Adoption, Reach, Implementation, and Maintenance of a Behavioral and Mental Health Assessment in Primary Care

Abstract

PURPOSE Guidelines recommend screening patients for unhealthy behaviors and mental health concerns. Health risk assessments can systematically identify patient needs and trigger care. This study seeks to evaluate whether primary care practices can routinely implement such assessments into routine care. METHODSAs part of a cluster-randomized pragmatic trial, 9 diverse primary care practices implemented My Own Health Report (MOHR)-an electronic or paperbased health behavior and mental health assessment and feedback system paired with counseling and goal setting. We observed how practices integrated MOHR into their workflows, what additional practice staff time it required, and what percentage of patients completed a MOHR assessment (Reach). RESULTSMost practices approached (60%) agreed to adopt MOHR. How they implemented MOHR depended on practice resources, informatics capacity, and patient characteristics. Three practices mailed patients invitations to complete MOHR on the Web, 1 called patients and completed MOHR over the telephone, 1 had patients complete MOHR on paper in the office, and 4 had staff help patients complete MOHR on the Web in the office. Overall, 3,591 patients were approached and 1,782 completed MOHR (Reach = 49.6%). Reach varied by implementation strategy with higher reach when MOHR was completed by staff than by patients (71.2% vs 30.2%, P <.001). No practices were able to sustain the complete MOHR assessment without adaptations after study completion. Fielding MOHR increased staff and clinician time an average of 28 minutes per visit.CONCLUSIONS Primary care practices can implement health behavior and mental health assessments, but counseling patients effectively requires effort. Practices will need more support to implement and sustain assessments. INTRODUCTIONA substantial burden of unhealthy behaviors leads to chronic diseases and mental health disorders among patients seen in primary care settings.1 Health risk assessments (HRAs) can help identify and address factors that place a person at enhanced risk for morbidity or mortality. Primary care is a promising setting to conduct HRAs because risk identification can be linked to assistance from clinicians who have a longstanding and trusting relationship with the patient.2 Unfortunately, many primary care practices are overwhelmed by competing demands, and typical office visits provide little time to address health risk information. 3,4 As early as 1970, clinician manuals promoted sample HRA questionnaires, risk computations, and feedback strategies.5 While HRAs were not widely adopted by the medical profession, they proliferated in workplaces and community-based programs. 6,7 In these settings, HRAs improved health indicators such as blood pressure, weight, physical activity, and general health status. 8,9 A critical finding was that merely administering an HRA questionnaire does not produce behavior change. [10][11][12] Comprehensive, well-resourced follow-up is essential to help individuals gain the skills they needed to change h...

Frequency and Prioritization of Patient Health Risks from a Structured Health Risk Assessment

“…14,16 Practices were geographically diverse, and 5 were rural and/or federally qualified health centers. 17 Practice size ranged from 1 to 5.5 full-timeequivalent providers.…”

The impact of behavioral and mental health risk assessments on goal setting in primary care

“…One explanation is that in exit interviews, clinicians reported not referring more patients because onsite counselors were already overburdened prior to participating in this study. Additionally, practices reported counseling patients about risky behaviors and mental health concerns for an additional 14 min per patient [30]. While this is a substantial time investment for practices, patients will require greater support over an extended period of time to sustain improvements [9].…”

“…Finally, it is unclear whether these findings can be generalized outside of a research setting. While the study design was highly ORIGINAL RESEARCH pragmatic to increase external validity [28,40], fielding MOHR required substantial resources and time from practices (an additional 28 min per patient) [30]. However, practice redesign efforts such as patientcentered medical homes, accountable care organizations, primary care and public health integrations, and primary care and mental health integrations are advancing team-based care models that can support all of the needed patient-centered HRA steps.…”

“…While the study methods, implementation findings, and frequency of unhealthy behaviors and mental health risks have been previously reported, the study design is detailed below [5,[28][29][30]. The study was approved by the Virginia Commonwealth University (VCU) (#HM12746), University of California, Los Angeles (#12-0017900), and five other participating institutional review boards.…”

In This Issue: Research Briefs and New Clinical and Policy Insights

“…The authors find a high rate of implementation and substantial reach into one-half of the patients to whom the assessment was offered, but also identify the need for local adaptation and resource use. 6 Another study that examined its reach is the BRIGHT trial of disability case finding among patients aged 75 years and older, seen in 60 primary care practices. All 8,308 community-dwelling patients were approached, one-half participated, and three-fourths completed the trial.…”