Reducing Racial and Ethnic Disparities in Medicare Annual Wellness Visit Uptake

Inclusion Criteria: * ≥1 in-person primary care visit during 18-month lookback period AND * Medicare or Medicare Advantage insurance AND * ≥1 risk factor shown to be associated with being overdue for Medicare Annual Wellness Visits (identified in preparatory analysis prior to pilot trial): Black/African American race or Latino/Hispanic ethnicity OR Not up-to-date for social needs screening OR Positive social need in past 18 months OR Medicaid insurance OR No use of scheduling features within patient portal in past 18 months * Preferred language English AND * Attributed primary care clinic is 1 of the participating clinics in the pilot trial AND * No AWV completion (CPT G0402, G0438, G0439, G0468) during 10-month lookback period AND * No appointment scheduled for upcoming AWV Exclusion Criteria: * Patients will be excluded if they are receiving palliative care or if their clinician feels that outreach for preventive care is inappropriate.