Improving Patient-Clinician Conversations During Annual Wellness Visits

Abstract

Background In 2010, the Patient Protection and Affordable Care Act instituted dedicated reimbursement for Annual Wellness Visits (AWVs) in primary care, requiring the use of comprehensive health risk assessment (HRA) that covers specific health content. HRAs have been implemented and studied for decades in various settings, but little is known about the effect of introducing HRAs on the dynamics and content of patient-clinician conversations during AWVs and if the effective use of HRAs requires additional training and resources. Methods We used established technology to video-record 40 AWVs conducted by 5 faculty in an academic family medicine residency practice. A comprehensive HRA-Health Planner report was implemented in these practices over a 3-month baseline period without additional training or resources. Subsequently, three of the five clinicians received a brief, low-intensity intervention to use the HRA to support patient behavior change. Patients received a 5-minute orientation on the purpose of the enhanced AWV and advice on how to communicate their needs and preferences more effectively. Twenty-two pre- and post-intervention visit recordings were carefully matched on known covariates and were explored by several evaluators using Conversation Analysis techniques to describe the dynamics and content of conversations. Short exit interviews with patients and clinicians were evaluated by standard content analytic techniques. Results Six overarching themes emerged that described the dynamics of AWV conversations. Patients and clinicians sub-optimally utilized the HRA report and missed many opportunities for promoting behavior change. However, a low-intensity, multi-component intervention significantly decreased the proportion of clinician talk time per visit by 9% (p<0.001), while it increased the proportion of patient talk time by 7% (p<0.001), robustly increased the number and duration of “change talk” by 639% (p= 0.0007), increased the number of patient cut-ins by 237% (p= 0.04) and tended to increase the number and duration of clinician “advice talk” (p=0.065). The total number, duration, and proportions of conversational turn types, “goal setting talk”, “education talk”, and “prescriptive talk” did not change. The majority of patients and clinicians had a positive experience. Patients felt more informed, empowered, and motivated by the HRA-enhanced wellness visit. Clinicians emphasized that the HRA report helped them construct and follow a visit agenda more effectively and that it facilitated the convergence of the patients’ goals with evidence-based recommendations suggested by the HRA report. Conclusions Our study suggests that HRAs introduced without proper framing, education, and additional resources may not allow patients and clinicians to optimally leverage AWVs for health planning and improvement. A low-intensity, multi-component intervention may help patients and clinicians improve the quality of HRA-supported health conversations and realize the potential of AWVs.

Remote Cognitive Screening Of Healthy Older Adults for Primary Care With the MyCog Mobile App: Iterative Design and Usability Evaluation

“…Patients, clinicians, and administrators share a common goal of efficiency in in-person primary care visits but may be motivated to achieve this goal for different reasons. Both clinicians and patients want to prioritize spending visit time on the issues that have the most impact on health and quality of life [ 68 ] and simultaneously want to ensure that they are not missing a nonobvious health problem that could be caught by a routine screening [ 69 - 71 ]. However, clinicians’ need for efficiency is also driven by the need to accommodate large daily patient loads, which can limit the time spent on individual patients [ 72 ].…”

Moving From Problem-Oriented to Goal-Directed Health Records

“…In recent implementation studies, patients could document and periodically update their long-term goals, which were then presented to clinicians during annual wellness visits to help them negotiate health care objectives and specific care strategies. 9,16,17 Finally, the goal-directed health record needs to consider the person's life and health context, which may interact with the patient's health in a complex manner (eg, family/community support, access to care, lack of transportation). Current health records, however, are not adequate for helping clinicians evaluate interactions between the patient's health conditions and their environment.…”

Improving Family Medicine with Thoughtful Research

“…Nagykaldi et al 5 provide importance guidance on strategies to improve the content of conversations stemming from health risk assessments (HRAs) at annual wellness visits. A low-intensity, multicomponent intervention resulted in several positive changes in the quality of these conversations, plus patients felt more informed, empowered, and mo-tivated by the HRA-enhanced wellness visits.…”