Implementing ACA-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, and if they implement the assessments, the high number of health risks identified will likely stretch many practices beyond treatment capacity, according to a Virginia Commonwealth University-led study that produced two articles 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, 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.

"Health risk assessments 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," said Alex Krist, M.D., associate professor in the Department of Family Medicine and Population Health, VCU School of Medicine, and co-director of the Community Engagement Core at the VCU Center for Clinical and Translational Research.

"However, conducting health risk assessments and then helping patients improve their behaviors and mental health takes time and a team-based approach. Primary care practices will need help with this work," said Krist, who is principal investigator of the first article , "How Primary Care Practices Field a Behavioral and Mental Health Assessment."

The article analyzes nine diverse primary care practices that conducted HRAs with more than 1,700 patients. 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.

Implementing the supplied HRA, including clinician counseling, increased the average office visit by 28 minutes.

"These challenges need to be addressed before primary care practices can be expected to conduct health risk assessments as part of routine care, but doing so could help improve health and well-being for patients," Krist said.

In the next article, 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. This article 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.

"Thus, 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," said Siobhan Philips, Ph.D., assistant professor in the Department of Preventive Medicine, Northwestern University Feinberg School of Medicine.

"At an individual patient level, it is much easier for patients and providers to address one or two of the risk factors that patients identify as priorities," said Philips, who was principal investigator on the second article. "At a practice level, knowing not only the frequency of health risks, but what patients identify as most salient to them, can help practices better coordinate their efforts to offer needed services or partner with community organizations or other entities to refer patients to these services."