Primary Care Assessment Summary 

• Our Primary Care assessment is most often used in primary care or specialty care settings to screen and address behavioral health issues.
• The assessment is given at every visit but no more often than once a week. 
• The primary care assessment tracks patient's progress against an expected path of progress individualized for that patient. 
• The assessment is normed and validated on more than 80,000 adults in outpatient mental health treatment. 

Primary Care Assessment Domains 

• Suicide Risk (C-SSRS)*
• Harm to Others
• Depression (PHQ9)*
• Anxiety (GAD2 / GAD7)*
• PTSD*
• Alcohol Use (US AUDIT 1-3)*
• Drug Use
• Subjective Well-being
• Functioning 
• Satisfaction with Others
• Psych History 
• Psych Medication Use & Barriers 

* Gold Standard Measures 

Median time to complete: 

• Intake: < 4 min
• Update: < 2 min 

Clinical Intake Reports 

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Intake Report Details 

Critical Alerts

Current Thoughts of Harming Others 

Over the last two weeks, how often have you had thoughts of harming someone else? 

If the question is positive, "Sometimes" or "Often" is printed, otherwise "Never" is printed.

History of Suicidal Thoughts 

Have you ever thought about or attempted to kill yourself? (Choose the option that best describes your most serious event). 

Possible Responses Include: 

• Never 
• Thought 
• Plan, Plan & intent
• Attempt, no intent
• Attempt & intent 

Suicide Risk 

The Columbia Suicide Severity Rating Scale (C-SSRS) identifies the severity and immediacy of suicide risk of your patients and gauges the level of support that the patient needs. 

This section will display the score and the patient's ideation and/or behavior. A score of 3 or higher on the C-SSRS indicates the need for a safety plan. 

The PHQ-9 response identifies how the patient answered the last question on the PHQ-9 questionnaire.  If the patient has answered the question "Several Days," "More than half the days," or "Nearly Every Day," the response will display on the report.  This will be helpful to identify if a patient has experienced suicidal ideation by indicating on the PHQ-9, but is not presented the C-SSRS questions.

0-2 Low Risk 

• Passive Ideation 
• Active Ideation, but nonspecific 
• No current history of suicidal behavior 

3 Moderate Risk

• Active ideation with method, but no intent or plan 
• History of suicidal behavior, more than 3 months ago

 4-6 High Risk

• Active ideation with a method and intent but no plan 
• Active ideation with a method, intent and plan 
• Suicidal behavior within the last 3 months

Symptoms 

Depression PHQ-9

All patients are asked the PHQ-9 to measure depression symptoms. The severity range is as follows: 

0 - 4 = None - Minimal 
5 - 9 = Mild 
10 - 14 = Moderate 
15 - 19 = Moderately Severe 
20 and above = Severe 

PHQ-9 Questions

Over the last two weeks, how often have you been bothered by...

• Little interest or pleasure in doing things?
• Feeling down, depressed, or hopeless?
• Trouble falling or staying asleep, or sleeping too much?
• Been feeling tired or having little energy?
• Poor appetite or overeating?
• Feeling bad about yourself - or that you are a failure or have let yourself or your family down?
• Trouble concentrating on things, such as reading the newspaper or watching television?
• Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual?
• Had thoughts that you would be better off dead, or of hurting yourself in some way?

Anxiety-GAD2/7

All patients are asked the first two GAD questions. If they screen positive then they are asked the full GAD7. The severity range is as follows: 

0 - 4 = None - minimal 
5 - 9 = Mild 
10 - 14 = Moderate 
15 and above = Severe 

GAD7 Questions 

Over the last two weeks, how often have you been bothered by...

• Feeling nervous, anxious, or on edge?
• Not being able to sleep or control worrying?
• Worrying too much about different things?
• Had trouble relaxing?
• Being so restless that it is hard to sit still?
• Becoming easily annoyed or irritable?
• Feeling afraid, as if something awful might happen?

PTSD (PC-PTSD-5)

PTSD Questions 

Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example:

• a serious accident or fire

• a physical or sexual assault or abuse

• an earthquake or flood

• a war

• seeing someone be killed or seriously injured

• having a loved one die through homicide or suicide
  
  Have you ever experienced this kind of event?

If the patient answers “Yes”, they are asked the remaining questions:

1. In the past month, have you…
   Had nightmares about the event(s) or thought about the event(s) when you did not want to?

2. In the past month, have you…
   Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)?

3. In the past month, have you…
   Been constantly on guard, watchful, or easily startled?

4. In the past month, have you…
   Felt numb or detached from people, activities, or your surroundings?

5. In the past month, have you…
   Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?

Getting Along Emotionally 

How well have you been getting along emotionally?

• Quite poorly 
• Fairly poorly 
• So-so 
• Fairly well 
• Quite well 
• Very well 

Behavioral Health Index (BHI)

Behavioral Health Index (BHI)

BHI is a composite score of overall behavioral health calculated from multiple questions pertaining to overall well-being, depression, anxiety, and functioning. Higher scores are indicative of more severe behavioral health issues. The scale ranges from 0 - 100. A BHI score of 50 indicates that a patient is in the 50th percentile relative to mental health patients at intake. 

Range: 

BHI 0 - 25 Low 
BHI 26 - 75 Moderate 
BHI 76 - 100 Severe 

Functional Impairment 

Manages Day-to-Day Life 

Over the last two weeks, how well have you been able to manage your day-to-day life?

• Very poorly 
• Fairly poorly 
• Fairly well
• Very well

Satisfied with Relationships 

Over the last two weeks, how often have you been satisfied with your relationship with others?

• Never or rarely 
• Some of the time 
• Often 
• All/Almost all of the time 

Performs Routine Tasks 

Over the last two weeks, how well have you been able to perform work/school/household tasks?

• Very poorly 
• Fairly poorly 
• Fairly well 
• Very well 

Treatment History 

Treatment History 

Have you ever been hospitalized for a psychological or emotional problem?

• Never 
• Once 
• Two or more times 

Medication 

Medication 

The responses regarding medication questions are presented. This includes if the patient has been prescribed a psychiatric medication and if so, how often they are taking them, any barriers to adherence, and if he/she thinks the medication(s) is helping.

Substance Use Detail 

Alcohol Use 

The AUDIT 1-3 (US) is a brief screening measure for Alcohol Use Disorders. Men over the age of 65 and women who score 7 or higher are considered to drink above the NIH threshold. A positive score indicates risk for alcohol-related problems and warrants further assessment. 

The maximum score is 18 

Individual responses to each question will be displayed 

Drug Use

If a patient indicates they are using a drug or prescription medication for non-medical reasons, they will be asked which drugs they are specifically using. "Yes" will be in red next to any drug they selected. 

Tracking Progress 

Clinical Monitoring Reports 

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Intake Report Details 

Treatment Response 

Treatment Response Curve

The treatment response curve (on the graph in red) is a prediction of how well this patient is expected to do over the course of the episode of care, specifically it predicts the patients BHI score over each of the next 19 weeks after intake. It is based on the patient’s responses to questions on their intake assessment.  The treatment response curve, also known as the Expected Treatment Response (ETR), is calculated from normative data for patients with similar characteristics at intake, using a statistical technique called hierarchical linear modeling (HLM), a form of regression analysis.  In essence, it answers “how does the average patient like this usually progress”?

Each time the patient completes an update assessment, their Behavioral Health Index (BHI) score is tracked (on the graph in blue). If the BHI score is tracking below the red line, this indicates that the patient is doing better than expected and above the red line indicates the patient is doing worse than expected. The ups and downs of the scores provide opportunities to ask the patient what they are doing differently or if issues have arisen since the last session.

For more information on our Treatment Response Curve, please view What is the Expected Treatment Response (ETR) Curve and How is it Relevant to My Patient's Care?