Abstract
Objective:
The pandemic contributed to increased mental and cognitive health concerns as well as reduced utilization of preventive and treatment focused care. Deferred care can contribute to negative clinical outcomes, including increased acuity of mental and cognitive health concerns that benefit from early intervention. A new visit type was launched with the aim of reaching patients who may need care and supporting early identification of cognitive and mental health issues.
Methods:
We developed the Healthy Mind visit, a preventative visit administered by Primary Care Providers (PCPs) within outpatient clinics. The Healthy Mind visit included use of a pre-visit mental health screener as well as a brief computerized cognitive assessment. The clinical interaction focused on identifying mental and cognitive health concerns and developing a plan for wellness. Outcomes data collection occurred over nearly 2.5 years and focused on analyzing booking patterns, depression screening and follow-up, and clinical outcomes such as health confidence and post-visit motivation.
Results:
The visit was effective in supporting depression screening and follow-up with 29.6% of those participating in a Healthy Mind visit receiving a PHQ-9, and 82.5% of patients with elevated PHQ-9 scores attending a subsequent visit with their PCP. Improvements in health confidence and high patient reported motivation post-visit represent other notable clinical outcomes. The visit also promoted care utilization, with 73.5% of patients who attended a Healthy Mind visit being new to the practice or those who had not attended an appointment in the past 6 months.
Conclusions:
The Healthy Mind visit, with a focus on mental and cognitive health, was successful in reaching patients who may not have otherwise sought care and supported positive clinical outcomes including early identification and treatment of depression and increased health confidence.
Recommendations:
These findings reflect the importance of developing innovative programs to connect patients with care, especially those who may have deferred care due to a variety of factors. Focusing on mental and cognitive health with the use of innovative tools such as a computerized assessment, can drive patient interest in care offerings and support positive clinical outcomes.
Introduction
The pandemic significantly impacted patient utilization of both preventative and treatment focused care, 1 while also triggering an escalating mental health crisis. 2 In addition to mental health conditions like depression, stressors of the pandemic also contributed to cognitive health concerns including issues with focus and mental fogginess. While many of the acute effects of the pandemic have reduced, there continues to be a need for innovative solutions within the context of primary care to both address cognitive and mental health concerns as well as connect those who need support with care.
Deferred care contributes to increased mortality and morbidity 3 across domains of health. Early identification and intervention on cognitive and mental health concerns is particularly important in order to both reduce the risk of developing psychiatric and medical comorbidities 4 and maximize the impact of lifestyle interventions. Numerous factors impact care utilization including stigma around mental and cognitive illness, 5 fear and anxiety, 6 financial limitations, and logistical issues that create barriers to care. Despite the clear link between early intervention and positive health outcomes, there is a paucity of research on practical solutions to increase utilization of care for patients who may particularly have mental and cognitive health concerns.
Cognitive and mental health are undeniably linked, 7 with various mental health conditions impacting cognitive functioning and lifestyle factors influencing wellness in both domains. Early identification within primary care supports prevention of various medical conditions and enables early intervention. Specifically, mental health concerns have been linked to heart disease, cancer, and pain syndromes.8 -10 When considering overall cognitive health, the risk of cognitive decline can start as early as 45 years old. 11 Nine modifiable risk factors have been identified to contribute to one third of all dementia cases which include metabolic risk, depression, and low social connections. 12 Efforts to decrease risk for cognitive decline have shown that cognitive health is most influenced by healthy lifestyle factors such as sleep, exercise, and stress management.13,14 The primary care setting is well positioned to be the optimal entry point for identifying cognitive and mental health concerns and delivering responsive care to address modifiable risk factors.
With the aim of supporting early identification of cognitive and mental health issues via connecting patients with care, we created a new clinical intervention targeting cognitive performance while incorporating engaging tools to drive care utilization. The Healthy Mind visit was launched to identify early manifestations of mental and cognitive health concerns. Use of a gamified cognitive assessment was specifically included to both offer a unique and engaging patient experience, as well as illuminate the connection between cognitive functioning and mental health concerns.
Methods
Study Design
To evaluate program effectiveness, we performed a retrospective analysis of aggregate data from patients who completed a Healthy Mind visit between July 2021 and November 2023. This visit was offered within employer onsite medical clinics which offer primary care where employees work. PCPs within this setting offer primary care services to patients within an outpatient setting covering a range of physical and mental health concerns. Patients who met the following criteria were eligible for the visit: (1) age 18 years or above and (2) enrolled in the practice through an employer sponsored benefit. Questionnaire and appointment data was collected through the electronic medical record and aggregate cognitive assessment data was shared by the cognitive assessment vendor, Creyos. As all analyzed data are routinely collected, this protocol was considered exempt by the WCG IRB (Protocol OM.001, 10/5/23).
Measurements
Pre and post visit questionnaire
In order to set the stage for the Healthy Mind appointment, all patients who booked a Healthy Mind visit were offered an opportunity to complete an electronically administered pre-visit questionnaire which included the following: prompts for the patient to identify areas of concern they would like to address in the visit; mental health screening questions specific to mental health concerns such as the PHQ-2 for depression; and a health confidence question. In cases where patients screened positive for depression, they were offered the PHQ-9. The post visit questionnaire was sent electronically following the visit and included a second administration of the health confidence question and a likert-scale question rating their level of motivation to make changes to improve their wellbeing following the visit. Health confidence was specifically assessed due to its association with increased engagement in health behaviors and reduced adverse experiences such as being hospitalized.15 -17 Similar to a vital sign, health confidence can be measured frequently in primary care settings to identify patients at risk or in need of additional support. Post-visit motivation was assessed in recognition that behavioral and lifestyle interventions are only effective if patients have motivation to take action.
Cognitive assessment
Mental acuity and focus are areas of functioning highly valued by patients, and a harbinger to later struggles. We included a gamified cognitive assessment in order to (1) offer patient feedback on cognitive functioning, (2) highlight connections between cognitive health, lifestyle factors, and mental health, and (3) build patient interest and care utilization. Patients who booked a Healthy Mind visit were offered an opportunity to complete the assessment electronically prior to the visit. The cognitive assessment was administered online through a third party vendor, Creyos, 18 and measured 4 domains of cognitive functioning including: divided attention, attention span, spatial planning, and working memory.
Post-visit provider rating
Following the visit, all patients were prompted to complete an electronic after-visit survey to offer feedback on their experience and rate the likelihood that they would recommend their provider to a friend or colleague.
Visit Protocol and Interventions
The visit protocol focused on offering structure for PCPs to facilitate conversations about a range of mental and cognitive health topics in order to clarify patient goals and areas of concern. PCPs met with patients remotely and reviewed the following topics in the visit: (1) introduction to the visit and expectation setting, (2) review of areas of concern and strength, (3) review of cognitive assessment results, (4) brief intervention focused on addressing areas of concern, and (5) establishing follow-up plans. Cognitive assessment results were shared with a focus on making connections between cognitive domains and issues that can impact associated functioning, such as sleep or stress. Using shared decision making, providers offered a variety of interventions aligned with the patient’s goals and areas of concern. Patient and provider education materials were developed for the visit to enable PCPs to offer interventions within several common areas including improving focus, sleep hygiene, exercise, and stress management, among others. Each visit concluded with finalizing a behavioral plan to support the patient’s goals and review of follow-up plans. During the course of the visit, additional needs were assessed and further support/follow-up was offered as clinically indicated, including the option of attending a follow-up Healthy Mind visit to check-in on progress.
Results
Table 1 includes demographic characteristics of patients who completed a Healthy Mind visit (n = 1626) who were on average 38 years old (SD = 7.9), predominantly male identified, and ethnically reflected a diverse patient population. Administration of the PHQ-9 and subsequent visit attendance with a provider was assessed to evaluate depression screening and follow-up. The PHQ-9 was completed by 29.6% (n = 482) of the patients who attended the visit and 35.5% (n = 171) of those endorsed elevated symptoms of depression (score of 10 or more). Of patients who endorsed elevated depressive symptoms, 82.5% (n = 141) attended a subsequent visit with a provider.
Patient Demographics.
Not Specified includes those who did not have an ethnicity selected within the electronic medical record.
Changes in health confidence scores were evaluated via a paired-samples t-test. Results are included in Table 2 and reflect a statistically significant increase in health confidence after the visit with the eta squared statistic(.17) indicating a large effect size. Overall, 81% of patients reported high health confidence after the visit (score of 7 or more 9 ). Post-visit motivation scores were high, averaging a score of 8 out of 10.
Pre-Post Health Confidence Change Paired-Samples T-Test.
Abbreviations: ηp2, parietal eta squared; df, degrees of freedom; HC, health confidence; M, mean; MD, mean difference; SD, standard deviation.
Attendance patterns were analyzed to better understand which patients the visit ultimately engaged in care. Of patients who attended a Healthy Mind visit, 73.5% (n = 1195) were new to the practice (were enrolled in the practice but had not previously attended a visit) or had not attended an appointment in the past 6 months. Post-visit patient feedback reflected positive experiences with an average provider rating of 9 out of 10, indicating that patients would recommend their provider to a friend or colleague.
Discussion
The Healthy Mind visit sought to address mental and cognitive health via a preventative approach while also engaging patients in care who may not have otherwise sought care. Overall the Healthy Mind visit was effective in supporting depression screening and follow-up efforts. Through the visit, 10.5% of patients (n = 171) were identified as having elevated symptoms of depression, which aligns with recent prevalence rates that found 8.3% of adults had at least 1 major depressive episode over the past year. 19 Of patients with elevated PHQ-9 scores, 82.5% attended a follow-up visit, demonstrating a positive impact on both screening and follow-up care for patients with depression. A portion of the remaining patients were referred to other employer sponsored mental health services, however that engagement data is not available. Lastly, the visit and associated interventions also contributed to positive clinical outcomes including improvements in health confidence and high patient reported motivation following the visit. High levels of motivation and health confidence are positive indicators that the visit not only had a positive immediate impact on patients, but that patients were subsequently more likely to be able to apply information gained in the visit.
Regarding care utilization, the visit seemed to particularly engage patients who were new to the practice and those who had not attended a visit within the last 6 months, with new or unengaged patients representing 73.5% of those who attended a Healthy Mind visit. Direct marketing to eligible patients which emphasized use of the gamified cognitive assessment, paired with the focus on mental and cognitive health, seemed to build patient interest and positively influence utilization of this care offering. Engagement by new or previously unengaged patients is a positive indicator that we were able to reach patients who may not have otherwise sought care. Taking action to address mental and cognitive health concerns and motivating interactions with healthcare providers likely supported improvements in health confidence.
As mental and cognitive health continue to be top of mind for patients and central to the practice of medicine, investment in new ways to connect patients with care is paramount. While some of the immediate impacts of the pandemic have passed, the resulting mental health crisis requires ongoing effort to identify and address mental and cognitive health concerns as early as possible, especially within the primary care context. We hope the Healthy Mind visit serves as a model for applying innovation within primary care to expand care routes, enhance care utilization, and support early intervention for mental and cognitive health issues.
Strengths and Limitations
There were several areas of strength that likely contributed to the success of the Healthy Mind visit. Launching Healthy Mind as a PCP delivered visit enabled us to utilize current staff without needing to lean on specialty clinicians. This created an opportunity to advance the mental health clinical skills of PCPs as well as launch a visit with potentially less stigma attached, thus making care more accessible to patients who might not normally seek care for mental or cognitive health concerns. Innovative application of a gamified cognitive assessment also seemed to set this visit type apart from typical care offerings and drove patient interest. Strong training for providers was also essential to make sure PCPs felt confident offering this new visit type. In addition to training on the visit protocol, interpreting the cognitive assessment, and various behavioral health interventions; PCPs also received ongoing consultative support from a psychologist.
The non-experimental design of the study presents some limitations. It is possible that self-selection bias influenced response patterns. Specifically, completion rates for the post-visit questionnaire were lower than the pre-visit assessment rate, with 20% of patients who completed a pre-visit survey also completing a post-visit survey. When interpreting improvements in health confidence, it is reasonable to consider if higher health confidence itself may have influenced patient response patterns. Despite this limitation, this real-world primary care intervention succeeded in supporting patients. As we continue to accrue data and iterate on the Healthy Mind visit, a more rigorous evaluation is planned.
Conclusion
Offering and marketing a visit focused on proactively addressing mental and cognitive health concerns enabled providers to detect mental health concerns like depression in a group of patients who may have not otherwise sought care. The visit also supported health confidence and patient motivation post-visit, a finding that highlights the positive impact of proactive interventions within primary care.
Recommendations
Primary care practices can engage patients by offering new visits focused on domains of health relevant to the needs of patients. With mental and cognitive health representing areas of particular need, new visits like Healthy Mind have the potential of drawing patients into care who need support but would not otherwise engage in care. For new care offerings to be successful, it is important to ensure providers are given sufficient support and training. Additionally, visit marketing helps ensure that patients who can benefit from the visit find the new care offering.
Footnotes
Acknowledgements
This paper would not have been possible without the support of Katherine Morris, Samantha Davey, Courtenay Stewart, and Esha Datta.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethical Considerations
This protocol was considered exempt by the WCG IRB (Protocol OM.001, 10/5/23).
