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

Alex H. Krist; Siobhan M. Phillips; Roy T. Sabo; Bijal A. Balasubramanian; Suzanne Heurtin-Roberts; Marcia G. Ory; Sallie Beth Johnson; Sherri N. Sheinfeld-Gorin; Paul A. Estabrooks; Debra P. Ritzwoller; Russell E. Glasgow

doi:10.1370/afm.1710

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Figure 1
Number of patients completing the MOHR assessment each week by practice.

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Table 1

Characteristics of Early Intervention Practices Fielding the My Own Health Report (MOHR) Assessment

	Site 1	Site 2	Site 3	Site 4	Site 5	Site 6	Site 7	Site 8	Site 9
State	VA	VA	VA	CA	VT	NC	CA	TX	TX
Setting	Suburban	Rural	Urban	Rural	Rural	Rural	Urban	Rural	Urban
Academic association	PBRN	PBRN	PBRN	PBRN	PBRN	CPCRN	CPCRN	CPCRN	CPCRN
Patients seen per year	1,500	2,500	4,770	3,500	9,500	12,800	2,180	4,800	2,518
Provider FTEs	1	1.6	5.3	5.5	5	4.5	2	2	1
Rooming staff FTE	1	7	14.9	15	13.5	12	6	6	2
Patient ethnicity or race
Latino (%)	20	1	1	3	1	2	75	48	67
Black (%)	10	49	17	1	5	60	25	23	13
Insurance
Medicare (%)	9	12	26	13	13	49	5	2	3
Medicaid (%)	0	1	42	3	1	10	45	15	22
None (%)	1	49	17	1	5	10	50	38	69
Practice ownership	Private	FQHC	Health system	FQHC	Health system	FQHC	FQHC	FQHC	FQHC
Year adopted EHR	–	2013	2001	2009	2010	2005	2011	2010	2010
Year adopted PHR	–	–	2012	2013	–	–	–	2010	–
PCMH designation	–	–	NCQA level 3	Applying	NCQA level 3	–	–	–	Joint commission
Prior/current HRA use	Wellness behavior form	–	–	New patient behavior form	–	–	Ask behavior and mental questions for wellness	Ask behavior questions for wellness	Tobacco and alcohol as vital sign
Onsite behavioral/mental health staff	–	Social worker	Social worker	- (system referral)	Psychologist	Behavioral health specialist	Counselor and Nutritionist	Psychologist and Psychiatrist	Behavioral health specialist

FTE = full time equivalent; PBRN = practice based research network; CPCRN = Cancer Prevention and Control Research Network; EHR = electronic health record; PHR = personal health record; PCMH = patient centered medical home; FQHC = Federally Qualified Health Center; HRA = health risk assessment; NCQA = National Committee for Quality Assurance.

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Table 2

MOHR Implementation Strategy Developed by Practices and Time to Complete Additional Tasks

			Minutes per Visit Beyond Usual Care, by Task Completed
Site	Implementation Strategy	Target Population	Query Visit Records	Mail Invitation	Match Summary to Visit	Counsel Patients	Follow-up	Other Task s	Total
Patients mailed an invitation to complete MOHR on the Web before an office visit
1^a	Patients mailed invitation to complete MOHR on the Web 2 weeks before appointment	Scheduled wellness and diabetes visits	2	8^a	3	11	2	–	25
3^b	Patients mailed invitation to complete MOHR on the Web 2 weeks before appointment with in office help on a kiosk for non-completers	30 scheduled chronic or wellness visits per week (randomly selected)	2	2	2	5	–	10 (In-office help at kiosk)	20
4	Patients mailed invitation to complete MOHR on the Web 2 weeks before appointment	Any appointment scheduled 3 weeks in advance	2.5^a	2^a	5	10	5	–	27
5	Patients mailed invitation to complete MOHR on the Web 2 weeks before appointment	Scheduled chronic and wellness visits	1^a	8^a	5	15	–	8 (review summary)	29
Patients called and completed MOHR on phone before an office visit
3^c	Health system call center called patients and asked MOHR questions over phone before a visit and entered patient responses on the Web site	All chronic and wellness visits	2	–	5	10	–	10 (ask MOHR by phone)	19
			Identify Eligible Patients	Complete MOHR	Match Summary to Visit	Counsel Patients	Follow-up	Other Task s	Total

Patients approached in the office to complete MOHR on the Web
6	Academic staff approached patients, asked MOHR questions in waiting room, and entered responses on tablet	Chronic and wellness visits (if consented)	1^a	15 ^a	–	–	–	–	16
7	Academic staff approached patients and helped them complete MOHR on a kiosk in the waiting room	Chronic and wellness visits	3.5^a	16^a	2	5	–	–	26.5
8^d	Practice rooming staff approached patients, asked MOHR questions in waiting room, and entered responses on tablet	Chronic visits	2	10	2	17	–	–	31
8^e	Academic staff approached patients, asked MOHR questions in waiting room, and entered responses on tablet	Chronic and wellness visits	2^a	10^a	2	17	–	–	31
9^f	Medical assistant approached patients, asked MOHR questions in waiting room, and entered responses on tablet	All patient visits Wellness visits	1	12	3	14	–	–	30
9^g	Academic staff approached patients, asked MOHR questions in waiting room, and entered responses on tablet	Chronic and wellness visits	1^a	8^a	3	14	–	–	26
2	Front desk staff approached patient, patient completed paper version of MOHR in the waiting room; when needed the clinician helped the patient answer MOHR questions	Chronic and wellness visits		10	5	9	5	–	28

↵a Task completed by academic staff.
↵b Study weeks 4–16, when site 3 mailed MOHR invitations to patients.
↵c Study weeks 14–19, when site 3 phoned patients to complete MOHR.
↵d Study weeks 1–17, when site 8 practice staff administered MOHR but only for chronic care visits.
↵e Study weeks 18–30, when site 8 academic team staff administered MOHR for wellness and chronic care visits.
↵f Study weeks 1–13, when site 9 practice staff administered MOHR to all patients (weeks 1–3) and then only chronic and wellness visits (weeks 4–13).
↵g Study weeks 14–33, when site 9 academic team staff administered MOHR for wellness and chronic care visits.

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Table 3

Total Number of Patients Who Were Offered and Who Completed MOHR by Practice and Implementation Strategy

Site	Number of Patients Offered MOHR	Number of Patients Completing MOHR	Implementation Reach (% of Patients Offered MOHR Who Completed It)
Staff mailed patients an invitation to complete MOHR on the Web
1	344	116	33.7
3^a	420	11	2.6
4	444	141	31.7
5	248	113	45.6
Staff called patients and completed MOHR over the phone
3^b	453	291	64.2
Staff assisted patients completing MOHR on the Web in the office
6	287	271	94.4
7	306	214	69.9
8	323	246	76.1
9	329	187	56.8
Patients completed MOHR on paper in the office
2	437	192	43.9
Total	3,591	1,782	49.6

↵a Study weeks 4–16, when site 3 mailed patients invitations to complete MOHR.
↵b Study weeks 14–19, when site 3 phoned patients to complete MOHR.

In Brief

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

Alex H. Krist , and colleagues

Background Guidelines recommend screening patients for unhealthy behaviors and mental health concerns. While health risk assessments can identify patients' needs and initiate care, it is not clear whether primary care practices can routinely implement such assessments. This study examines the experiences of nine primary care practices implementing the My Own Health Report (MOHR), a new electronic or paper-based health behavior and mental health risk assessment and feedback system to support counseling and goal setting.

What This Study Found Although practices were willing and able to implement the behavior and mental health assessments, most lacked the capacity and infrastructure to do so without additional support once the trial ended. Most practices agreed to adopt MOHR, and one-half of the 3,591 patients who were approached, completed the assessment. Reach varied by implementation strategy, with higher reach when MOHR was completed by staff than by patients. The observed reach of 50 percent was double the completion rates previously published by large health systems and on par with worksite completion rates coupled with economic incentives. In addition, practices were successful in getting patients of all ethnic, racial and socio-economic levels to participate in MOHR. Fielding MOHR increased staff and clinician time an average of 28 minutes per visit. As a result, no practices were able to sustain the complete MOHR assessment without adaptations after study completion.

Implications

Most primary care practices are overwhelmed by competing demands, and typical office visits provide little time to address health risk information. As a result, more substantial practice transformation will be necessary to routinely integrate assessments such as MOHR into primary care.
Current incentives for practice transformation are insufficient to facilitate this practice change. For example, according to the authors, mandating that health risk assessments be added to an already packed wellness visit increases the chances that practices will do it poorly or not at all.