Research Activities, March 2014
Moving health assessments into the future
The idea behind health assessments isn't new.
Clinicians have been asking about their patients' personal behaviors, risks, life-changing events, health goals, and priorities for decades.
The answers were often on pieces of paper tucked away on medical charts.
But health assessments in the 21st century are different. They can be incorporated in electronic health records, and they are often evidence-based. In some cases, they're also mandatory.
"The Affordable Care Act has given us new opportunities for wellness," says Ric Ricciardi, Ph.D., N.P., health scientist in AHRQ's Center for Primary Care and Prevention. "Many people know about the annual Medicare wellness visit, but they don't necessarily know there's a health assessment component. Practices are not only required to do annual health assessments for Medicare patients, they can now get reimbursed for them."
For clinicians, figuring out which questions to ask, how to ask the questions, when to ask, how to involve the health care team, and how and when to followup on the answers and engage patients can be complicated. AHRQ's Health Assessments in Primary Care: A How-To Guide for Clinicians and Staff can help.
The guide, one of many tools AHRQ has developed to improve primary care, provides evidence-based information on health assessments, followup activities, and monitoring of progress. It can help practices implement the Medicare Annual Wellness visit and support national initiatives, such as the Center for Medicaid & Medicare Services' meaningful use standards for electronic health records. The guide can also help practices seeking recognition or accreditation as a patient-centered medical home.
To learn more, Research Activities spoke with Ricciardi, researchers who developed the guide, and clinicians who tested it. The guide was prepared by the University of Colorado, Department of Family Medicine, the Colorado Health Outcomes Program, and the Shared Networks of Collaborative Practices and Partners (SNOCAP), which is a practice-based research network.
AHRQ's guide complements the Centers for Disease Control and Prevention report entitled "Framework for Patient-Centered Health Risk Assessments," which provides a theoretical framework for implementing health assessments. "The AHRQ guide takes a practical how-to approach to help clinicians start or improve their implementation of health assessments," says Ricciardi. Health assessments, also referred to as health risk assessments, allow clinicians to systematically collect and analyze health-related information to identify and support beneficial health behaviors like a low-fat diet and exercise and to identify and counsel change of potentially harmful behaviors, such as smoking, lack of exercise, and heavy drinking.
"It's also important to learn what health assessments aren't. They are not intended to be diagnostic tools and they are not complete health histories," says Ricciardi.
"Health assessments give clinicians the opportunity to talk about issues and concerns that don't always come up during other visits. Ideally, they help engage patients in their own health and lead to better lifestyle choices and improved health behaviors in the long run." "Health assessments are tailored to the patient population of the particular practice and thus there is no one size fits all," says Ricciardi. "A one-provider practice in Wyoming and a 10-provider practice in downtown Washington, DC, will do things differently." Even within a practice, clinicians may use different techniques. Health assessments can be done in person, by phone, by written questionnaire, or on a computer or tablet. Says Ricciardi, "The individual taking the assessment needs to feel comfortable giving answers. Clinicians ask about drinking and other behaviors that people might find sensitive or difficult to talk about."
Health assessments can help clinicians and patients evaluate and prioritize behaviors that can be changed, such as diet and exercise for patients with a sedentary lifestyle. "The questions aren't necessarily about diabetes but about eating habits and exercise," explains Ricciardi. "The assessment focuses on behaviors that are modifiable."
Beyond the questions
"It's not good enough to ask the questions," says Douglas Fernald, M.A., project manager for the AHRQ guide and a senior instructor at the Department of Family Medicine at the University of Colorado. When Fernald spoke with families and patient advisory groups about health assessments, he found a lot of agreement about the use and purpose of health assessments in primary care.
But he emphasizes, "The information is most beneficial if there's a trusting relationship between the patient and the health care team, and the patient needs to know how clinicians are going to use the information. Followup is crucial."
Followup can begin with what Fernald calls an "informed conversation" that focuses on the patient's priorities. Nurses or other staff can be involved with referrals to community resources, such as smoking cessation programs, and support to reinforce behavior changes.
But followup can be challenging, according to Fernald. "How do you work this in? There are competing demands in a practice."
The principal investigator of the project to develop and test the guide and director of the University of Colorado Health Outcomes Program, David R. West, Ph.D., notes that implementing health assessments takes work, thought, and structure. "You can't assume because you've been through medical school or office management training that you can arrive on the scene with the right skill set and approaches."
West and Fernald advocate for a team approach to health assessments. "Implementation works best when it's a team effort involving everyone in your practice," says Fernald. "Health assessments can provide a way for practitioners and patients to have more informed conversations."
During the past 5 years, Tracy Hofeditz, M.D., owner of Belmar Family Medicine in Lakewood, CO, has been implementing changes to transform his practice into a medical home model of care. "I needed to have the awareness, humility, and openmindedness to know that I wasn't doing things as well as I could have," says Hofeditz.
He explains: "Physicians, at least older physicians like myself, we weren't trained to use those kinds of tools to collect information from patients. We're used to physical exams, history exams, diagnostic testing. That paradigm is shifting significantly to engage patients in a more direct way. The health assessment is a tool that allows us to engage the patient more by providing us with information to help them get better care."
At the Rocky Ford Family Health Center in rural Colorado, Doug Miller, F.N.P., tries to make the most of health assessments. His health assessments include questions about smoking, depression, activity levels, daily living, and substance abuse. To encourage his patients to tell the truth, Miller tells them, "You're not going to hurt my feelings and you're not going to shock me."
This year, Miller plans to encourage people to take advantage of the health assessments at the same time they come in for flu shots. All the information will be included in the patients' electronic health record. He says, "With the touch of a button, I can go in and see their answers, how much they smoke, if we addressed counseling, and more." Miller knows that following through on the information isn't always enough. "A lot of people don't want to make the necessary changes despite the fact that you're there, willing to help," he explains. "But I'm always still glad I asked the questions. It's important for them to hear what I have to say, too."
Sometimes patients not only listen, they act. "We've been harping on a patient's smoking for years," he says. "Today, she told me that she's gone from two packs a day to a third a pack. I'm still smiling."