Health Assessments in Primary Care - AHRQ

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Health Assessments in Primary Care A How-to Guide for Clinicians and Staff

Health Assessments in Primary Care A How-to Guide for Clinicians and Staff Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 540 Gaither Road Rockville, MD 20850 www.ahrq.gov Prepared by: University of Colorado School of Medicine, Department of Family Medicine, the Colorado Health Outcomes Program, and the Shared Networks of Collaborative Practices and Partners (SNOCAP) Contract No. HHSA29020071008 Authors:

Douglas H. Fernald, M.A. Adam G. Tsai, M.D., M.S.C.E. Betsy Vance, M.P.H. Katherine A. James, Ph.D., M.S.C.E., M.S.P.H. Juliana Barnard, M.A. Elizabeth W. Staton, M.S.T.C. Wilson D. Pace, M.D. David R. West, Ph.D.

AHRQ Publication No. 13-0061-EF September 2013

Disclaimer This toolkit is based on research conducted by SNOCAP-USA under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. HHSA29020071008). The findings and conclusions in this document are those of the authors, who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services. The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment. Public Domain Notice

This document is in the public domain and may be used and reprinted without permission.

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Acknowledgements SNOCAP-USA is grateful to the primary care practices that participated in the pilot project and freely shared their experiences so that future practices could learn. We wish to extend our thanks to each practice for their hard work and effort, as well as their willingness to participate in the evaluation: • Belmar Family Medicine • Emory Family Medicine • Exempla Capitol Hill Internal Medicine • Exempla Green Mountain Family Medicine • Exempla Oasis Family Medicine

• • • • •

Family Care Medical Center Foothills Family Medicine Rocky Ford Family Health, LLC Sheridan Health Services University of Colorado Family Medicine, Park Meadows • Walsh Medical Clinic

We also thank the practice-based research networks—and their clinicians and staff— including Building InvestiGative practices for better Health Outcomes Research Network (BIGHORN), the Colorado Research Network (CaReNet), the High Plains Research Network (HPRN), and the American Academy of Family Physicians National Research Network (AAFP NRN). We extend special thanks to Richard Ricciardi, Ph.D., N.P., who provided outstanding support, direction, and feedback throughout this guide's development and production.

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Table of Contents Introduction ............................................................................................................................... 2 Section 1. How Ready is Your Practice to Implement a New Health Assessment? ................. 5 Section 2. How Does Your Practice Choose an Assessment? .................................................. 9 Section 3. How Do You Work Health Assessments into Your Office Workflow? ................ 13 Section 4. How Do You Use the Health Assessment Information You Collect? ................... 19 Section 5. How Do You Activate and Engage Patients in Using Their Health Assessment Information? ............................................................................................................................ 23 Section 6. How Does Your Practice Sustain Health Assessments? ........................................ 27 Appendices .............................................................................................................................. 31 Appendix 1: Background on Health Assessments in Primary Care ...................................... 32 Appendix 2: Health Assessment Case Study ......................................................................... 33 Appendix 3: Health Assessments for Adults ......................................................................... 35 Appendix 4: Adult Health Assessment Sample Questions .................................................... 37 Appendix 5: Assessments for Children.................................................................................. 42 Appendix 6: Assessments for Adolescents ............................................................................ 43 Appendix 7: Health Assessments for Seniors ........................................................................ 44 Appendix 8: Crosswalk of Health Assessments Related to Incentive and Quality Programs 47 Appendix 9: Tools for Making Changes in Your Practice .................................................... 49 Appendix 10: Health Assessment Information for Patients ................................................... 51 Appendix 11: Patient Feedback Survey Example.................................................................. 53 References ............................................................................................................................... 53

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Introduction Obtaining periodic health assessments on patients provides an opportunity for primary care teams to get a snapshot on the health status and the health risks of empanelled patients. Health assessment is a process involving systematic collection and analysis of health-related information on patients for use by patients, clinicians, and health care teams to identify and support beneficial health behaviors and mutually work to direct changes in potentially harmful health behaviors. Health assessments are not intended to be diagnostic tools and they are not complete health histories; instead, they aim to be one method to engage patients in their own health, leading to better health choices and improved health behaviors in the long term. Much of the research on health assessments has focused primarily on their use and application in work settings. In these settings, successful use of health assessments requires assessments of health risks combined with health education programs. However, effective use of health assessments in primary care will require broader adoption and better implementation, including assessment, review, feedback and follow-up support for patients.

There are a variety of reasons to spark primary care practices to begin implementation of health assessments. For example, primary care practices may want to 1) systemically identify health issues in their patients, 2) take advantage of incentives provided by insurers or accrediting agencies, 3) implement the Medicare Annual Wellness Visit (AWV),1 or 4) support national initiatives like the National Committee for Quality Assurance (NCQA) Patient Centered Medical Home (PCMH) Recognition Program and the Centers for Medicare & Medicaid Services meaningful use standards.2 Thus, the purpose of this guide is to provide a framework and practical evidenced-based guidance for primary care teams to adopt and successfully implement health assessments in primary care practices. Additional background information on health assessments can be found in Appendix 1 (p. 32).

Who Should Use This Guide? This guide is designed to be used by a team of clinicians and staff in a practice. The guide can help: •

Practices with limited experience in implementing health assessments. 1

• •

Practices that have struggled with implementing health assessments in the past. Practices experienced in implementing health assessments.

Practices with extensive experience can benefit from this guide by reviewing key decision points and reminders about effective change strategies and processes.

How to Use This Guide To use this guide effectively, first identify the health assessment “champion” or lead in your practice. The lead should: •

• • •

Review this entire guide to become familiar with its overall contents and process. Set aside a minimum of one hour for this task. Make notes in the guide for you and your team. Review the key decision points below.

Seek guidance from the rest of your practice team.

Implementing a new health assessment effectively is not simply an “add-on” to the daily routine; it will have an impact on workflow, patient engagement, and office resources. Implementing health assessments is a process with “decision points” (shown below), from the early stages of health assessment selection and adoption to workflow integration through ongoing maintenance. For an example of the process, see the brief Case Study in Appendix 2, p. 33. Is your practice ready?



How do you How do you integrate choose an  assessments assessment? into practice flow?



How do you use the information you collect?



How do you How do you involve  sustain health patients? assessments?

This guide provides guidance and tools for each of these decision points. The appendices provide additional resources--including specific health assessment questions you can review, modify, and use--and links to other sources. Look for the blue bar in the margin and a link to the appendix location.

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The quotations highlighted throughout the Guide are from the clinicians, staff, and experts who participated in a field test of the guide or in the best practices data collection.

How Was This Guide Developed? The content and recommendations in this guide follow from our observations and interviews with primary care providers, staff, and administrators conducted in two phases across four practice-based research networks. In phase one, we combined observational data from six primary care practices about how they have implemented health assessments with results from a literature review, listserv discussions, two patient advisory councils’ recommendations, and expert panel recommendations. The combined results were used iteratively to develop a complete implementation guide. In phase two, the “How-To” Guide was field tested in another group of eight primary care practices. Observational data were again collected during the field test to further refine the content and organization of the guide based on user experiences

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Is your practice ready? 1

How do you choose an assessment? 2

How do you integrate assessments into practice flow? 3

How do you use the information you collect? 4

How do you involve patients? 5

How do you sustain health assessments? 6

Section 1. How Ready Is Your Practice to Implement a New Health Assessment? How do you know if your practice is ready to start work on implementing a health assessment? Answer the questions below to help identify areas where more preparation is needed. Table 1: A Checklist to Evaluate Your Practice Readiness

Questions for Your Practice or Team

Yes

No

Where to Find Help in This Guide

Do most clinicians and staff in your practice agree that implementing a health assessment is an important issue?

Section 1 (this section): benefits of implementing health assessments

Is your practice prepared to commit resources to the process of implementing a new health assessment? Does your practice have an idea of where the health assessment will fit into your practice’s current workflow?

Section 2: health assessment selection and resource considerations Section 3: workflow integration strategies

Does your practice have a plan for how the data from the health assessment will be used once it is collected?

Section 4: approaches to using information with your patients

How will your practice organize its resources (internal and external) to provide care based on the results of the health assessment?

Section 4: approaches to using information with your patients

Has your practice thought about ways to engage your patients in the health assessment process (review of results, prioritization, action plan, etc.)?

Section 5: strategies for engaging patients with health assessment information

Has your practice considered how it will sustain and improve the health assessment?

Section 6: tips for sustaining health assessments

If you found yourself marking “No” more often than “Yes”, you may need to address those barriers before moving forward on a full health assessment implementation. If 5

the barriers are relatively minor, some education may help. Below are some ideas to help weigh the pros and cons of adopting and implementing a new health assessment.

Benefits of Routine Health Assessment • • • • • • • • •

Improve relationships with patients by using the data to stimulate dialogue. Help clinicians identify and prioritize patient health issues and health goals.

Help pinpoint focused messages when talking with patients about what matters to their health. Help patients understand their current health status and act to improve their health. Consistently remind patients to increase their awareness about specific behaviors and habits that affect their health or chronic conditions.

Track patient health behaviors over time (e.g., physical activity, smoking, stress, or quality of life), which can also help with patient follow-up.

Measure and monitor patient data at the practice/population level for proactive, planned care. Identify issues requiring patient referral to additional resources.

Fulfill requirements for and generate revenue from incentive programs and national guidelines.

Don’t be afraid of the information you are going to start seeing. You will have better insight and probably learn more about your patients, thus building a far better relationship with your patient than you may have thought possible. - Practice manager, urban private practice, Colorado

Challenges of Routine Health Assessments • • •

Selecting an instrument that is meaningful, but practicable.

Dedicating time and training (including technical assistance if using EHR) required to effectively integrate health assessment into the practice workflow.

Accepting the practice work flow interruptions that may occur during the early implementation phase. 6

• • • •

Identifying a method to analyze and prepare data for easy and expedient use by the health care team. Prioritizing and addressing a patient’s identified health risks.

Organizing and deploying appropriate staff and resources to intervene on and treat identified health risks. Documenting and coding correctly in order to receive incentives and facilitate appropriate referrals.

There is a balance: You don’t want to have to do too much routinely. Right now we have to do a lot of documentation for “meaningful use,” which is a burden. I am very sensitive to adding to this burden. Yet, I also can see the importance of having this information for reaching public health goals and collection of data. - Family physician, suburban private practice, Colorado

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Is your practice ready? 1

How do you choose an assessment? 2

How do you integrate assessments into practice flow? 3

How do you use the information you collect? 4

How do you involve patients? 5

How do you sustain health assessments? 6

Section 2. How Does Your Practice Choose an Assessment? Many health assessments are available, so the choice may seem overwhelming. Think about ways to start small by focusing on a specific group of patients. This section provides guidance on how to select a health assessment that is appropriate for your patient population and practice situation. The first step is to identify your practice’s priorities in two areas: the type of patients you want to focus on and the health concerns you routinely discuss with those patients. This is what [my staff] and I have talked about: “How do we want to do [our assessment]?” You’ve got to think about who you are going to [assess]; and then, you think about, “What are we going to do when we get the answers?” - Family nurse practitioner, rural private practice, Colorado

The following questions will help you select a health assessment while making sure the assessment you choose includes questions important to your practice. 1. Which patient group is most important to your practice to begin assessing more routinely now?     

Adults Seniors Adolescents Children Other: ___________________________________________________________________________________

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2. What specific health concerns do you want to more systematically ask the above patients about?           

Depression and anxiety Healthy eating and physical activity Social support or social isolation Alcohol or substance abuse Sexual activity Tobacco or smoking Personal safety Pain Confidence or ability to manage their own health Quality of life Other health behaviors, risks, or concerns: ___________________________________ ____________________________________________________________________________________

3. What are your practice constraints in conducting health assessment? Are you constrained by any of the following factors?

 The time required for you and your staff to conduct the assessment(s)  The potential for reimbursement

 The health risk questions already in your electronic medical record

 Other quality improvement initiatives that may be ongoing within your practice: ____________________________________________________________________________________ 4. How will you and your health care team act on the results of health assessment? When thinking about the types of questions you may ask, you must consider how your team will act on the results. •



What resources does your practice have to follow up and treat conditions identified by the assessment?

Which care team members can help to identify resources for patients for specific health concerns? 10

The work of addressing risks identified on a health assessment does not have to fall entirely on clinicians or practice staff. Community and online resources may be available to help activate and engage patients with addressing behaviors such as smoking or weight loss. •



Which resources outside the office can your practice connect patients to (e.g., community or web-based resources)? How else can your practice staff activate and engage patients when a health concern has been identified (e.g., motivational interviewing techniques, protocols for planned follow up)?

After answering the above questions, you should now have a good idea of the type of assessment you want to implement. The next step is to determine the exact assessment to conduct in your practice. The Appendices contain many types of sample questions and additional resource links. Appendix 3 (p. 35): Adult health assessment resources

Appendix 4 (p. 37): Sample questions for adult health assessments Appendix 5 (p. 42): Child health assessment resources

Appendix 6 (p. 43): Adolescent health assessment resources

Appendix 7 (p. 44): Information about the Annual Wellness Visit and assessments for seniors You don’t want to ask questions if you’re not prepared to address them; that is, don’t ask if you won’t review and act on it, especially if you lack the resources to address the problem. We ask about violence in our preventive care question set. Although positives are uncommon, we recently did catch one instance of domestic violence that we were able to address that we wouldn’t have caught otherwise -Family physician, suburban private practice, New Jersey

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Are you already collecting this information? Several quality improvement or recognition programs require documenting or reporting specific information about your patients. Some of the items required may contain elements of health assessments, though they are often incomplete. Here are some common programs in primary care and their related health assessment items. Table 2: Health Assessments Related to Incentive and Quality Programs

Comprehensive Health Assessment Items Alcohol Use Depression Fall Risk Physical Activity Tobacco Use 1

CMS Medicare Annual Wellness Visit X X X X X

CMS Meaningful Use - Stage 1

NCQA HEDIS Measures 2012

3

2

NCQA 1 PCMH 2011

PQRS Measures 2011

The Joint Commission Core Measure Sets

USPSTF “A” or “B” Grade Recs

X X

X 2 X X

X

X 2 X

X

X

2

X

X

X 3 X

X

2

2

PCMH: Requirement 2C Comprehensive Health Assessment includes “Behaviors affecting health” Includes assessment and follow-up action (e.g., referral, counseling, other intervention) 3 Medicare patients only 2

A complete crosswalk can be found in Appendix 8 (p. 47). If you are already using a health assessment in your practice, like those listed in the table above, you may find you can augment it with a specific health assessment tool to conduct a full health assessment with your patients. The hospital requires certain information to be collected on each patient at every visit, which drives most of the content and questions the practice asks. The practice then decides how to collect the data and enter it into the EHR. The practice may add additional questions to the form that they feel are relevant and already exist in the EHR as fields. At the practice level, staff and providers work together to tweak the questions to fit their practice. - Medical assistant, suburban university-affiliated practice, Colorado

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Is your practice ready? 1

How do you choose an assessment? 2

How do you integrate assessments into practice flow? 3

How do you use the information you collect? 4

How do you involve patients? 5

How do you sustain health assessments? 6

Section 3. How Do You Work Health Assessments into Your Office Workflow? Now that your practice has identified which health assessments to incorporate into routine patient care, the next step is to consider how the assessment fits into the patient visit workflow. If this still feels overwhelming, start with a small pilot test, then move forward sequentially. This section is organized into five subsections addressing key strategies for implementing health assessments into the workflow of the patient visit: practice-wide involvement, training, patient visit planning, standardization, and EHR integration.

Start small. For instance, have one doctor who is interested in [a new assessment] and owns, and hones it to perfect, and then presents it [to the rest of the staff]. -General internal medicine physician, urban private practice, Colorado

Is your whole staff involved in the implementation? Implementing a new health assessment—like many practice improvement efforts— works best as a team effort. Clinicians, staff, and managers must all be involved in the final decisions about how an assessment will be implemented. To achieve this, engage staff and clinicians throughout the entire process of testing and improving how tools or questions are integrated into the office flow. In a larger practice, it might be more practical to do some of the work in a smaller team, bringing in the whole practice at key decision points. Multidisciplinary teams, regular meetings, plan-do-study-act (PDSA) cycles, and ongoing reviews of office processes will help to: 13

• •

Share the planning, design, execution, and maintenance of implementing health assessments Spread the effort and responsibility for handling health assessments across the health care team Links to PDSA and Workflow tools can be found in Appendix 9 (p. 49).

Our recommendations are: 1. Figure out your workflow. 2. Assess what you are going to do with the data you get. 3. Determine what elements of health you are most interested in and know how to deal with the results most effectively. 4. Start small and then expand. -Family physician, suburban private practice, New Jersey

In what areas do you need more training? Well-trained clinicians and staff will facilitate successful health assessment implementation. Staff might not immediately understand their important role in effectively implementing health assessments; however, training staff, setting expectations, getting buy-in from key leaders, and providing evidence on the value of health assessments may help to overcome resistance. Train on both the completion of health assessments and how to discuss results with patients. Consider providing training on the following: • • • • • •

Patient engagement techniques (e.g., how to emphasize the importance of completing the assessment and how to explain how the information is used) Specialized EHR training (e.g., work flows, templates, and reporting)

Issues specific to the selected health assessment instruments (e.g., scoring, decision support, patient feedback) Implementation (e.g., work flow, data entry, scheduling)

Tracking and reporting (e.g., documenting in and reporting from EHR or registry) How the selected health assessment(s) will improve patient care 14

How will new health assessments affect patient flow? To succeed with a sustainable implementation, the workflow for health assessments should aim to streamline the patient visit, improve (or at least not increase) patient cycle times, maximize clinician-patient contact time, and improve the use of patient contact time. With some careful planning, this can be accomplished. Allow a patient enough time to complete the health assessment thoughtfully, whether that means allowing them to complete it at home before the visit (possibly using a family member to help) or having them complete it in the waiting room while they wait to be seen. Here are a few considerations: •

• • •

Best types of visits for patients to complete a health assessment (e.g., well visit, sports physical)

Options for completing the survey outside of the office (e.g., mail to patients prior to a visit or complete online)

Staff availability to help patients complete health assessments (e.g., MA/RN reviews and asks about unanswered questions)



Options for review of the completed health assessment (e.g., MA/RN as part of rooming process or while patients wait; scan completed paper surveys; review EHR template or report)



Acknowledging to patients that you received and reviewed the information

• •

Formatting and ordering of questions to ensure efficient review or data entry (e.g., reorder questions to fit with EHR data entry work flow, organize “positive” responses in the same column for quick visual scanning)

Working collaboratively with patients to create a care plan (e.g., templates or handouts with health goals, priorities, and action items)

Coding appropriately for administration and review of health assessments (e.g., preventive coding “cheat sheet” for staff or clinicians)

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Should you standardize your processes?

We identify Annual Wellness Visit patients before their visit so the correct materials can be sent. The patient is sent an Annual Wellness Visit questionnaire ahead of time to fill out before they arrive in the clinic. The average patient takes about 10 minutes to complete [the questionnaire]. So far, most patients come back with the questionnaire already filled out. - Family physician, urban residency practice, Georgia

Consider developing a process map to visually describe the complete health assessment process in your practice. A sample process map can be found in Appendix 9 (p. 49). Standardization of processes, especially establishing expectations for roles and responsibilities, is important for practices to implement health assessments completely and more routinely. Consistency in processes can be especially important when documentation of health assessment questions is required for incentive programs. Writing a brief protocol, guide, or checklist can help the health care team to learn how to work with health assessments. Here are some ways to think about standardizing your health assessments: •

Which patients (or groups of patients) should receive the health assessment?



Who will make sure the patients get the health assessment? How (checklists; EHR reminders)?



How often do patients complete the health assessment (e.g., at all well care or preventive visits; annually for patients with chronic conditions)?



Where will the data go (into your EHR; into a database; into a paper chart)?



Who on your team will primarily review the information with the patient? When?



How will your practice arrange patient follow up?

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Special considerations for integrating health assessments into EHR work flows Health assessment data are more useful when they can be stored in structured fields in the EHR and retrieved through queries or reports. Integration into the EHR allows computerized tools to generate standardized decision support to identify health behavior risks and guide behavior change recommendations. Integration may also include using administrative databases to identify high-risk patients for further assessment or follow-up and support for accurate coding and billing. Consider the questions below to help guide the integration of health assessment into your practice’s EHR: •

What health assessments (or specific questions) are already in your EHR?



Do you already have a template for the health assessment?



Does your EHR have a patient portal to collect health assessment data?



What can you learn about implementation strategies from other practices using your same EHR?



If entering data from paper forms, do your paper forms follow EHR workflows?



Are answers to confidential or sensitive questions stored in a way to avoid improper release of this information?



Does the EHR allow the data from the health assessment to be easily collected for reporting (e.g., quality improvement or population management)?

In some cases, EHR integration might not be practical. Integration with EHRs is not essential—paper can still work well and be efficient for some assessments. For example, a paper health assessment form can be a quick and effective reminder tool for both clinicians and patients to discuss a particular topic that could be affecting the patient’s health.

Do you have an alternative to the EHR?

While integrating health assessments into your EHR is desirable in the long term, it could be more practical to consider some alternatives: • •

Standalone data repository (e.g., a patient registry) Simple spreadsheet or database

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Web-based tools for gathering and storing the health assessment information

Be sure that any electronic files you create are secure and comply with patient privacy regulations. It is not easy to find [information] in the EMR so it is rarely used. Also, since patients cannot input the data directly, it takes time to ask the questions. It is easier to have the patient fill this out on paper and put the final number result in [the EMR] as data. -Family physician, suburban residency practice, New York

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Is your practice ready? 1

How do you choose an assessment? 2

How do you integrate assessments into practice flow? 3

How do you use the information you collect? 4

How do you involve patients? 5

How do you sustain health assessments? 6

Section 4. How Do You Use the Health Assessment Information You Collect? How you use the information you gather depends on the type of information you collected, what you want to achieve, and what resources you have available.

Did you tell your patients that you reviewed their health assessment? An important first step is to tell patients you have reviewed the information. Regardless of how you choose to handle the information collected during health assessment, acknowledge to patients that you have reviewed the data you collected. Patients often wonder, “Why am I filling this out if the clinician isn’t going to look at it?” Let them know you really do look at it. The acknowledgement can be brief: “Thank you, Ms. Jones, for filling out this questionnaire. It looks like you’re having some minor symptoms of depression or stress, which we can talk about.” Or, use the opportunity to deliver a focused reminder or praise about how a specific behavior affects a health concern of the patient. “It looks like you’re doing a good job limiting your fatty foods and snacks. That can help keep your cholesterol at a healthy level. Keep it up.”

When should your practice use the health assessment information? Options for when to use the information include:

During the Visit • Usually feasible for shorter health assessments • •

Can be done once a year during wellness visits

Ideally administered by practice staff with “flags” for clinicians 19

Between Visits • Better for longer assessments • •

Can be administered by any trained member of the health care team

Depending on results, may require additional follow-up visits with primary care clinician or other team member or referral to community-based services

A Dedicated Health Assessment Visit A more comprehensive health assessment could take an entire visit to complete and to review. For example, the Medicare Annual Wellness Visit (AWV) is designed to set aside time for a focused discussion with patients about their completed health assessment. A healthy elderly patient may identify no major health concerns, in which case the visit may take only 20 to 30 minutes. Alternatively, a patient may identify hearing loss, increased fall risk, depression, or previously unidentified chronic pain. Each of these concerns is potentially an issue that required comprehensive follow-up.

You will very likely have to bring the patient back for a separate visit in the event that you identify the patient to have a chronic disease. It is acceptable to bill for the AWV and to also bill the ICD-9 codes for the chronic disease diagnoses you evaluated and treated at the visit (e.g., hearing loss, falls/fall risk).

How is health assessment information used at the population or practice level? The above paragraphs address how the information is used with an individual patient. A related question is: How can health assessment data be used to improve the health of a population? The answer depends in part on the infrastructure available and how the information is to be used. If your health assessment includes questions about depression risk, you may be able to generate a list of patients who had a positive response on the depression questions, then review the list to determine who may require further follow-up. If a high percentage needs follow-up, it may be appropriate to develop a quality improvement activity to purposefully follow up with those patients.

An EHR may facilitate the collection and reporting of health assessment data at a population level. If the EHR does not have this functionality, you can manually review a random sample of patient charts (either electronic or paper) to evaluate assessment rates for conditions or risks your practice has determined are a high priority. Your practice may already have dedicated staff members working on this type of activity through PCMH or other quality reporting programs. 20

There are also web-based assessments available to primary care practices that—for a fee—will help manage health assessment data and provide reports. [We] generate reports on each practices’ diabetic patients, covering nine different data points. [We] have two teams that review the reports regularly and call patients if they are not within NCQA goals. - Family physician, suburban university-affiliated practice, Colorado

Appendix 3 (adults, p. 35) and Appendix 6 (adolescents, p. 43) are links to online assessment tools.

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Is your practice ready? 1

How do you choose an assessment? 2

How do you integrate assessments into practice flow? 3

How do you use the information you collect? 4

How do you involve patients? 5

How do you sustain health assessments? 6

Section 5. How Do You Activate and Engage Patients in Using Their Health Assessment Information? An essential part of using a health assessment in your practice will be to activate and engage patients in the process of using health assessments to help improve their health. Patients clearly want some kind of acknowledgement that you have reviewed their completed assessments; however, this is only one of several considerations to engage patients in a conversation to plan a course of action.

What do you need to tell patients about health assessments? Patients need to hear from their clinicians that taking the time to complete the health assessment accurately is important and that health assessments will help you to work as a team to improve their health. Consider creating a script for staff and clinicians to use when talking about health assessments so they deliver a consistent, reinforcing message. •



• •

Remind patients that health assessments give you meaningful information about their health and that it is critical that the information is accurate and complete.

Tell patients that the information will help to identify potential health concerns, and, if needed, agree on a plan of action to address these concerns.

Let patients know who will see the information on their health assessment.

Clearly connect specifics on the health assessment to a patient’s health or specific health concern (e.g., “This is about your diabetes and heart health.”).

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What do patients expect? Patients expect health assessments to inform the conversation between a patient and his or her clinician. As part of any systematic health assessment activity, patients also want a place to state what health concerns are of most importance to them. Discussing patient priorities can help create an agenda with the patient right away, leading to a more efficient visit and a long-term plan of care. You can use the health assessment as a springboard to gauge the patient’s readiness to change. A patient’s motivation will help him or her follow through with mutually agreed on treatment and lifestyle recommendations. Health assessment information may also facilitate a mutually agreed on priority list and an action plan with reasonable goals. Consider adding a question to your assessment asking patients which health care issue is most important to them. Appendix 10 (p. 51): “Health Assessment Information for Patients” includes resources for setting patient agendas and goals and a patient-developed definition of health assessments.

Do you already have a clinical relationship with your patient? Patients and clinicians agree that health assessments, particularly those involving sensitive questions (e.g., depression, alcohol and drug use), work best when there is an established, trustful relationship between a patient and his or her clinician. Health assessments can contribute important information that only a patient knows about his or her health and that might not be routinely acquired during typical office visits. In terms of prioritization, the provider reviews the problem list, then talks with the patient about possible treatment plans considering all of the different problems at the same time. The patient helps prioritize, which is important, as you cannot get it done if the patient isn’t participating. Depending on the decided-on plan, they will agree to do some now (e.g., prescription) or do some now and some later (e.g., lifestyle). -Family physician, urban private practice, Colorado

What works for adolescents? Technology! While paper-based surveys can work well for adolescents and are relatively easy to integrate into the workflow, there is some evidence that teens are 24

more interested in answering health assessments using computers (especially tablets, like an iPad) and they might be more likely to answer sensitive questions honestly.3

Set expectations for the Medicare Annual Wellness Visit.

Explain to patients that the information obtained from health assessment is valuable for setting health and wellness goals. Remind them that it is not the same as an annual physical exam. Use a standard script for staff (especially appointment schedulers) and clinicians to help set patient expectations for this new type of office visit. Appendix 7 (p. 44): Sample script explaining the Annual Wellness Visit

A patient’s relationship with a provider is most important and is the primary consideration in terms of patients’ willingness to share information on health assessments. It’s not just about collecting data. - Certified physician assistant, rural private practice, Colorado

Ask patients about their experience completing the health assessment. As part of your assessment of quality of care, consider asking for patient feedback on the health assessment process. Establishing a more formal approach to patient feedback using focus groups or a patient advisory group can provide a richer understanding of patient views. Using a brief patient feedback form (sample in Appendix 11) can provide you with a quick evaluation of what patients think of the health assessment questions and process. You may learn that completing a health assessment helps to raise awareness in your patients about important health issues. As one clinician learned from an older patient after completing a comprehensive health assessment: “It helps me remember to take care of myself. Maybe you could suggest some activities that are age-appropriate.”

This information will be valuable when considering how to improve the sustainable use of a health assessment in your practice. Appendix 11 (p. 53): Sample patient feedback survey for a new health assessment 25

Is your practice ready? 1

How do you choose an assessment? 2

How do you integrate assessments into practice flow? 3

How do you use the information you collect? 4

How do you involve patients? 5

How do you sustain health assessments? 6

Section 6. How Does Your Practice Sustain Health Assessments? Several barriers may prevent your practice from sustaining the process of routinely using health assessments after trying it out: time, expense, lack of engagement from clinicians and practice staff, and low perception of value to patients. Below we address how to overcome some of these barriers.

Select a “high value” health assessment The most important factor in deciding whether to continue health assessments is the perceived value to patients and clinicians. Some health assessment questions are considered high value by patients (such as those related to tobacco use and readiness to quit); others are considered high value by clinicians, health care payers, or regulatory bodies. The questions included in your assessment should align with your practice priorities and patient priorities and should reach enough patients on a regular basis so that using the health assessment becomes routine and delivers important information about your patients. Plan for tracking and reporting on health assessment data to be able to show who has or has not been assessed and to evaluate how it is going. While such tracking and reporting might not be required, it can help to demonstrate success as part of a planned, continuous quality improvement process.

Evaluate the financial incentives for health assessments Clearly, financial incentives make a difference in the decision about whether to conduct and maintain health assessment. The Medicare Annual Wellness Visit is a comprehensive health assessment that, if done correctly, is a way to receive payment for the work you are doing. Other preventive health assessments and specific follow-up may also have reimbursement associated with them. For example, if you choose to ask all your patients about sexual behavior, you will inevitably find some risky behaviors, and then can use the diagnosis code for “high risk sexual behavior.”

27

Appendix 3 (p. 35): Coding and billing resources for adult preventive care Appendix 5 (p. 42): Coding and billing resources for child preventive care

Appendix 6 (p. 43): Coding and billing resources for adolescent preventive care

Appendix 7 (p. 44): Coding and billing resources for seniors and the Annual Wellness Visit

Consider the intangible incentives for conducting health assessment By incorporating routine health assessments as part of your services to patients, your practice or institution may earn a reputation for its focus on health maintenance and prevention and, by doing so, you may bring more patients into your practice and increase patient satisfaction.

Ask your practice how the health assessment process is working Once your health assessment is fully and routinely implemented, how do you know whether it is improving care for your patients and whether it is sustainable for the clinicians and staff? This could already be part of a planned quality improvement initiative or a less formal evaluation (see checklist below). Either way, remember to: •



• •

Talk with clinicians to find out if they think the assessment helps to provide better care, how it affects the content of visits, and how it affects the flow of patients. Talk with practice staff to find out how much time the health assessment adds to their interactions with patients, whether they feel it has value, and how they perceive patients’ reactions to it. Ask a few patients from your practice to get their reactions (see page 21 above). Share what you learned—and any successes—with your team. Show them data from the EHR or from chart reviews or patients about what has improved. Acknowledge team members’ roles and remind them how they contribute to improving the health of patients. 28



Look at your clinical data to see where there have been improvements in your documentation and in patient health (e.g., better documentation of asking about health behaviors, fewer smokers, more patients reporting better quality of life.)

Here is a simple checklist that can help you and your practice think about what is working or not working: Table 3: A Checklist for Reviewing Your Implementation Progress

Questions for your practice or team

Yes No If, “No,” how can you improve this part of the assessment process?

In general, are patients completing the health assessments as expected? In general, are patients responding positively to the assessment? Are you reaching all or most of the patients you wanted to with the assessment? Can most patients complete the assessment in a timely manner? Do patients routinely complete all the questions on the assessment? Are staff members able to review the completed assessments as expected? Are clinicians able to review the completed assessments as expected? Are the clinicians in the practice providing acknowledgment and feedback to patients as expected? Are assessments being entered into patient charts correctly? Are you able to respond to “positives” as expected? Do you have data to show how the practice has improved screening/assessment rates?

Appendix 9 (p. 49): More resources for implementing and assessing practice changes.

29

Appendices The appendices include additional tools for your practice and health assessment sample questions. Appendix 1: Background on Health Assessments in Primary Care Appendix 2: Health Assessment Case Study

Appendix 3: Health Assessments for Adults

Appendix 4: Adult Health Assessment Sample Questions Appendix 5: Assessments for Children

Appendix 6: Assessments for Adolescents

Appendix 7: Health Assessments for Seniors

Appendix 8: Crosswalk of Health Assessments Related to Incentive and Quality Programs Appendix 9: Tools for Making Changes in Your Practice

Appendix 10: Health Assessment Information for Patients Appendix 11: Patient Feedback Survey Example

31

Appendix 1: Background on Health Assessments in Primary Care •

AHRQ-commissioned environmental scan about how health assessments were being used in primary care. The final report, Health Risk Appraisals in Primary Care: Current Knowledge and Potential Applications To Improve Preventive Services and Chronic Care, is available here: Link: http://www.ahrq.gov/clinic/enviroscan/



Centers for Disease Control and Prevention worked with the Centers for Medicare & Medicaid Services to develop an evidence-informed framework for the Annual Wellness Visit health assessment, available here: Link: http://www.cdc.gov/policy/opth/hra/



Centers for Medicare & Medicaid Services provides a quick reference guide for implementation of health assessments related to the Annual Wellness Visit: Link: http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNProducts/downloads/AWV_chart_ICN90570 6.pdf

32

Appendix 2: Health Assessment Case Study Setting Family and preventive medicine residency program in Georgia. 20+ faculty clinicians, mostly part-time; 18+ resident physicians.

Getting Started (Week 1)

Practice leaders knew they needed to start consistently implementing the Annual Wellness Visit (AWV) for their Medicare-eligible patients. As the AWV clinicianchampion noted, “The AWV was an easy way to increase our revenue and it was something we needed to do anyway for our patients. This was low-hanging fruit to continue the culture change in our practice toward becoming a patient-centered medical home.” Unfortunately, in this large practice, clinicians, staff, and the off-site scheduling system were not completely ready. First, they started with a small team meeting (two clinicians and staff) to talk about their general interests and priorities for health assessments for the practice. Next, the clinician-champion and a physician assistant read the How-to Guide to make sure they weren’t forgetting an important step.

Selecting a Health Assessment (Week 2)

After settling on the AWV as the focus for a new health assessment, they began looking at different options for the questions they might use. They looked to their professional societies (the American College of Physicians and the American Academy of Family Physicians) for sets of questions that were suitable for their practice and patients. They selected a set of questions and modified them somewhat for their specific needs and practice flow. The final draft resulted in a more user-friendly tool for the nurses, patients, and clinic workflow.

Planning and Integrating (Weeks 3-4)

There were a number of logistical hurdles to consider: How and when would patients complete the health assessment? What kind of visit would work to review the assessment? What would staff and clinicians need to know about the assessment and the new type of visit? Here’s how they approached this by type of personnel involved: IT Specialist •

Work with IT to develop lists of eligible patients to contact and schedule visits. 33

• •

Create an “Annual Wellness Visit” in the scheduling system. Develop a method to draw attention to AWV appointments when the schedule is printed so the clinic is properly prepared for the visit.

Schedulers • • •

Mail patients paper copies of the health assessment to complete prior to their scheduled visit. They chose to mail these out 2 weeks in advance of the visit. Work with the institution’s schedulers to develop a script to talk to patients about the AWV and how it’s different from an annual physical exam. Work with the schedulers and staff to set the appropriate visit.

Management and Leadership •

• •

Develop and deliver a one-hour formal training on the new AWV for faculty, residents, and staff. The slides developed for the training were also sent to staff by email for easy access and future reference. Develop a protocol for staff to score the health assessment quickly at the office visit. Share strategies for successful AWVs.

Assessing and Refining (Weeks 5-6)

Once the initial processes were in place, the team continued to watch how the implementation went and how patients reacted. Because there was some ongoing confusion among patients (and a few clinicians) about the purpose of the AWV, the practice looked for a script they could use with patients. Again, they looked to their online resources at professional societies and found one they could start with. They had the schedulers and staff use the same script to send a consistent message to patients. Since then, they have tailored the script to suit their specific needs.

Because the practice also wanted to know what patients thought about the new health assessment, they surveyed a small sample of patients with a brief one-page survey. They learned that most patients completed the survey just fine. More importantly, they also learned that the health assessment helped remind some patients about behaviors and habits that affect their health. Looking Ahead (7-8 Weeks and Beyond)

The practice knew that the new health assessment was basically working well. They also recognized that they would have to revisit the process in a few weeks to look at their data on who had completed their annual wellness visits to help them identify any gaps and make a few more improvements. 34

Appendix 3: Health Assessments for Adults Questionnaires •

See Appendix 4 below for a full set of sample questions.



How’s Your Health: Online assessment for all adult patients (completed by patients); printable output for patients. Link: http://www.howsyourhealth.org

Billing and Coding •

American Medical Association: no-cost pocket guide for preventive services recommend by the U.S. Preventive Services Task Force and other coding resources. Link: http://www.ama-assn.org/ama/pub/physicianresources/solutions-managing-your-practice/codingbilling-insurance/cpt/cpt-preventive-services.page



The American Academy of Family Physicians: billing and coding guidance for preventive visits, including non-Medicare preventive visits. Link: http://www.aafp.org/fpm/topicModules/viewTopicMo dule.htm?topicModuleId=65



A searchable database of ICD-9 codes. 35

Link: http://icd9cm.chrisendres.com/

36

Appendix 4: Adult Health Assessment Sample Questions This list of brief health assessment questions is organized by behavior or risk and sorted alphabetically.4-7 In some cases, you can choose one of two options (A or B, not both). Questions marked with AWV  are suitable for the CMS Annual Wellness Visit health risk assessment. The topic headings are provided for your convenience, but may not be appropriate for patients to see. Select questions that are appropriate for your patient population. Reformat the questions as needed to fit with your practice flow or information systems.

ACTIVITIES OF DAILY LIVING (ADL) / INSTRUMENTAL ADL AWV 

AWV 

Activities of Daily Living (ADL) In the past 7 days, did you need help from others to perform everyday activities such as eating, getting dressed, grooming, bathing, walking, or using the toilet?

❒ No

❒ Yes

Instrumental Activities of Daily Living (ADL) In the past 7 days, did you need help from others to take care of things such as laundry and housekeeping, banking, shopping, using the telephone, food preparation, transportation, or taking your own medications?

❒ No

❒ Yes

ALCOHOL USE

AWV

MEN UNDER 65 ONLY: How many times in the past year have you had 5 or more drinks in a day?

❒0

❒1

❒2

❒ 3 or more times

ALL OTHERS: How many times in the past year have you had 4 or more drinks in a day?

❒0

❒1

❒2

❒ 3 or more times

ANXIETY AWV 

a. Over the past 2 weeks, how often have ❒ Not at all ❒ Several days ❒ More days ❒ Nearly you felt nervous, anxious, or on edge? than not every day b. Over the past 2 weeks, how often were ❒ Not at all ❒ Several days ❒ More days ❒ Nearly you not able to stop worrying or than not every day controlyour worrying?

37

DEPRESSION a. Over the past 2 weeks, how often have ❒ Not at all ❒ Several days ❒ More days ❒ Nearly you felt down, depressed, or hopeless? than not every day b. Over the past 2 weeks, how often have ❒ Not at all ❒ Several days ❒ More days ❒ Nearly you felt little interest or pleasure in doing than not every day things?

GENERAL HEALTH AWV 

❒ Excellent ❒ Very good

❒ Good

❒ Fair

❒ Poor

How would you describe the condition of ❒ Excellent ❒ Very good your mouth and teeth, including false teeth or dentures?

❒ Good

❒ Fair

❒ Poor

In general, would you say your health is:

❒ No

Have you suffered a personal loss or misfortune in the last year? (For example: a job loss, disability, divorce, separation, jail term, or the death of someone close to you.)

❒ Yes, one serious loss

❒ Yes, two or more serious losses

MEDICATION ADHERENCE How often do you have trouble taking medicines the way you have been told to take them?

❒ I do not ❒ I always take ❒ Sometimes ❒ I seldom take have to them as I take them as take prescribed them as prescribed medicine prescribed

NUTRITION / EATING PATTERNS AWV 

Option A Over the past 7 days: a. How many times did you eat fast food or snacks or pizza?

❒0

❒1

❒2

❒ 3 or more times

b. How many servings of fruits or vegetables did you eat each day?

❒ 3 or more servings

❒2

❒1

❒0

❒1

❒2

❒ 3 or more sweet drinks

c. How many sodas and sugar sweetened ❒ 0 drinks (regular, not diet) did you drink each day?

38

Option B Over the past 7 days, how many servings of fruits or vegetables did you eat each day?

❒ 3 or more servings

❒2

❒1

❒0

PAIN ❒ None

In the past 7 days, how much pain have you felt?

❒ Some

❒ A lot

PATIENT PRIORITIES Which of the above health topics is the most important one to talk with your doctor about today?

_____________________________________________________

PERSONAL SAFETY AWV 

❒ Yes

Do you always fasten your seat belt when you are in a car? Do you ever drive after drinking, or ride with a driver who has been drinking?

❒ No

❒ No ❒ Yes

PHYSICAL ACTIVITY AWV 

Option A a. On how many of the last 7 days did you engage in moderate to strenuous exercise (like a brisk walk)? b. On those days that you engage in moderate to strenuous exercise, how many minutes, on average, do you exercise at this level?

AWV

❒7

❒6

❒5

❒4 days

❒3

❒2

❒1

❒0

_______ minutes

Option B In the past week, on how many days have you done a total of 30 minutes or more of physical activity, which was enough to raise your breathing rate? (This may include sport, exercise and brisk walking or cycling for recreation or to get to and from places, but should not include housework or physical activity that may be part of your job.)

39

❒7

❒6

❒5 ❒4 ❒3 days

❒2

❒1

❒0

SEX a. How many different sexual partners have you had in ❒ 0 the past year? b. When you have sex, do you have sex with men, ❒ Men women, or both?

❒1

❒2

❒ Women

❒ Both

❒ 3 or more

SLEEP ❒ No

a. Do you snore or has anyone told you that you snore? b. In the past 7 days, I was sleepy during the daytime…

❒ Never

❒ Rarely

❒ Yes

❒ Sometimes

❒ Often

❒ Always

SOCIAL / EMOTIONAL SUPPORT AWV How often do you get the social and  emotional support you need?

❒ Always

❒ Usually

❒ Sometimes

❒ Rarely

❒ Never

STRESS Option A Please circle the number (0-10) that best describes how much distress you have been experiencing in the past week including today.

No distress 0

1

2

Option B How often is stress a problem for you in handling ❒ Never or such things as: Your health? Your finances? Your rarely family or social relationships? Your work?

Extreme distress 3

4

5

❒ Sometimes

6

7

❒ Often

8

9

❒ Always

SUBSTANCE USE How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?

40

❒0

❒1

❒2

10

❒ 3 or more times

TOBACCO USE AWV 

Option A In the last 30 days, have you used tobacco? a. Smoked cigarettes: b. Used a smokeless tobacco product: Option B Have you smoked one or more cigarettes in the past month?

AWV

41

❒ No ❒ No

❒ Yes ❒ Yes

❒ No

❒ Yes

Appendix 5: Assessments for Children Questionnaires •

Bright Futures: American Academy of Pediatrics Bright Futures information, resources, clinical tools, and questionnaires. Link: http://brightfutures.aap.org/tool_and_resource_kit.html

Billing and Coding •

American Academy of Pediatrics offers detailed coding and billing guidance for preventive care on its “Bright Futures” web page. Link: http://brightfutures.aap.org/clinical_practice.html

42

Appendix 6: Assessments for Adolescents Questionnaires • GAPS: American Medical Association Guidelines for Adolescent Preventive Services (GAPS) information, resources, and questionnaires. Link: http://www.ama-assn.org/ama/pub/physicianresources/public-health/promoting-healthylifestyles/adolescent-health/guidelines-adolescentpreventive-services.page • RAAPS: The Rapid Assessment for Adolescent Preventive Services© (RAAPS) information, resources, and questionnaires. Link: http://www.raaps.org

Billing and Coding •

American Academy of Pediatrics offers detailed coding and billing guidance for preventive care on its “Bright Futures” web page. Link: http://brightfutures.aap.org/clinical_practice.html

43

Appendix 7: Health Assessments for Seniors

Questionnaires •

See Appendix 4 for sample questions marked with AWV  and are suitable to for the Annual Wellness Visit.



American Academy of Family Physicians Annual Wellness Visit questionnaire and resources (membership may be required for some resources). Link: http://www.aafp.org/fpm/topicModules/viewTopicMo dule.htm?topicModuleId=76



American College of Physicians Annual Wellness Visit questionnaire and resources (membership may be required for some resources). Link: http://www.acponline.org/running_practice/payment_ coding/medicare/annual_wellness_visit.htm



“How’s Your Health” online Medicare Wellness Checkup questionnaire (with printable results). Link: http://www.medicarehealthassess.org

44

Billing and Coding •

The American College of Physicians offers billing and coding guidance specifically for Medicare patients, including the Annual Wellness Visit. Link: http://www.acponline.org/running_practice/payment_ coding/medicare/



The American Academy Family Physicians: billing and coding guidance for the Annual Wellness Visit. Link: http://www.aafp.org/fpm/topicModules/viewTopicMo dule.htm?topicModuleId=65

45

Sample Script for Annual Wellness Visit Scheduling

Patient: “I'd like to schedule my annual physical. I am a Medicare patient and I think there should be no co-pay for this.” Scheduler: “Are you interested in the Annual Wellness Visit? That visit is covered once a year by Medicare with no co-pay. There is also a Welcome to Medicare visit which is also no co-pay if it is your first year having Medicare coverage.” Patient: “I think it's the Annual Wellness Visit that I had heard about.”

Scheduler: “Yes, we can schedule that. The Annual Wellness Visit looks at your overall health, plus plans to help you stay healthy. Instead of a head-to-toe exam, it involves completion of a questionnaire which may take up to 20 minutes to complete. These questions are very helpful for your doctor/provider in determining how to keep you healthy.” Patient: “Thank you. Yes I'd like to schedule it. I'm fairly healthy overall.” Scheduler: “Very good. I'll schedule it for you now. Keep in mind that if your provider spends time to address issues that arise from completion of the wellness questionnaire, you'll have a co-pay or deductible just like you would for any other visit.”

Note: Schedule the annual wellness visit appointment and recommend the patient read his or her Medicare information about what to expect during the annual wellness visit.

46

Appendix 8: Crosswalk of Health Assessments Related to Incentive and Quality Programs

Comprehensive HA Items ADLs and Instrumental ADLs Alcohol Use Anxiety Cognitive impairment Depression Diet/Nutrition Fall Risk Fatigue Frailty Health Status/Well Being Level of Safety Oral Health Pain Physical Activity Physical Functioning Seat Belt Use/Driving Safety Sexual Practices Sleep Social Isolation/Social Support Stress Substance Use/Abuse Tobacco Use/Smoking 4BMI Assessment/ Height + Weight 4Cancer Screenings 4HTN/Blood pressure 4Immunizations 4Demographic Data (age, gender, race)

CMS Medicare Annual Wellness Visit X

CMS Meaningful Use - Stage 1

NCQA HEDIS Measures 2012

NCQA PCMH (2011)1

PQRS Measures 2011

Joint Commission Core Measure Sets

USPSTF “A” or “B” grade recs

X

X2

X X X

X

X

X X

X

X2

X3

X2

X

X X

X X X

X3

X X X

X2

X

X2,5

X X

X

X

X

X2

X

X2, 5

X

X2 X5 X X

X X

X

1PCMH:

Requirement 2C Comprehensive Health Assessment includes “Behaviors affecting health” assessment and follow-up action (e.g., referral, counseling, other intervention) 3Medicare patients only 4Information in these categories may already exist in medical records and may not be needed in a health assessment 5Includes children and adolescents 2Includes

47

Sources: o o o o o o

Centers for Medicare & Medicaid Services, Meaningful Use, http://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html National Committee for Quality Assurance, HEDIS Measures, http://www.ncqa.org/HEDISQualityMeasurement/HEDISMeasures.aspx; National Committee for Quality Assurance, Patient-Centered Medical Home Recognition Program, http://www.ncqa.org/Programs/Recognition/PatientCenteredMedicalHomePCMH.aspx Centers for Medicare & Medicaid Services, Physician Quality Reporting System, http://www.cms.gov/Medicare/QualityInitiatives-Patient-Assessment-Instruments/PQRS/index.html The Joint Commission, Core Measures Sets, http://www.jointcommission.org/core_measure_sets.aspx U.S. Preventive Services Task Force A and B Recommendations, http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm

48

Appendix 9: Tools for Making Changes in Your Practice •

Institute for Healthcare Improvement (IHI) provides numerous tools for improving practice, including information about plan-do-study-act (PDSA) methods. Link: http://www.ihi.org/knowledge/Pages/HowtoImprove/ default.aspx



AHRQ’s HIT web site provides extensive guidance on workflow assessments for implementing information technology. Many of the online tools and guidance are perfectly applicable to thinking through workflows and mapping office processes. Look for the “workflow tools” link. Link: http://healthit.ahrq.gov/health-it-tools-andresources/workflow-assessment-health-it-toolkit



AHRQ also sponsored the development of an office efficiency decision guide available here: Link: http://fammed.ucdenver.edu/efficiency/default.htm

49

Example Process Map for an Annual Health Assessment

50

Appendix 10: Health Assessment Information for Patients The Colorado Research Network’s Patient Advisory Council created this definition of health assessments for patients. What is a health assessment?

A health assessment is a set of questions, answered by patients, that asks about personal behaviors, risks, life-changing events, health goals and priorities, and overall health. Health assessments are usually structured screening and assessment tools used in primary care practices to help the health care team and patient develop a plan of care. Health assessment information can also help the health care team understand the needs of its overall population of patients. Health assessments can vary in length and scope. They can be completed during office visits or between office visits, either on paper or computers. Health assessment questions may be asked about patients of all ages, including children and adolescents. Some common health assessment questions ask about: • • • • • • • • • • • • •

Tobacco use Stress Healthy eating Physical activity Sexual practices Sedentary behaviors such as sitting and watching TV or playing computer games Alcohol usage Addictive behaviors such as gambling or drug use Violence, bullying or physical abuse Depression or anxiety Emotional and social support Safety issues such as wearing a seat belt while driving Overall health or well being

CaReNet Patient Advisory Council © 2012 – reprinted with permission

51

Agenda-setting with patients The “Establishing Focus Protocol” helps physicians set an agenda at the beginning of the visit with input from the patient. The protocol can increase patient satisfaction without increasing the length of visits. More information is in the Family Practice Management article Have You Really Addressed Your Patient's Concerns? 8 Link: http://www.aafp.org/fpm/2008/0300/p35.html

Goal-setting with patients AHRQ offers a number of tools for medical professionals related to implementing components of the Chronic Care Model. Toolkit for Implementing the Chronic Care Model in an Academic Environment is one available tool is for helping patients create a selfmanagement goal. Link: http://www.ahrq.gov/professionals/education/curricu lum-tools/chroniccaremodel/chronic3a13a.html

Health literacy for better patient communication AHRQ funded the development of the Health Literacy Universal Precautions Toolkit. Developed by the North Carolina Network Consortium, the toolkit guides clinicians and staff in reducing complexity of medical care to help patients. Link: http://www.ahrq.gov/professionals/ quality-patient-safety/quality-resources/ tools/literacy/index.html

52

Appendix 11: Patient Feedback Survey Example NOTE: Revise this survey as needed to fit with your practice and patient population. We have started using a new health assessment questionnaire to improve our care. We want to hear from you about how the health assessment process is working in our practice so we can continue to improve our care to you. Please answer a few questions about the health assessment that you completed. Please return this completed survey to the front desk before you leave. Your answers to the questions are confidential. For the following questions about the health assessment you completed, please indicate how well each statement applies to your experience. 1. The questions on the assessment were easy to answer.

☐ Yes

☐ Somewhat

☐ No

2. I had enough time to complete the assessment.

☐ Yes

☐ Somewhat

☐ No

3. I know why I completed the assessment.

☐ Yes

☐ Somewhat

☐ No

4. My provider let me know that he or she had reviewed my assessment.

☐ Yes

☐ Somewhat

☐ No

5. I talked with my provider about my answers to questions on the assessment.

☐ Yes

☐ Somewhat

☐ No

6. The assessment covered most of my current health concerns.

☐ Yes

☐ Somewhat

☐ No

7. Overall, I think that completing the assessment will help my doctor provide better care.

☐ Yes

☐ Somewhat

☐ No

Please help us make the health assessment better by answering a few more questions: 8. What other health topics or concerns should the assessment ask about that are important to you? ____________________________________________________________________ 9. How can the information on the assessment be made more useful to you to improve your health ? ____________________________________________________________________ 10. How else can we make the health assessment process better? ____________________________________________________________________

Thank you! 53

References 1. 2. 3. 4. 5. 6. 7. 8.

Koh HK, Sebelius KG. Promoting prevention through the Affordable Care Act. N Engl J Med. 2010;363(14):1296-1299.

Blumenthal D, Tavenner M. The "meaningful use" regulation for electronic health records. N Engl J Med. 2010;363(6):501-504.

Olson AL, Gaffney CA, Hedberg VA, Gladstone GR. Use of inexpensive technology to enhance adolescent health screening and counseling. Arch Pediatr Adolesc Med. 2009;163(2):172-177. Estabrooks PA, Boyle M, Emmons KM, et al. Harmonized patient-reported data elements in the electronic health record: supporting meaningful use by primary care action on health behaviors and key psychosocial factors. JAMIA. 2012;19(4):575-582.

Goetzel RZ, Staley P, Ogden L, et al. A framework for patient-centered health risk assessments – providing health promotion and disease prevention services to Medicare beneficiaries. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention;2011. Milton K, Clemes S, Bull F. Can a single question provide an accurate measure of physical activity? Br J Sports Med. 2012:1-6.

Diemert LM, Bondy SJ, Victor JC, et al. Efficient screening of current smoking status in recruitment of smokers for population-based research. Nicotine Tob Res. Nov 2008;10(11):1663-1667. Epstein RM, Mauksch L, Carroll J, Jaén CR. Have you really addressed your patient's concerns? Fam Pract Manag. Mar 2008;15(3):35-40.

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AHRQ Pub. No. 13-0061-EF September 2013

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Health Assessments in Primary Care - AHRQ

Health Assessments in Primary Care A How-to Guide for Clinicians and Staff Health Assessments in Primary Care A How-to Guide for Clinicians and Staf...

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