India Carson, RN, MSN

Clinical Product Specialist

Important Questions to Ask When Developing a Health Risk Assessment

You work for a health plan and your organization wants to develop a Health Risk Assessment (HRA).  Where do you start?  What questions do you want to ask?  What questions should you ask?  What do you intend to accomplish by completing the HRA with your members?  Do you simply want to fulfill a requirement, or do you wish to identify members who have a chronic condition or may benefit from case management or a behavioral health program?


Don’t Go It Alone

You may want to form a committee to assist with the question development.  The committee members may include Case Managers, Disease Managers, Prior Authorization staff and anyone else that has member contact.  This will provide you with information about which questions may elicit the right information and which questions will be appropriate for your members.

Categorize the questions.  For instance, the HRA may include several questions about health history, medications, and health habits.  You will want to arrange the HRA by categories of questions.


Understanding Your Target Audience

Who is the target audience for the health plan?  Does the health plan serve a Medicare or Medicaid population, or does it include Commercial lines of business?  Does it serve both plans?  The desire is to ask questions geared toward the members you serve.  You may have questions that are hidden depending on the member’s age or sex.  For example, you may hide the questions regarding memory for members who are less than 65 years of age and hide the questions for mammograms for male members.

Required Questions for Accreditation

Are you seeking NCQA or URAC accreditation?  If so, you may wish to include questions geared toward satisfying those requirements.  Does your company have a contract with CMS or a CMS entity?  If so, you may want to look at the CMS requirements for a health risk assessment.  According to CMS, the questions that one should ask during an annual wellness visit include, at a minimum:  demographic data, self-assessment of health status, psychosocial risk factors, behavioral risk factors, activities of daily living, such as dressing, bathing, walking, and instrumental activities of daily living, such as shopping, housekeeping, managing one’s own medications, and handling finances.1

In any event, you should consider questions that help you meet the requirements for the accreditation which you are seeking.  You also want to keep in mind that requirements change over time, therefore you will want to stay current with the accrediting agency’s requirements.


Questions to Include in Your HRA

In addition to the questions listed above, the HRA should include information about a member’s personal health history (including immunizations, surgeries, past hospitalizations), and chronic illnesses.   The member’s personal health habits should be explored, including any screenings and annual lab tests and immunizations.   A current list of medications should also be gathered, including over-the-counter, vitamins, any supplements, and the member’s adherence to prescription directions.  Also, if the member is not complying with the prescription directions, you will want to explore why the member isn’t adhering to the medication regimen as prescribed.  Is the medication too expensive or is the member experiencing unpleasant side effects from the medication?  You should also explore any medication interactions.

Member’s height and weight, and self-reported blood pressure should also be collected.  One should conduct a depression screening and either ask about or conduct a cognitive impairment exam, and ask personal safety questions.2

One should also explore the member’s social determinants of health.  Asking questions about their ability to meet daily needs, access to health care services, transportation options, public safety, social support, and culture or social norms will provide you with important information about the member.3


Literacy Requirements for Members

An HRA for an annual wellness visit, according to CMS requirements, must be written at a sixth-grade literacy level and members should be able to complete it in 20 minutes or less.4  Educational materials should also be composed at a sixth-grade level and be available in the language of preference of the member.  Although scoring the HRA is helpful to indicate the number of risk factors, CMS does not require scoring the HRA.4  You will want to check with your compliance officer to validate educational requirements for your specific population and your contractual obligations.

Understanding What Your Reporting Requirements Are

Depending on the accreditation your organization is seeking, you may want to report on the requirements they have outlined.  Additionally, you will want to see if the coaching methods your organization is employing prompted a change in the member’s behavior over time.  The “HRA Plus” program review noted sufficient evidence of reduction of tobacco use, dietary fat consumption, seat belt nonuse, high blood pressure, total serum cholesterol levels, and high-risk drinking.  The review also found improvements in physical activity, overall health and well-being scores, and a reduction of hospital admissions and days of care.5  Your organization may want to invest in a motivational interviewing course for the Case Managers to assist them with these skills.


Types of Delivery Methods for an HRA

Years ago, paper and pen were the delivery methods of an HRA.  Today, electronic delivery of the HRA is preferred, but it is not the only method that should be available.  An HRA should be available for the member to complete via a Member Portal.  It should also be available for the Case Manager to complete with a member while on the phone or in person.  A Case Manager may also conduct a home visit to complete the HRA and should be given the option to complete it via pen and paper.  Members may also be uncomfortable with an electronic version of an HRA and should be given the option to complete a pen and paper version.5

The CDC also recommends that accommodations be made for the individuals with physical, sensory, and cognitive limitations.  For members with low vision, printed material in large font or versions available in Braille, audio, or questions read to the individual by a Case Manager may be required.  Access to HRA materials and documents should be in compliance with the Office for Civil Rights; Title VI of the Civil Rights Act of 1964; Policy Guidance on the Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons.5


Follow up Activities for Members

A customized summary of the HRA should be provided to the patient indicating what areas of their health they are having difficulty with, their habits and behaviors, how they can improve on their own healthcare, a review of the preventive strategies they have completed, and a list of ones they have not done.  It may also include a list of articles they may read to improve their knowledge of a healthcare topic.4

In the “HRA Plus” process the HRA is often supplemented with a biometric measurement of physiologic health along with a mechanism for providing feedback, educational messages or counseling on methods to change health habits and development of a Personal Prevention Plan which includes goal setting, coaching, referrals, and monitoring.5  This is a useful model to follow if you wish for your organization to have a positive impact on a member’s health habits.  Follow-up visits and an ongoing HRA assessment may also be employed.

The CDC also recommends following a “person-centered” model which involves components of health care that are important to the member, i.e., office hours, location and co-pays.  It also puts the focus on outcomes which are valued by them, for example, improved quality of life and enhanced functioning.5


Developing an HRA is no easy task, but it can be done!  With the proper planning and assistance from others on your team, you can create a terrific HRA that will be useful to your membership and to the Case Managers within your organization.