracts. We recognize that your practices serve patients covered by many payors, not just those in our network. Strengthening AWV outreach will benefit all these populations by enhancing preventive care and meeting broader payer expectations. For example, one major Medicare Advantage plan has even pushed for AWVs for every member. So, improving AWV rates is a “rising tide” strategy that lifts care quality and value across the board.
Let’s capitalize on this momentum. Annual Wellness Visits are a cornerstone of our strategy for thriving in value-based care. We celebrate the pharmacists and nurses who’ve jump-started our AWV efforts, and we challenge every practice to build on their success. That means embracing innovative workflows (like pharmacist- and RN-led AWV visits), using data to identify patients due for an AWV, and making outreach a priority. With a network-wide push, we can meet our upcoming AWV target and ensure no patient misses out on this vital visit. The finish line (50% and beyond) is within reach. Through our commitment to Annual Wellness Visits, we will capture more value-based rewards, improve outcomes for our Medicare patients, and deliver better care for every population we serve. Let’s get there together, one wellness visit at a time.
Quality Corner
Be SMART About Asthma: A Simpler, Safer Way to Prevent Exacerbations
Single Maintenance and Reliever Therapy (SMART) is a modern, patient-friendly approach that can significantly improve asthma control. By prescribing an ICS-formoterol inhaler for both maintenance and relief, primary care providers can simplify treatment and provide on-demand anti-inflammatory therapy that heads off exacerbations.
Who can use SMART?
U.S. guidelines now recommend SMART in appropriate patients, reflecting its strong evidence. Here’s how current guidelines incorporate SMART, summarized by age group in the table below:
Table – Guideline Recommendations for SMART by Age Group (based on NHLBI 2020 Focused Updates)
|
Age Group |
NHLBI 2020 (NAEPP) |
|
0-3 years |
No SMART. Standard ICS controller therapy; consider intermittent ICS for viral wheezing as per guidelines. |
|
4-11 years |
SMART recommended for moderate persistent asthma (Step 3). Use low-dose ICS-formoterol for daily control and as-needed relief. Max ~8 total puffs/day (using low-dose pediatric inhaler) in this age group. [1] |
|
12 years and older |
SMART strongly recommended for moderate to severe asthma (Steps 3–4). Use low or medium-dose ICS-formoterol for maintenance and relief. Max ~12 total puffs/day (no more than 4–6 puffs at one time). For Step 5 (very severe), continue high-dose ICS/LABA and add biologics or other add-ons as needed (SMART may be part of Step 5 plan). |
Why Switch? The Benefits of SMART
- Fewer Severe Attacks: Large studies show ~30% fewer asthma exacerbations requiring oral steroids, ED visits, or hospitalization
- Reduced ED Visits & Hospitalizations
- Less Oral Steroid Exposure
- Simpler Routine, Better Adherence
- Empowering Patients: the treatment adapts to a patient’s day. More symptoms = more doses (stepping up automatically); good control = just the baseline doses.
Initiating SMART: Patient Selection & How to Prescribe
The NHLBI 2020 asthma guidelines are a free resource that can help you identify patients who would benefit from SMART, how to prescribe, and educate patients about their new therapy to avoid confusion. Checking back in with patients in 4-6 weeks is an important step after starting SMART to review how often they’ve been using the inhaler and to ensure they have an adequate supply. Since one inhaler is used for both maintenance and rescue, they might go through it faster than a traditional maintenance inhaler. Sometimes it helps to write the prescription for a larger quantity or indicate on the script that it’s for SMART (insurance may allow extra refills when they understand the therapy plan).
With the right education and follow-up, you can help more patients breathe easy, prevent exacerbations, and reduce costly urgent visits and hospitalizations.
Network Spotlight: The Importance of Colorectal Cancer Screening
March is National Colorectal Cancer Awareness Month, a key opportunity to remind patients that routine colonoscopies remain the most effective way to detect colorectal cancer early. Colonoscopy is considered the gold standard for screening because it allows for both detection and removal of precancerous polyps during the same procedure, significantly lowering cancer risk and improving long term outcomes. Other screening options such as stool based tests can be appropriate for some patients, but colonoscopy provides the most comprehensive evaluation. Encouraging adults age 45 and older, and anyone with a family history or elevated risk factors, to stay current with screenings can make a measurable difference in early detection and survival rates.
Download a copy of the Colorectal Cancer Screening Toolkit developed by Legacy Health Partners. You can also view a list of providers in the LHP network who do colonoscopies.
Announcements, deadlines, and reminders
- Thank you to all adult primary care practices who recently submitted supplemental clinical data from your electronic health record to support 2025 measure results. Our teams are loading these additional data points to contribute to measure outcomes and quality scores. Once we have finalized 2025 performance, LHP’s performance dashboards and reporting for 2026 will display in Power BI. We will notify the network soon once the current year’s data is available later this spring.
- Have any performance measures to suggest? We want to hear your ideas on performance measures we should consider for the future of LHP. Complete this online form to propose a measure. We will accept suggestions throughout the year, but those submitted by the end of April have the best chance of being considered for the 2027 program since we are already planning for next year.
- Last month, CARES Northwest moved its Washington County location to the new Family Peace Center of Washington County, in Hillsboro. The new clinical space brings together more than 20 partner agencies to provide holistic, coordinated services across medical care, legal support, housing, mental health, and early childhood services. Access the 24-hour referral line through Randall Children’s Hospital at 503-276-9100.
