The Annual Wellness Visit (AWV) Playbook: Staffing Blueprints, Metrics, and Measurable Results for Every Practice Size

Annual Wellness Visits (AWVs) are often described as the cornerstone of Medicare’s preventive care strategy, and for good reasons. In our earlier article “AWV 101: What It Is and Why It’s Important,” we laid out the foundational elements: eligibility criteria, required components, and how AWVs differ from routine exams. In “Using AWVs and CCM Together: Maximizing Preventive and Chronic Care,” we explored how AWVs and Chronic Care Management (CCM) can create a powerful continuum, from annual check-in to continuous oversight, and in “Annual Wellness Visits and Preventive Care: How AWVs Help Close Care Gaps,” we highlighted AWVs as a systematic engine for catching overdue services, chronic disease gaps, and risk factors. This new article picks up where those leave off.

At Lara Health, we work with our partnering medical practices to help them implement a structured, reliable system to improve performance across clinical, financial, and operational dimensions, so, if the first article taught you what an AWV is, and the second showed why you should pair it with CCM, and the third showed you how to use AWVs to improve patient outcomes, this article tells you how to implement AWVs operationally, and enhance your economics. While we cannot go in the details of everything we do for our customers, this article lays-out staffing blueprints, key performance indicators (KPIs), and real-world ROI scenarios tailored to practices of any size. Think of it as the AWV & CCM playbook, the bridge between strategy and execution, built to amplify what those foundational pieces already teach.

Let’s dig into how to design your team, define your metrics, and unlock measurable results from AWVs and CCM at scale.

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Premises for this playbook

Before diving into staffing models, KPIs, and ROI, it’s important to clarify the assumptions behind this playbook.

• CCM already operationalized. We assume your practice has already stood up a functioning Chronic Care Management (CCM) program, meaning you’re capturing consent, logging minutes, and running monthly follow-up workflows. The AWV framework described here is designed to plug directly into that existing structure, creating a seamless bridge between annual preventive planning and monthly chronic care execution.
• Flexible care team models. Practices working with Lara Health can choose the model that fits them best. Some prefer to run CCM and AWVs entirely with their own in-house staff, using Lara Health’s platform for automation, compliance, and reporting. Others supplement their internal team with Lara Health’s US-based, licensed, and highly experienced virtual care managers, who slot directly into existing workflows to expand capacity without adding local headcount.
  

With those premises in place, the remainder of this article focuses on how to staff, measure, and scale AWVs as a complementary engine to your CCM program, turning annual encounters into year-round performance.

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The choice to use in-house staff with Lara Health's software platform, or use Lara Health's seasoned Virtual Care team is up to the practice

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Team design blueprints at different scales

No two practices look alike, and neither should their approach to Annual Wellness Visits (AWVs) and Chronic Care Management (CCM). A solo physician’s office needs to be lean and efficient, while a multi-site ACO needs centralized processes and robust analytics. Below are scalable blueprints that show how to staff, structure, and operationalize AWVs at different practice sizes.

Small practice (up to three clinicians). For small offices, resources are tight and every team member must wear multiple hats. The key is cross-training and protected time.

• Cross-train staff: One MA can handle AWV intake (vitals, risk assessments, HRA) and also log CCM minutes. This dual role ensures that AWVs feed directly into CCM without adding headcount.
• Block time deliberately: Protect ten AWV slots each week. With a panel of 1000 eligible patients, this supports a realistic goal of 50–80% AWV completion in year one.
• CCM coverage: Dedicate 2-3 FTE RN/MA to CCM. With 500 patients, this allows manageable caseloads while producing recurring revenue.
• Why it works: A single well-trained MA or nurse who can handle both AWV prep and CCM follow-up makes the program sustainable without overwhelming the physician.
• ‍With Lara Health: Look for smaller staffing requirements (or none at all with the Virtual Care Team solution). How efficient your implementation is depends on how well the platform you are using allows you to "capture" work that your staff was already doing without being billed. The right platform lowers the effort required by your staff.‍

Medium practice (four to twenty clinicians). Medium practices benefit from dedicated pods that split preventive and chronic care from routine office visits.

• Preventive & Chronic Care Pod: Create a dedicated pod consisting of one RN and one to two MAs working from a shared patient queue.
• Weekly huddles: Use a recurring 30-minute meeting to review the AWV backlog and hand off flagged patients into CCM. This ensures no eligible patient is missed.
• Escalation rules: Define clear criteria that empower the pod team (e.g., “If BP ≥160/100 on two separate readings the ensure same-day clinician message”). This reduces delays and keeps clinicians focused on decision-making, not monitoring.
• Why it works: The pod structure balances efficiency with accountability. With a dedicated team, AWVs don’t compete for resources with same-day sick visits.
• ‍With Lara Health: Look for measurably enhanced staff productivity and patient outcomes
  

Large group or ACO. Large groups and ACOs must manage AWVs at population scale, with several thousands of patients eligible each year. The key is centralization of complex tasks, paired with local patient engagement.

• Centralized functions: Outreach campaigns, AWV templates, and compliance auditing should be centralized to ensure consistency across sites.
• Decentralized continuity: Patient calls and CCM check-ins are best handled at the local practice level so patients feel connected to their own care team.
• Add a quality analyst: A dedicated analyst tracks AWV completion, CCM minutes, and quality performance. Their insights tie directly to contract-based incentives and shared savings programs.
• Why it works: This “hub and spoke” model ensures standardization at scale while preserving the local relationships that keep patients engaged.
• ‍With Lara Health: Look for greater coordination, compliance and measurably enhanced staff productivity and patient outcomes

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KPIs that prove it’s working

A well-designed AWV program should not only generate more visits but also show tangible improvement in patient outcomes, quality scores, and revenue. To know if it’s working, you need to track a balanced scorecard of throughput, execution, clinical, financial, and equity metrics.

1. Throughput: Are you reaching enough patients?

• AWV completion rate: Target ≥70% of eligible patients annually. Top-performing practices achieve 80-90% completion by embedding AWVs into scheduling scripts and outreach campaigns.
• CCM enrollment rate: Among eligible patients (≥2 chronic conditions), aim for at least 30-40% enrollment (albeit leading implementations for CCM achieve much higher levels of enrollment, we will not discuss this here, as this article is dedicated to AWVs). This ensures AWVs don’t just create a plan, but that the plan is carried through with ongoing CCM.‍
• How to measure: Use your EHR or Lara Health dashboards to calculate completion percentages monthly, stratified by provider and patient demographics.

2. Execution: Are you closing the gaps identified during AWVs?

• Order follow-through: Track the percentage of AWV-generated orders (labs, screenings, vaccines, referrals) completed within 60 days. A healthy benchmark is ≥80%.
• CCM minutes captured: Ensure monthly CCM time logs show ≥20 minutes per patient for the base code, with add-ons as appropriate for complex patients.
• How to measure: Run care-gap closure reports and compare ordered vs. completed services; audit CCM notes monthly for time compliance.

3. Clinical movement: Are patients getting healthier?

• Hypertension control: Monitor average systolic BP changes in enrolled patients. A 5 mmHg average reduction is clinically meaningful and tied to quality benchmarks.
• Diabetes control: Track A1c improvement; target a ≥0.5% reduction in poorly controlled diabetics.
• Screening and exam completion: Track percentage of diabetics with annual retinal and foot exams; target ≥80%.
• Fall-risk mitigation: Document interventions (PT referrals, home safety modifications, de-prescribing). Aim for ≥70% follow-through in high-risk patients.
• How to measure: Aggregate patient-level data from AWV/CCM care plans into Lara Health’s analytics dashboards or EHR reports.

4. Financial: Is the program paying for itself?

• AWV revenue: Calculate total AWV billing (CPT G0438 / CPT G0439) captured vs. eligible opportunities (see the next section for additional details).
• CCM per-member-per-month (PMPM) revenue: Track average reimbursement ($62-$160 PMPM, see the next section for additional details).
• Incentive/bonus revenue: Measure dollars tied to closed care gaps (MIPS, Medicare Advantage Star Ratings, ACO shared savings).
• No-show rate: Lower no-show rates indicate patients value and prioritize AWVs. Target <15%.
• How to measure: Use monthly revenue reports, payer dashboards, and internal billing audits.

5. Equity and access: Are you reaching the patients who need it most?

• Measure effectiveness in rural areas: Track percentage of rural patients completing AWVs and implement workflows that support patients living in rural areas
• SDOH barrier resolution: Count and resolve documented issues like transportation, food insecurity, or medication cost barriers.
• How to measure: Monitor SDOH fields in care plans; track resolutions (e.g., transportation arranged, food program referrals).

Turning KPIs into management tools

KPIs should not just sit on a dashboard: they should drive weekly and monthly decisions.

• Weekly pod huddles (medium practices): Review backlog and care-gap closure metrics.
• Monthly leadership reviews: Compare throughput and revenue KPIs against goals.
• Quarterly quality meetings: Use clinical and equity KPIs to evaluate impact and adjust staffing or workflows.

With Lara Health, all these KPIs flow into audit-ready reports and dashboards that combine AWV and CCM data, so practices can see exactly how performance translates into outcomes and revenue.

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ROI from implementing AWVs with CCM

Scaling Annual Wellness Visits (AWVs) alongside Chronic Care Management (CCM) generates both direct reimbursement and indirect financial impact through downstream services and incentive programs. The numbers below are illustrative scenarios based on typical Medicare fee schedule averages, while actual results will vary by payer mix, geography, and program execution. Always validate reimbursement with your local Medicare Physician Fee Schedule (PFS).

Front-end revenue (AWVs)

• 90% completion rate across 1,000 eligible patients implies 900 AWVs annually.
• At around $200 per AWV, this yields around $180,000/year in direct AWV reimbursement.
• Sensitivity: At $175 per AWV, total equals to $157,500 per year; at $225 per AWV, total equals to $202,500 per year.
  

Recurring revenue (CCM)

• 80% enrollment rate across 1,000 eligible patients implies 800 patients in CCM.
• At about $62-160 PMPM, this equals around $595,200-1,536,000/year recurring revenue.
• Sensitivity: Every 100-patient swing in enrollment represents around $74,400-192,000/year of revenue.
  

Preventive lift and quality incentives

• AWVs often surface additional reimbursable services (e.g. vaccines, labs, cancer screenings) plus payer incentive dollars tied to care-gap closures.
• Conservative estimate: $50,000-100,000/year, depending on contract structures (e.g., Medicare Advantage Star Ratings, ACO shared savings).
  

Total potential impact

• Combined annual revenue potential: around $825,000-1,816,000.
• For many primary care practices, this can represent a 1.5-3.4x increase in annual Medicare-related revenue, depending on baseline billing volume.
• Beyond revenue: consistent dual AWV-CCM execution produces near-universal prevention-plan coverage, high CCM adoption, and measurable improvements in clinical performance indicators (blood pressure control, A1c reduction, fall-risk mitigation).
  

Hidden ROI drivers

The revenue line items tell only part of the story. Hidden ROI drivers amplify both financial stability and care quality:

• Reduced patient leakage: Patients engaged in AWVs and CCM are less likely to leave the practice or seek care elsewhere. This keeps referrals, labs, and procedures inside your network, preserving downstream revenue.
• Enhanced staff efficiency: Standardized templates and dashboards (as provided by Lara Health) minimize duplication, prevent missed documentation, and make closing care gaps faster. A more efficient team means more capacity to see additional patients or expand panel size without proportionally increasing staff costs.
• Financial predictability: CCM’s recurring PMPM revenue creates a steady cash flow, helping practices weather seasonal dips in office visits or fluctuations in fee-for-service demand.
• Stronger contract performance: High AWV completion and CCM enrollment directly improve payer quality scores (MIPS, Star Ratings, ACO benchmarks), unlocking bonus pools and positioning practices as high-performing partners.
• Patient loyalty and satisfaction: Continuous monthly engagement strengthens patient trust, leading to higher retention rates and better CAHPS scores, both of which matter in value-based contracts.

Overall, implementations of CCM with AWVs see revenue multipliers from their starting revenue baseline between 1.5 and 3.4x, but moving from a conservative to a top-end of the range performance level isn’t about working harder, it’s about working smarter. Lara Health helps practices close that gap by automating patient identification, outreach, and scheduling for AWVs, streamlining CCM documentation and time capture, and ensuring every eligible patient is flagged and enrolled. Whether you rely on your in-house staff or choose to leverage Lara Health’s US-based virtual care managers, our platform builds the consistency needed to reach 80–90% AWV completion and 80%+ CCM enrollment. That’s how practices transform ROI scenarios from theoretical to real, and how they move toward doubling or even tripling their Medicare-related revenue while delivering better care.

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Final take

Annual Wellness Visits are far more than a billing opportunity: they are the front door to a year-long continuum of care. Done well, AWVs bring structure to prevention, surface chronic disease risks early, and create a steady stream of patients eligible for Chronic Care Management. But without a staffing blueprint and clear metrics, AWVs too often stall at 20-30% completion, leaving revenue and quality gains on the table. This playbook shows that with the right design, any practice can make AWVs scalable:

• Small practices can lean on cross-training and protected time to reach 50-60% completion in the first year.
• Medium groups can build preventive pods with clear escalation rules, ensuring AWVs flow naturally into CCM.
• Large organizations and ACOs can centralize outreach and auditing while maintaining local continuity, linking AWV performance directly to contract incentives.
  

The KPIs outlined (from throughput to equity metrics) provide a simple management dashboard to keep programs on track. And the ROI scenarios prove that scaling AWVs with CCM can transform the economics of primary care, delivering anywhere from a 1.5x to 3.4x lift in annual  revenue while improving outcomes across the board.

At Lara Health, we help practices turn this blueprint into reality. Our platform automates AWV scheduling and CCM time capture, integrates seamlessly with your EHR, and provides audit-ready reports. And for practices short on bandwidth, our US-based, licensed virtual care team can extend your staff capacity without adding headcount.

The message is simple: AWVs aren’t just a compliance requirement: they are the launchpad for better care and stronger economics. Pair them with CCM, track the right metrics, and use Lara Health to operationalize the workflows, and your practice can unlock both healthier patients and a healthier bottom line. Book a demo with Lara Health to see how your practice can move from conservative execution to aggressive success, and make AWVs the engine of year-round preventive and chronic care.

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FAQ

How often can Medicare patients receive an AWV?

Medicare covers one Initial Annual Wellness Visit (CPT G0438) in a patient’s lifetime and one Subsequent AWV (CPT G0439) every 12 months.

What’s the difference between an AWV and a routine physical exam?

An AWV is focused on prevention, risk assessments, screenings, and a personalized prevention plan. Medicare, for example, does not cover a “routine physical” exam, but it does cover AWVs.

Can AWVs and CCM be billed together?

Yes. AWVs are billed annually, and CCM is billed monthly for eligible patients with two or more chronic conditions. Both can be reimbursed if requirements are independently met and time is not double-counted.

How do AWVs help feed into CCM?

AWVs identify patients with chronic conditions and unmet preventive needs. These patients are ideal candidates for CCM, which provides ongoing monthly follow-up to ensure preventive plans and chronic care goals are carried out.

What KPIs should practices track to measure AWV success?

Completion rate (≥70% of eligible patients), CCM enrollment rate (30-40%+), order follow-through within 60 days, clinical outcomes (BP, A1c, foot/retinal exams), and financial performance (AWV revenue, CCM PMPM, incentive dollars).

What ROI can practices expect from AWVs paired with CCM?

A practice with 1,000 eligible patients, achieving 90% AWV completion and 80% CCM enrollment, can generate a $825,000-$1,816,000 annually in combined revenue streams, often representing a 1.5x-3.4x increase in Medicare-related revenue.

How does Lara Health help practices operationalize AWVs?

Lara Health automates AWV scheduling, patient identification, and CCM documentation, while providing audit-ready reports and dashboards. Practices can use their in-house team or leverage Lara Health’s US-based, licensed virtual care managers to expand capacity and ensure consistent execution.

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Other articles you might find interesting

Annual Wellness Visit (AWV) 101: What It Is and Why It’s Important

Annual Wellness Visits and Preventive Care: How AWVs Help Close Care Gaps

Using AWVs and CCM Together: Maximizing Preventive and Chronic Care

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Sources

CMS. “Medicare Wellness Visits.” MLN Booklet, 2024.

CMS. “Medicare Preventive Services: Annual Wellness Visit.” CMS.gov, 2024.

CMS. “Chronic Care Management Services.” MLN Fact Sheet, 2025.