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Adult Health Maintenance

Adult health maintenance focuses on the prevention and early detection of disease and is usually addressed during routine physical examinations and Medicare Wellness Visits (for Medicare Part B beneficiaries), but can also occur at other office visits and outside of a clinical encounter. Important components of adult health maintenance include identifying risk factors for disease, providing recommended vaccinations, counseling on health behaviors, and performing screening studies. The recommended screening studies outlined in this article are in line with USPSTF guidance and are based on factors such as age, sex, risk factors for disease, and prior screening history.

See “Well-child visits” and “Adolescent health” for recommendations on routine wellness visits for younger individuals and “Prenatal care” for routine visits in pregnancy. See “Preventive health care for transgender individuals” for special considerations for transgender individuals.

General principles [1][2]

  • Adult health maintenance is aimed at disease prevention and early detection of disease through:
    • Primary prevention strategies
    • Screening studies
  • Health maintenance may occur during:
    • Dedicated visits for preventive care, e.g., routine physical examination or Medicare Annual Wellness Visit (AWV) [3][4]
    • Health care visits occurring for other reasons
  • Problem-based concerns are not part of health maintenance visits. [5]
  • The type of health maintenance visit depends on the individual's insurance status.
    • Commercial or Medicaid: routine physical examination
    • Medicare Part B: Medicare wellness visit
  • Some women have a well-woman visit with a gynecologist in addition to or instead of a routine health maintenance visit. [6]

Routine physical examination [7]

  • Description [4]
    • Focuses on assessing risk factors for disease and providing age-appropriate preventive counseling and screening
    • Not used to evaluate specific symptoms or concerns
    • Covered by Medicaid and most commercial insurance plans; not covered by Medicare Part B [8]
  • Frequency: may be performed annually or less frequently [9]

Visit components [1][2]

  • Review of:
    • Past medical history
    • Surgical history
    • Medications and allergies
    • Family history
    • Social history (e.g., social determinants of health, substance use)
  • Physical examination
  • Preventive screening and counseling
  • Preconception counseling and contraception counseling for individuals of reproductive age
  • Age-appropriate vaccinations

Medicare wellness visits [10][11]

  • Description
    • Focuses on a general health assessment and providing preventive care and screening
    • For Medicare beneficiaries
    • May be conducted by a physician or selected other health care professional under the direct supervision of a physician
  • Frequency: annually

Types of visit

  • Initial Preventive Physical Examination (IPPE): a one-time health maintenance visit that occurs within the first 12 months of Medicare enrollment
  • Annual Wellness Visit (AWV): health maintenance visit that occurs ≥ 12 months after Medicare enrollment
    • Initial Annual Wellness Visit (IAWV)
      • ≥ 12 months after the IPPE
      • OR ≥ 12 months after Medicare enrollment if the individual did not have an IPPE
    • Subsequent Annual Wellness Visit (SAWV): annually after the IAWV

Visit components

  • All visits include:
    • Review of patient history
    • General health assessments
    • Preventive counseling
    • Referral for preventive services and screening as indicated
  • An AWV has more elements than an IPPE, including a Medicare Health Risk Assessment, which includes:
    • Demographics
    • Self-assessment of health
    • Psychosocial assessment (e.g., evaluating stress, depression, social support)
    • Lifestyle factors (e.g., diet, exercise, home safety, risk factors for STIs)
    • Substance use (e.g., nicotine and tobacco use, unhealthy alcohol use, unhealthy drug use)
    • Activities of daily living and instrumental activities of daily living
Overview of Medicare wellness visits [10][11]
Element Initial Preventive Physical Examination (IPPE) Annual Wellness Visit (IAWV and SAWV)
Review of history
  • Past medical history, surgical history, family history
  • Medications and supplements, especially:
    • Current opioid prescriptions
    • Risk factors for opioid-related harm
  • Social history: diet and exercise
  • Past medical history, surgical history, family history
  • Medications and supplements, especially:
    • Current opioid prescriptions
    • Risk factors for opioid-related harm
  • Current medical providers
Assessments
  • Depression screening
  • Screening for substance use disorders
  • Fall risk and functional status
  • Limited physical examination
    • Height, weight, BMI, blood pressure, waist circumference
    • Vision screen
    • Additional targeted examination depending on history
  • Medicare Health Risk Assessment
  • Cognitive assessment
  • Depression screening (IAWV)
  • Screening for substance use disorders
  • Limited physical examination
    • IAWV: height, weight, BMI, waist circumference, blood pressure
    • SAWV: weight , blood pressure
    • Additional targeted examination depending on history
Education and follow-up
  • One-time screening ECG based on clinical decision-making [10]
  • Education on advance care planning
  • Preventive counseling and referrals based on clinical findings
  • Written preventive health care plan (e.g., including relevant screening and age-appropriate vaccinations)
  • Advance care planning
  • Written preventive screening plan for the next 5–10 years based on USPSTF recommendations
  • Preventive counseling and referrals based on clinical findings
  • Referrals for behavioral and lifestyle interventions (e.g., smoking cessation, weight loss, fall prevention strategies) if needed

A complete physical examination is not included as part of a Medicare wellness visit. [10]

  • Screen all adults for risk factors and offer counseling and/or prophylaxis as appropriate.
  • For additional requirements in special patient groups, see:
    • Prenatal care
    • Introduction to geriatrics
    • Preventive health care for transgender individuals
  • For counseling techniques, see “Patient communication and counseling.”
Primary prevention strategies for adults [12][13]
Topic Assessments Prevention strategies
Cardiovascular disease [13]
  • Determine if cardiovascular risk factors are present.
  • All adults: Recommend lifestyle modifications for ASCVD prevention.
  • Individuals with cardiovascular risk factors: Consider pharmacological prevention for ASCVD.
Sexually transmitted infections [14]
  • Identify risk factors for STIs.
  • Individuals with risk factors for STIs: Educate patients on STI prevention.
Nutrition [15]
  • Review dietary habits including adherence to any special diets (e.g., vegan, vegetarian).
  • Identify any diet goals.
  • All adults: Recommend adherence to US dietary guidelines. [15][16]
  • For individuals at risk for nutrient deficiency (e.g., those with a vegan diet may be at risk for vitamin D deficiency, calcium deficiency, vitamin B12 deficiency, and iron deficiency):
    • Counsel on adequate micronutrient consumption to prevent nutritional deficiencies.
    • Discuss potential complications of nutritional deficiency (e.g., low bone mineral density due to lack of calcium and vitamin D consumption). [17]
    • Consider nutritional supplementation with vitamins or through the consumption of fortified foods.
Immunizations [18]
  • Review immunization history.
  • Ensure recommended immunizations are up-to-date, including:
    • Age-appropriate immunizations; see “Immunizations in adults.”
    • Immunizations for individuals with specific indications
  • Address vaccine hesitancy if necessary.
Sun safety [19]
  • Identify risk factors for skin cancer.
  • Individuals with risk factors for skin cancer: Encourage adherence to photoprotective measures.
  • Routine screening allows for the early detection of disease processes and unhealthy behavior.
  • Conditions that are screened for include:
    • Mental illness, including unhealthy substance use
    • Malignancy
    • Cardiovascular disease (e.g., hypertension, hyperlipidemia)
    • Infectious diseases, including screening for STIs
    • Endocrine disorders (e.g., diabetes mellitus, osteoporosis)
  • Some screening studies (e.g., colorectal cancer screening) are recommended for all adults, while others (e.g., syphilis screening) are only recommended for those with risk factors.
  • For additional screening recommendations in special patient groups, see:
    • Screening for geriatric syndromes
    • Prenatal care
    • Preventive health care for transgender individuals

These screening recommendations summarize the most important guidance from the USPSTF and other major societies; for more detailed information, refer to the respective articles for each condition.

All adults

There are no recommended repeat screening intervals for the following conditions; consider repeating either when risk factors arise or at routine health checks.

Recommended psychosocial screening for all adults [12]
Condition Methods Management of patients with positive screening results
Substance use disorders Tobacco-related disorders [20]
  • Screen for current or past tobacco product use.
  • Provide or refer for smoking cessation.
Unhealthy drug use [21]
  • Screening tools include:
    • TAPS tool
    • NIDA quick screen
  • See “Management of substance use disorder” and “Management of opioid use disorder.”
Alcohol-related disorders [22]
  • Screening tools include:
    • AUDIT-C
    • SASQ
  • See “Management of unhealthy alcohol use.”
Major depressive disorder [23]
  • Depression screening tools include:
    • PHQ-2
    • PHQ-9
    • Geriatric Depression Scale-15
  • See “Treatment of depression” and “Depression in older adults.”

Specific patient groups

Additional screening for adults with risk factors [12]
Condition Indication Methods
Intimate partner violence [24][25]
  • All women of reproductive age
  • Use IPV screening tools.
  • If positive, see “Management of intimate partner violence” and “Counseling on support options for intimate partner violence.”
Anxiety [26]
  • Adults ≤ 64 years of age
  • Use a screening tool such as GAD-7.
  • If positive, see “Anxiety disorders.”

These screening recommendations summarize the most important guidance from the USPSTF and other major societies; for more detailed information, refer to the respective articles for each condition. For screening studies in transgender individuals, see “Preventive health care for transgender individuals.”

Cancer screening [12]
Indication Screening modalities and frequency
Colorectal cancer screening [27][28][29]
  • All adults 45–75 years of age
  • Colonoscopy (gold standard) every 10 years
  • Alternatives to colonoscopy: Colonoscopy is required if results are abnormal.
    • Stool-based tests
      • FIT test or fecal occult blood test every year
      • Fecal DNA test every 3 years
    • Flexible sigmoidoscopy
      • Every 5 years
      • OR every 10 years with an annual immunochemical fecal occult blood test
    • CT colonography every 5 years
  • Individuals at high risk of colorectal cancer
  • See “Colorectal cancer screening for high-risk individuals.”
Breast cancer screening [30][31][32] [33]
  • Women at average risk [30][31][32]
    • 40–74 years of age: all women [31][32]
    • ≥ 75 years of age: based on shared decision-making and life expectancy
  • Mammography every 1–2 years [30]
  • See “Breast cancer screening for individuals at average risk.”
  • Women at high risk: Screening usually starts earlier (depending on individual risk factors). [33][34][35]
  • Screening is often more frequent and may include supplemental screening modalities to mammography (e.g., MRI) [33][34][35]
  • See “Breast cancer screening for individuals at high risk.”
Cervical cancer screening [36][37][38][39]
  • Women 21–29 years of age at average risk [40][41]
  • Pap smear (cytology-alone screening) every 3 years [37]
  • Women 30–65 years of age at average risk
  • Pap smear (cytology-alone screening)every 3 years
  • OR primary HPV test every 5 years
  • OR HPV/Pap cotest every 5 years
  • Women at high risk
  • See “Screening recommendations for individuals at high risk of cervical cancer.”
Lung cancer screening [42][43][44]
  • Individuals 50–80 years of age with a ≥ 20 pack-year smoking history [42][43][44]
  • Low-dose CT scan of the chest every year
Prostate cancer screening [45]
  • Consider based on shared decision-making for: [45][46]
    • All men aged 45–69 years [45][46]
    • Men aged ≥ 40 years with risk factors for prostate cancer
  • PSA test every 2–4 years

These screening recommendations summarize the most important guidance from the USPSTF and other major societies; for more detailed information, refer to the respective articles for each condition. For screening studies in transgender individuals, see “Preventive health care for transgender individuals” and for screening studies in pregnant individuals, see “Prenatal care.”

Screening recommendations for nonpregnant women by age [12]
Recommended screening
Starting age 18 years
  • Screening for hypertension [13][47]
  • Hepatitis B screening [48][49]
  • HCV screening [14][50]
  • HIV screening [51][52]
  • Chlamydia screening and gonorrhea screening [14]
    • Until 24 years of age: all sexually active women
    • Continued at ≥ 25 years of age: women with risk factors for STIs
  • Psychosocial screening for adults
  • Additional screening if risk factors are present
    • Syphilis screening: risk factors for syphilis [14]
    • Screening for latent TB infection: risk factors for TB [53][54]
    • Early initiation (< 35 years of age) of screening for diabetes mellitus in women: [55]
      • With risk-enhancing comorbidities (e.g., prediabetes, HIV)
      • OR who are overweight or obese with ≥ 1 additional risk factor for T2DM
Starting age 20 years
  • Screening for lipid disorders [56]
Starting age 21 years
  • Cervical cancer screening (until 65 years of age) [36][37][39]
Starting age 35 years
  • Screening for diabetes mellitus [55][57]
Starting age 40 years
  • Breast cancer screening [30][31][32]
Starting age 45 years
  • Screening for colorectal cancer [27][28][29]
  • Early initiation of osteoporosis screening in women who are: [58]
    • Postmenopausal
    • AND at increased risk of osteoporosis as determined by a clinical risk assessment tool
Starting age 50 years
  • Screening for lung cancer in women with a ≥ 20 pack-year smoking history [42][43][44]
Starting age 65 years
  • Screening for osteoporosis [58]
  • Screening for AAA (until 74 years of age) in women with:
    • Family history (first-degree relative) [59][60][61]
    • History of smoking [59][60][61]

These screening recommendations summarize the most important guidance from the USPSTF and other major societies; for more detailed information, refer to the respective articles for each condition. For screening studies in transgender individuals, see “Preventive health care for transgender individuals.”

Screening recommendations for men by age [12]
Recommended screening
Starting age 18 years
  • Screening for hypertension [13][47]
  • Hepatitis B screening [48][49]
  • HCV screening [14][50]
  • HIV screening [51][52]
  • Psychosocial screening for adults
  • Additional screening if risk factors are present
    • Chlamydia screening and gonorrhea screening: selected men with risk factors for STIs [14][62]
    • Syphilis screening: risk factors for syphilis [14]
    • Screening for latent TB infection: risk factors for TB [53][54]
    • Early initiation (< 35 years of age) of screening for diabetes mellitus in men: [55]
      • With risk-enhancing comorbidities (e.g., prediabetes, HIV)
      • OR who are overweight or obese with ≥ 1 additional risk factor for T2DM
Starting age 20 years
  • Screening for lipid disorders [56]
Starting age 35 years
  • Screening for diabetes mellitus [55][57]
Starting age 40 years
  • Consider prostate cancer screening for men with risk factors for prostate cancer. [45][46]
Starting age 45 years
  • Screening for colorectal cancer [27][28][29]
  • Consider prostate cancer screening for all men. [45][46]
Starting age 50 years
  • Screening for lung cancer in men with a ≥ 20 pack-year smoking history [42][43][44]
Starting age 65 years
  • Screening for AAA (until 74 years of age) in men with: [59][60][61]
    • Family history (first-degree relative) [59][60][61]
    • History of smoking
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