Adoption, reach, implementation, and maintenance of a behavioral and mental health assessment in primary care.
OBJECTIVE
Guidelines recommend screening patients for unhealthy behaviors and mental health concerns. Health risk assessments can systematically identify patient needs and trigger care. This study seeks to evaluate whether primary care practices can routinely implement such assessments into routine care.


METHODS
As part of a cluster-randomized pragmatic trial, 9 diverse primary care practices implemented My Own Health Report (MOHR)-an electronic or paper-based health behavior and mental health assessment and feedback system paired with counseling and goal setting. We observed how practices integrated MOHR into their workflows, what additional practice staff time it required, and what percentage of patients completed a MOHR assessment (Reach).


RESULTS
Most practices approached (60%) agreed to adopt MOHR. How they implemented MOHR depended on practice resources, informatics capacity, and patient characteristics. Three practices mailed patients invitations to complete MOHR on the Web, 1 called patients and completed MOHR over the telephone, 1 had patients complete MOHR on paper in the office, and 4 had staff help patients complete MOHR on the Web in the office. Overall, 3,591 patients were approached and 1,782 completed MOHR (Reach = 49.6%). Reach varied by implementation strategy with higher reach when MOHR was completed by staff than by patients (71.2% vs 30.2%, P <.001). No practices were able to sustain the complete MOHR assessment without adaptations after study completion. Fielding MOHR increased staff and clinician time an average of 28 minutes per visit.


CONCLUSIONS
Primary care practices can implement health behavior and mental health assessments, but counseling patients effectively requires effort. Practices will need more support to implement and sustain assessments.
Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia (A.H.K.); Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland (S.M.P.); Department of Biostatistics, Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia (R.T.S.); Division of Epidemiology, Human Genetics, and Environmental Science, University of Texas, School of Public Health, Dallas, Texas (B.A.B.); Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland (S.H R.); Department of Health Promotion and Community Health Sciences, Texas A&M Health Sciences Center School of Public Health, College Station, Texas (M.G.O.); Department of Family and Community Medicine, Carilion Clinic, Roanoke, Virginia (S.B.J. & P.A.E.); Leidos Biomedical Research, Inc, Division of Cancer Control and Population Sciences of the National Cancer Institute, New York Physicians Against Cancer (NYPAC), Herbert Irving Comprehensive Cancer Center, New York, New York (S.N.S-G.); Department of Human Nutrition, Foods, and Exercise, Virginia Tech, Blacksburg, Virignia (P.A.E.); Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado (D.P.R.); Department of Family Medicine, University of Colorado School of Medicine, Denver, Colorado (R.E.G.) ahkrist@vcu.edu.
Alex H
AH
Krist
Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia (A.H.K.); Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland (S.M.P.); Department of Biostatistics, Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia (R.T.S.); Division of Epidemiology, Human Genetics, and Environmental Science, University of Texas, School of Public Health, Dallas, Texas (B.A.B.); Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland (S.H R.); Department of Health Promotion and Community Health Sciences, Texas A&M Health Sciences Center School of Public Health, College Station, Texas (M.G.O.); Department of Family and Community Medicine, Carilion Clinic, Roanoke, Virginia (S.B.J. & P.A.E.); Leidos Biomedical Research, Inc, Division of Cancer Control and Population Sciences of the National Cancer Institute, New York Physicians Against Cancer (NYPAC), Herbert Irving Comprehensive Cancer Center, New York, New York (S.N.S-G.); Department of Human Nutrition, Foods, and Exercise, Virginia Tech, Blacksburg, Virignia (P.A.E.); Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado (D.P.R.); Department of Family Medicine, University of Colorado School of Medicine, Denver, Colorado (R.E.G.).
Siobhan M
SM
Phillips
Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia (A.H.K.); Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland (S.M.P.); Department of Biostatistics, Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia (R.T.S.); Division of Epidemiology, Human Genetics, and Environmental Science, University of Texas, School of Public Health, Dallas, Texas (B.A.B.); Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland (S.H R.); Department of Health Promotion and Community Health Sciences, Texas A&M Health Sciences Center School of Public Health, College Station, Texas (M.G.O.); Department of Family and Community Medicine, Carilion Clinic, Roanoke, Virginia (S.B.J. & P.A.E.); Leidos Biomedical Research, Inc, Division of Cancer Control and Population Sciences of the National Cancer Institute, New York Physicians Against Cancer (NYPAC), Herbert Irving Comprehensive Cancer Center, New York, New York (S.N.S-G.); Department of Human Nutrition, Foods, and Exercise, Virginia Tech, Blacksburg, Virignia (P.A.E.); Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado (D.P.R.); Department of Family Medicine, University of Colorado School of Medicine, Denver, Colorado (R.E.G.).
Roy T
RT
Sabo
Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia (A.H.K.); Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland (S.M.P.); Department of Biostatistics, Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia (R.T.S.); Division of Epidemiology, Human Genetics, and Environmental Science, University of Texas, School of Public Health, Dallas, Texas (B.A.B.); Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland (S.H R.); Department of Health Promotion and Community Health Sciences, Texas A&M Health Sciences Center School of Public Health, College Station, Texas (M.G.O.); Department of Family and Community Medicine, Carilion Clinic, Roanoke, Virginia (S.B.J. & P.A.E.); Leidos Biomedical Research, Inc, Division of Cancer Control and Population Sciences of the National Cancer Institute, New York Physicians Against Cancer (NYPAC), Herbert Irving Comprehensive Cancer Center, New York, New York (S.N.S-G.); Department of Human Nutrition, Foods, and Exercise, Virginia Tech, Blacksburg, Virignia (P.A.E.); Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado (D.P.R.); Department of Family Medicine, University of Colorado School of Medicine, Denver, Colorado (R.E.G.).
Bijal A
BA
Balasubramanian
Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia (A.H.K.); Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland (S.M.P.); Department of Biostatistics, Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia (R.T.S.); Division of Epidemiology, Human Genetics, and Environmental Science, University of Texas, School of Public Health, Dallas, Texas (B.A.B.); Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland (S.H R.); Department of Health Promotion and Community Health Sciences, Texas A&M Health Sciences Center School of Public Health, College Station, Texas (M.G.O.); Department of Family and Community Medicine, Carilion Clinic, Roanoke, Virginia (S.B.J. & P.A.E.); Leidos Biomedical Research, Inc, Division of Cancer Control and Population Sciences of the National Cancer Institute, New York Physicians Against Cancer (NYPAC), Herbert Irving Comprehensive Cancer Center, New York, New York (S.N.S-G.); Department of Human Nutrition, Foods, and Exercise, Virginia Tech, Blacksburg, Virignia (P.A.E.); Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado (D.P.R.); Department of Family Medicine, University of Colorado School of Medicine, Denver, Colorado (R.E.G.).
Suzanne
S
Heurtin-Roberts
Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia (A.H.K.); Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland (S.M.P.); Department of Biostatistics, Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia (R.T.S.); Division of Epidemiology, Human Genetics, and Environmental Science, University of Texas, School of Public Health, Dallas, Texas (B.A.B.); Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland (S.H R.); Department of Health Promotion and Community Health Sciences, Texas A&M Health Sciences Center School of Public Health, College Station, Texas (M.G.O.); Department of Family and Community Medicine, Carilion Clinic, Roanoke, Virginia (S.B.J. & P.A.E.); Leidos Biomedical Research, Inc, Division of Cancer Control and Population Sciences of the National Cancer Institute, New York Physicians Against Cancer (NYPAC), Herbert Irving Comprehensive Cancer Center, New York, New York (S.N.S-G.); Department of Human Nutrition, Foods, and Exercise, Virginia Tech, Blacksburg, Virignia (P.A.E.); Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado (D.P.R.); Department of Family Medicine, University of Colorado School of Medicine, Denver, Colorado (R.E.G.).
Marcia G
MG
Ory
Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia (A.H.K.); Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland (S.M.P.); Department of Biostatistics, Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia (R.T.S.); Division of Epidemiology, Human Genetics, and Environmental Science, University of Texas, School of Public Health, Dallas, Texas (B.A.B.); Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland (S.H R.); Department of Health Promotion and Community Health Sciences, Texas A&M Health Sciences Center School of Public Health, College Station, Texas (M.G.O.); Department of Family and Community Medicine, Carilion Clinic, Roanoke, Virginia (S.B.J. & P.A.E.); Leidos Biomedical Research, Inc, Division of Cancer Control and Population Sciences of the National Cancer Institute, New York Physicians Against Cancer (NYPAC), Herbert Irving Comprehensive Cancer Center, New York, New York (S.N.S-G.); Department of Human Nutrition, Foods, and Exercise, Virginia Tech, Blacksburg, Virignia (P.A.E.); Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado (D.P.R.); Department of Family Medicine, University of Colorado School of Medicine, Denver, Colorado (R.E.G.).
Sallie Beth
SB
Johnson
Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia (A.H.K.); Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland (S.M.P.); Department of Biostatistics, Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia (R.T.S.); Division of Epidemiology, Human Genetics, and Environmental Science, University of Texas, School of Public Health, Dallas, Texas (B.A.B.); Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland (S.H R.); Department of Health Promotion and Community Health Sciences, Texas A&M Health Sciences Center School of Public Health, College Station, Texas (M.G.O.); Department of Family and Community Medicine, Carilion Clinic, Roanoke, Virginia (S.B.J. & P.A.E.); Leidos Biomedical Research, Inc, Division of Cancer Control and Population Sciences of the National Cancer Institute, New York Physicians Against Cancer (NYPAC), Herbert Irving Comprehensive Cancer Center, New York, New York (S.N.S-G.); Department of Human Nutrition, Foods, and Exercise, Virginia Tech, Blacksburg, Virignia (P.A.E.); Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado (D.P.R.); Department of Family Medicine, University of Colorado School of Medicine, Denver, Colorado (R.E.G.).
Sherri N
SN
Sheinfeld-Gorin
Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia (A.H.K.); Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland (S.M.P.); Department of Biostatistics, Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia (R.T.S.); Division of Epidemiology, Human Genetics, and Environmental Science, University of Texas, School of Public Health, Dallas, Texas (B.A.B.); Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland (S.H R.); Department of Health Promotion and Community Health Sciences, Texas A&M Health Sciences Center School of Public Health, College Station, Texas (M.G.O.); Department of Family and Community Medicine, Carilion Clinic, Roanoke, Virginia (S.B.J. & P.A.E.); Leidos Biomedical Research, Inc, Division of Cancer Control and Population Sciences of the National Cancer Institute, New York Physicians Against Cancer (NYPAC), Herbert Irving Comprehensive Cancer Center, New York, New York (S.N.S-G.); Department of Human Nutrition, Foods, and Exercise, Virginia Tech, Blacksburg, Virignia (P.A.E.); Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado (D.P.R.); Department of Family Medicine, University of Colorado School of Medicine, Denver, Colorado (R.E.G.).
Paul A
PA
Estabrooks
Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia (A.H.K.); Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland (S.M.P.); Department of Biostatistics, Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia (R.T.S.); Division of Epidemiology, Human Genetics, and Environmental Science, University of Texas, School of Public Health, Dallas, Texas (B.A.B.); Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland (S.H R.); Department of Health Promotion and Community Health Sciences, Texas A&M Health Sciences Center School of Public Health, College Station, Texas (M.G.O.); Department of Family and Community Medicine, Carilion Clinic, Roanoke, Virginia (S.B.J. & P.A.E.); Leidos Biomedical Research, Inc, Division of Cancer Control and Population Sciences of the National Cancer Institute, New York Physicians Against Cancer (NYPAC), Herbert Irving Comprehensive Cancer Center, New York, New York (S.N.S-G.); Department of Human Nutrition, Foods, and Exercise, Virginia Tech, Blacksburg, Virignia (P.A.E.); Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado (D.P.R.); Department of Family Medicine, University of Colorado School of Medicine, Denver, Colorado (R.E.G.).
Debra P
DP
Ritzwoller
Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia (A.H.K.); Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland (S.M.P.); Department of Biostatistics, Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia (R.T.S.); Division of Epidemiology, Human Genetics, and Environmental Science, University of Texas, School of Public Health, Dallas, Texas (B.A.B.); Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland (S.H R.); Department of Health Promotion and Community Health Sciences, Texas A&M Health Sciences Center School of Public Health, College Station, Texas (M.G.O.); Department of Family and Community Medicine, Carilion Clinic, Roanoke, Virginia (S.B.J. & P.A.E.); Leidos Biomedical Research, Inc, Division of Cancer Control and Population Sciences of the National Cancer Institute, New York Physicians Against Cancer (NYPAC), Herbert Irving Comprehensive Cancer Center, New York, New York (S.N.S-G.); Department of Human Nutrition, Foods, and Exercise, Virginia Tech, Blacksburg, Virignia (P.A.E.); Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado (D.P.R.); Department of Family Medicine, University of Colorado School of Medicine, Denver, Colorado (R.E.G.).
Russell E
RE
Glasgow
D005240:Feasibility Studies; D015438:Health Behavior; D006801:Humans; D020407:Internet; D007407:Interviews as Topic / Q000706:statistics & numerical data; D001523:Mental Disorders / Q000175:diagnosis*; D008603:Mental Health; D011320:Primary Health Care / Q000379:methods* / Q000458:organization & administration / Q000706:statistics & numerical data*; D018570:Risk Assessment / Q000379:methods / Q000458:organization & administration / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires / Q000706:statistics & numerical data
health behavior; health risk appraisal; mental health; patient reported measures; pragmatic clinical trial; primary health care