Health Risk Assessments

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It is said that.... "You cannot manage what you don't measure".  As of 2020 there are now 218 approved MACRA/MIPS measures.  We have researched multiple clinical data repositories and found over 50 applicable Health Risk Assessment tools that you should consider adding to your new VB program.

Any new VBC Program patient assessment process should start with the Medicare Annual Wellness Visit (AWV).  Incorporating clinically validated HRA tools into your AWV workflow will significantly enhance patient engagement and clinical outcomes.  

Below we list some the commonly used Health Risk Assessment (HRA) tools along with the clinical benefit for your new VBC program:

VR-36:

 Creates a Whole Person view of 8 core domains including Physical Functioning (PF), Role Physical (RP), Bodily Pain (BP), General Health (GH), Vitality (VT), Social Functioning (SF), Role-Emotional (RE) and Mental Health (MH).  We use this assessment tool to assist help your staff develop a working care plan for which areas a patient needs to focus on first.

PACIC:

The "Patient Assessment of Chronic Illness Care" is an assessment tool that was developed as a component of the Chronic Care Model.  It provides an objective look at the patient’s perspective of their care.  From a population health measures perspective, our use of this tool provides an ability to report on the success of your program to your team on an annual basis.  The scoring function is from 20 to 100 points.  We typically see very low scores prior to being involved in a CCM program, with the score rapidly increasing over the initial 24 months.

PSOCQ:

The "Pain Stages of Change Questionnaire" is used for patients with substance abuse challenges.  The four domains measured give us a solid look into whether or not the patient is willing to accept change in their life as it relates to their overall chronic pain challenges.  Progress reporting and measures and also created with this tool.

Berlin Sleep:

Over 80% of the Medicare patient population may have some variety of sleep disorder (over 90 sleep conditions included in this category). Sleep is one of the most un-diagnosed areas of healthcare, that dynamically impacts other chronic conditions and their management. We use this simple assessment tool to provide a baseline measure for sleep awareness of the patient. 

PHQ-9:

This HRA consists of 9 questions used to screen for depression.  Depression is commonly overlooked by many providers.  A referral to a Psychologist, LCSW or Psychiatrist is suggested when a positive score is realized.  This diagnosis is also another example of being included in the PCP chart note in the EMR, although it is not commonly included as a ICD-10 code for the diagnosis.   This assessment tool is the standard of care for a brief screening for patient depression.  Performing this questionnaire is also a MIPS/QPP clinical measure providing additional compliance with the potentials of the MIPS bonus of up to 9% by 2022.  It is also a billable CPT code and clinical service. 

PAM:

The Patient Activation Measure (PAM) is licensed from Insignia Health.  It is an excellent assessment tool to generate a baseline and progress reporting "Activation" measure related to patient health literacy and knowledge.  Generally, we suggest using the 10 question version, and then following up on an annual basis to demonstrate patient literacy and knowledge progress.

Risk Stratification:

This is a custom tool that we have developed to assist with "Risk Stratification" to help determine the complexities involved in patient care in 4 domains.  The higher the score the more likely it is important to have a more highly trained Allied Health staff member perform patient engagement and education services for a CCM eligible patient.

Additional HRA's:

We have selected almost 50 different HRA's that are all clinically validated and scoreable.  Each assessment tool provides deeper insight into the challenges of each patient.... we also can engage the patient better based upon their responses.

We are happy to discuss with you how the use of HRA's significantly expand the Care Management patient experience.  Give us a call anytime.