BACKGROUND: Assessing patient-reported health behaviors is a critical first step in prioritizing prevention in primary care. We assessed the feasibility of point-of-care behavioral health assessment in 9 diverse primary care practices, including 4 federally qualified health centers (FQHCs), 4 practice-based research network practices, and a Department of Veterans Affairs practice. METHODS: In this prospective mixed-methods study, practices were asked to integrate a standardized paper-based health behavior and mental health assessment into their workflow for ≥50 patients. We used 3 data sources to examine the implementation process: (1) patient responses to the health assessment, (2) patient feedback surveys about how assessments were used during encounters, and (3) postimplementation interviews. RESULTS: Most nonurgent patients (71%) visiting the participating practices during the implementation period completed the health assessment, but reach varied by practice (range, 59% to 88%). Unhealthy diet, sedentary lifestyle, and stress were the most common patient problems, with similar frequencies observed across practices. The median number of positive screens per patient was similar among FQHCs (3.7 positives; standard deviation [SD], 1.8), practice-based research network practices (3.8 positives; SD, 1.9), and the Veterans Affairs clinic (4.1 positives; SD, 2.0). Primary care clinicians discussed assessment results with patients about half of the time (54%), with considerable variation between practices (range, 13% to 66%; lowest use among FQHC clinicians). Although clinicians were interested in routinely implementing assessments, many reported not feeling confident of having resources or support to address all patients behavioral health needs. CONCLUSIONS: Primary care practices will need to revamp their patient-reported data collection processes to integrate routine health behavior assessments. Implementation support will be required if health assessments are to be actively used as part of routine primary care.

Background

Assessing patient-reported health behaviors is a critical first step in prioritizing prevention in primary care. We assessed the feasibility of point-of-care behavioral health assessment in 9 diverse primary care practices, including 4 federally qualified health centers (FQHCs), 4 practice-based research network practices, and a Department of Veterans Affairs practice.

Methods

In this prospective mixed-methods study, practices were asked to integrate a standardized paper-based health behavior and mental health assessment into their workflow for ≥50 patients. We used 3 data sources to examine the implementation process: (1) patient responses to the health assessment, (2) patient feedback surveys about how assessments were used during encounters, and (3) postimplementation interviews.

Results

Most nonurgent patients (71%) visiting the participating practices during the implementation period completed the health assessment, but reach varied by practice (range, 59% to 88%). Unhealthy diet, sedentary lifestyle, and stress were the most common patient problems, with similar frequencies observed across practices. The median number of "positive screens" per patient was similar among FQHCs (3.7 positives; standard deviation [SD], 1.8), practice-based research network practices (3.8 positives; SD, 1.9), and the Veterans Affairs clinic (4.1 positives; SD, 2.0). Primary care clinicians discussed assessment results with patients about half of the time (54%), with considerable variation between practices (range, 13% to 66%; lowest use among FQHC clinicians). Although clinicians were interested in routinely implementing assessments, many reported not feeling confident of having resources or support to address all patients' behavioral health needs.

Conclusions

Primary care practices will need to revamp their patient-reported data collection processes to integrate routine health behavior assessments. Implementation support will be required if health assessments are to be actively used as part of routine primary care.

Patient-centered health risk assessments (HRAs) that screen for unhealthy behaviors, prioritize concerns, and provide feedback may improve counseling, goal setting, and health. To evaluate the effectiveness of routinely administering a patient-centered HRA, My Own Health Report, for diet, exercise, smoking, alcohol, drug use, stress, depression, anxiety, and sleep, 18 primary care practices were randomized to ask patients to complete My Own Health Report (MOHR) before an office visit (intervention) or continue usual care (control). Intervention practice patients were more likely than control practice patients to be asked about each of eight risks (range of differences 5.3-15.8 %, p < 0.001), set goals for six risks (range of differences 3.8-16.6 %, p < 0.01), and improve five risks (range of differences 5.4-13.6 %, p < 0.01). Compared to controls, intervention patients felt clinicians cared more for them and showed more interest in their concerns. Patient-centered health risk assessments improve screening and goal setting.Trial RegistrationClinicaltrials.gov identifier: NCT01825746.

Abstract Background There is a pressing need for greater attention to patient-centered health behavior and psychosocial issues in primary care, and for practical tools, study designs and results of clinical and policy relevance. Our goal is to design a scientifically rigorous and valid pragmatic trial to test whether primary care practices can systematically implement the collection of patient-reported information and provide patients needed advice, goal setting, and counseling in response. Methods This manuscript reports on the iterative design of the My Own Health Report (MOHR) study, a cluster randomized delayed intervention trial. Nine pairs of diverse primary care practices will be randomized to early or delayed intervention four months later. The intervention consists of fielding the MOHR assessment – addresses 10 domains of health behaviors and psychosocial issues – and subsequent provision of needed counseling and support for patients presenting for wellness or chronic care. As a pragmatic participatory trial, stakeholder groups including practice partners and patients have been engaged throughout the study design to account for local resources and characteristics. Participatory tasks include identifying MOHR assessment content, refining the study design, providing input on outcomes measures, and designing the implementation workflow. Study outcomes include the intervention reach (percent of patients offered and completing the MOHR assessment), effectiveness (patients reporting being asked about topics, setting change goals, and receiving assistance in early versus delayed intervention practices), contextual factors influencing outcomes, and intervention costs. Discussion The MOHR study shows how a participatory design can be used to promote the consistent collection and use of patient-reported health behavior and psychosocial assessments in a broad range of primary care settings. While pragmatic in nature, the study design will allow valid comparisons to answer the posed research question, and findings will be broadly generalizable to a range of primary care settings. Per the pragmatic explanatory continuum indicator summary (PRECIS) framework, the study design is substantially more pragmatic than other published trials. The methods and findings should be of interest to researchers, practitioners, and policy makers attempting to make healthcare more patient-centered and relevant. Trial registration Clinicaltrials.gov: NCT01825746

Behavioral and mental health risk factors are prevalent among primary care patients and contribute substantially to premature morbidity and mortality and increased health care utilization and costs. Although prior studies have found most adults screen positive for multiple risk factors, limited research has attempted to identify factors that most commonly co-occur, which may guide future interventions. The purpose of this study was to identify subgroups of primary care patients with co-occurring risk factors and to examine sociodemographic characteristics associated with these subgroups. We assessed 12 behavioral health risk factors in a sample of adults (n=1628) receiving care from nine primary care practices across six U.S. states in 2013. Using latent class analysis, we identified four distinct patient subgroups: a 'Mental Health Risk' class (prevalence=14%; low physical activity, high stress, depressive symptoms, anxiety, and sleepiness), a 'Substance Use Risk' class (29%; highest tobacco, drug, alcohol use), a 'Dietary Risk' class (29%; high BMI, poor diet), and a 'Lower Risk' class (27%). Compared to the Lower Risk class, patients in the Mental Health Risk class were younger and less likely to be Latino/Hispanic, married, college educated, or employed. Patients in the Substance Use class tended to be younger, male, African American, unmarried, and less educated. African Americans were over 7 times more likely to be in the Dietary Risk versus Lower Risk class (OR 7.7, 95% CI 4.0-14.8). Given the heavy burden of behavioral health issues in primary care, efficiently addressing co-occurring risk factors in this setting is critical.

Background

Chronic diseases that drive morbidity, mortality, and health care costs are largely influenced by human behavior. Behavioral health conditions such as anxiety, depression, and substance use disorders can often be effectively managed. The majority of patients in need of behavioral health care are seen in primary care, which often has difficulty responding. Some primary care practices are providing integrated behavioral health care (IBH), where primary care and behavioral health providers work together, in one location, using a team-based approach. Research suggests there may be an association between IBH and improved patient outcomes. However, it is often difficult for practices to achieve high levels of integration. The Integrating Behavioral Health and Primary Care study responds to this need by testing the effectiveness of a comprehensive practice-level intervention designed to improve outcomes in patients with multiple chronic medical and behavioral health conditions by increasing the practice's degree of behavioral health integration.

Methods

Forty-five primary care practices, with existing onsite behavioral health care, will be recruited for this study. Forty-three practices will be randomized to the intervention or usual care arm, while 2 practices will be considered "Vanguard" (pilot) practices for developing the intervention. The intervention is a 24-month supported practice change process including an online curriculum, a practice redesign and implementation workbook, remote quality improvement coaching services, and an online learning community. Each practice's degree of behavioral health integration will be measured using the Practice Integration Profile. Approximately 75 patients with both chronic medical and behavioral health conditions from each practice will be asked to complete a series of surveys to measure patient-centered outcomes. Change in practice degree of behavioral health integration and patient-centered outcomes will be compared between the two groups. Practice-level case studies will be conducted to better understand the contextual factors influencing integration.

Discussion

As primary care practices are encouraged to provide IBH services, evidence-based interventions to increase practice integration will be needed. This study will demonstrate the effectiveness of one such intervention in a pragmatic, real-world setting.

Trial registration

ClinicalTrials.gov NCT02868983 . Registered on August 16, 2016.