Implementing Affordable Care Act mandated health risk assessments will stretch primary care providers beyond capacity

Primary care practices are willing to implement behavioral and mental health assessments required by the Affordable Care Act, but lack the resources to do so effectively. If they implement the assessments, the high number of health risks identified will likely stretch many practices beyond treatment capacity, according to two studies published this month in the Annals of Family Medicine.

The Affordable Care Act established a Medicare Annual Wellness Visit that mandates the inclusion of routine health risk assessments (HRAs), but until recently little was known about the extent to which health care providers can routinely engage patients, and about the health risks and patient attitudes that will be uncovered.

Coordinated by clinical researchers at Virginia Commonwealth University, three national funding agencies and researchers from eight universities collaborated on these studies including Regents and Distinguished Professor Marcia Ory, Ph.D., of the Texas A&M Health Science Center School of Public Health. Ory helped direct the research at two clinics in the Brazos Valley examining the way HRAs work in clinics in more rural areas.

As described in “How Primary Care Practices Field a Behavioral and Mental Health Assessment,” HRAs can be effective in identifying patients who are at risk, and primary care practices are promising places to conduct HRAs because of the long-term relationships these doctors have with their patients. However, conducting health risk assessments and then helping patients improve their behaviors and mental health takes time and a team-based approach.

“We know that primary care clinicians can be strong change agents, but to be most effective they need to be taught basic behavior change principles. Additionally, such assessments will work best if they are embedded into clinical practice and not seen as an ‘added on’ activity,” Ory said.

In that study, nine diverse primary care practices conducted HRAs with more than 1,700 patients, but most of the practices lacked capacity and infrastructure to maintain the work on their own and none chose to maintain the HRA after study completion. Most sites did, however, integrate elements of the supplied HRA into their workflow.

In the next study, researchers described the patient-reported frequency, readiness to change, desire to discuss and perceived importance of 13 health risk factors identified on the supplied HRA — which was called My Own Health Report (MOHR). This study is titled “Frequency of and Prioritization of Patient Health Risks: Findings from the My Own Health Report (MOHR) Implementation Trial.”

Close to 55 percent of patients had more than six risks ranging from inadequate fruit and vegetable consumption to depression, but on average, they only wanted to change or discuss one of those risks. Engaging patients in prioritizing health risks and then focusing on the one to three that are of highest priority may be a more realistic, acceptable and manageable compromise between neglecting these health risks and trying to address all of them simultaneously.

“This study advanced knowledge about best practices for behavior change by pulling together an interdisciplinary team of clinicians, behavioral scientists and public health researchers who took a very practical approach to addressing how standardized assessments could be embedded into clinical practices” Ory said. “In particular this study shows that HRAs can help patients identify risks and prioritize those they would like assistance dealing with in the primary care setting.”

Attending to patient concerns is the essence of patient-centered medical care and can ultimately lead to better health outcomes, according to Ory.

Both studies were jointly supported by the National Cancer Institute (NCI), the Agency for Healthcare Research and Quality (AHRQ) and the Office of Behavioral and Social Sciences Research (OBSSR).

In addition to Ory, researchers from Carilion Clinic, Fielding School of Public Health UCLA, OCHIN, University of Colorado School of Medicine, University of North Carolina Chapel Hill, University of Texas Health Science Center at Houston, University of Vermont and Virginia Tech were involved in these studies.