Using Well-Being Measurements to Enhance Clinical Practice

In recent years, there has been a growing call for healthcare providers to expand their primary focus beyond treating disease to addressing the needs of the “whole person.”^1,2 This shift has been driven in part by growing awareness of the substantial impact that patients’ broader well-being—including the extent to which they are thriving in their everyday roles and activities—has on both health and healthcare outcomes.³ Yet, healthcare providers have received little guidance regarding which well-being measures are best suited to the clinical context or how these measures may be best applied to enhance clinical practice.⁴ Although there are many well-being measures available in the research literature,⁵ these measures do not always translate well to the clinical care context and many are too burdensome to be practical for the clinical setting.

In this article, we describe 2 well-being measures that were designed for use in the clinical setting. These measures were developed within the Veterans Health Administration (VHA), with support from the Office of Patient-Centered Care and Cultural Transformation. They include (1) a 3-item measure of patients’ psychosocial well-being that can be used in treatment planning (well-being signs [WBS]) and (2) a ~6-min domain-based well-being measure that can be used to guide referrals to well-being promotion supports (WBB). Both of these measures may also be useful in research and population health surveillance.

WELL-BEING SIGNS: A BRIEF MEASURE OF PSYCHOSOCIAL WELL-BEING

A key question with regard to the effectiveness of clinical care is whether it not only effectively treats disease but helps patients live better, more fulfilling lives. The WBS was designed to provide insight into patients’ psychosocial well-being with regard to the most important roles or activities they do or wish to do in their daily lives, offering information that can be used to ensure that treatment plans are optimized to enhance patients’ well-being. Building on research suggesting the value of a tripartite approach to measuring well-being,^6,7 this screening measure assesses the extent to which patients are able to participate in the roles and activities that are most important to them, function well in those endeavors, and are generally satisfied with how things are going in these aspects of their lives. This measurement approach aligns with the VHA’s Whole Health initiative’s focus on addressing what matters most to patients in clinical care,⁸ and stands in contrast with well-being measurement approaches that identify assessment foci a priori by allowing patients to evaluate their well-being with regard to what matters most to them. The WBS includes three items and takes less than one minute to administer.

Use of the Well-Being Signs in Clinical Care

As described in greater depth on the VHA website,⁹ the WBS can be used to prompt discussion between healthcare staff and patients regarding how treatment plans may be designed and/or modified to best optimize patients’ well-being, or whether additional support may be needed to address areas of lower well-being. This measure can be administered directly by a clinician or other healthcare team members, or it may be self-administered during or before healthcare appointments. Within the VHA, this tool is currently accessible in the electronic health record and the VHA Mental Health Assistant platform. In addition to its use in the clinical context, the WBS may be useful in monitoring the well-being of patients on a population level, as evidenced by its recent inclusion in VHA’s annual survey of patients (Survey of Enrollees).¹⁰

Psychometric Properties of the Well-Being Signs

As described in greater depth in the full report on the development and validation of the WBS (available from the first author upon request), an initial evaluation of the WBS provided evidence that this tool was reliable, valid, and able to capture meaningful changes in patient well-being over time. There was good variability in how a sample of approximately 300 VHA patients responded to WBS items, and the internal consistency reliability of the measure was strong. In addition, total WBS scores correlated highly with other brief measures of related well-being concepts but were not found to be redundant in content focus. WBS scores also increased significantly for patient groups expected to show improvement over time, providing preliminary evidence that the measure can capture expected changes.

A subsequent evaluation at 4 VHA facilities revealed several areas for minor refinements to enhance the measure’s acceptability to healthcare team members and patients. These included shortening the instructions, streamlining items, and simplifying response options. Another wave of psychometric testing with a new sample of 312 patients revealed that the refined measure retained good psychometric quality, including good variability in responses, high internal consistency, moderate to high correlations with other well-being measures, and good discrimination between subgroups expected to differ in well-being. Results revealed relatively high consistency in scores over time for the entire sample, providing evidence for the measure’s test-retest reliability, with meaningful changes observed for those expected to experience changes in well-being over time, providing evidence for the measure’s sensitivity to change. Psychometric testing did not support the use of individual items as stand-alone indicators of participation, functioning, and satisfaction, leading to the recommendation to only use total WBS scores. The finalized measure and scoring instructions are included in Appendix A, Supplemental Digital Content 1, http://links.lww.com/MLR/C903.

WELL-BEING BRIEF

The growing awareness that patients who struggle with broader aspects of their lives have poorer health and healthcare outcomes has fostered a call for attention to unmet needs for support in domains that extend beyond the health domain. The WBB is a self-administered measure that was designed to fulfill this need. It provides a more in-depth, but still relatively brief assessment (~ 6 min) of patients’ psychosocial well-being that can be used to pinpoint areas in which they may benefit from additional support that extend beyond the health domain. Unlike the WBS, this measure assesses well-being in 4 prespecified domains (health, vocation, finances, and social relationships), drawing from research demonstrating the relevance of these well-being domains across multiple populations and administration contexts.⁷ Within each domain the WBB addresses objective life conditions such as housing stability and ability to meet basic financial needs (concepts that are often referred to as “social determinants of health”), as well as patients’ functioning in and satisfaction with respect to key life roles and activities (see Appendix B, Supplemental Digital Content 1, http://links.lww.com/MLR/C903 for components of well-being addressed in the WBB). This measure was designed to target aspects of well-being that can inform referrals to well-being promotion supports. For example, this measure can be used to identify patients who would benefit from career counseling, financial-management support, or counseling to improve their social relationships.

Use of the Well-Being Brief in the Healthcare Setting

Although the WBB was initially developed for use as part of measurement-based readjustment support, a self-administered, web-based well-being check-up and resource referral tool,¹¹ it may also be used as a stand-alone measure. As a stand-along tool, the WBB can be used to gather information on areas of well-being in which individuals may benefit from additional support and inform referrals to relevant well-being promotion programs, services and supports. It may also be useful as a research and population health surveillance tool.

Psychometric Properties of the Well-Being Brief

An initial psychometric evaluation of this measure in approximately 300 post-9/11 Veterans provided preliminary evidence for reliability and validity, including evidence for good variability in individual item responding, as well as in overall well-being scores. In addition, well-being scores were correlated as expected with other well-being measures, and there was evidence for the measure’s ability to discriminate between subgroups expected to differ in well-being. We are currently in the process of finalizing this measure and will examine test-retest reliability and sensitivity to change as part of this efforts. For additional information on this measure and its psychometric evaluation please contact the first author.

CONCLUSIONS AND FUTURE DIRECTIONS

This article describes 2 well-being measures that were designed for use in the clinical setting. The WBS provides an efficient evaluation of patients’ overall well-being with regard to those roles and activities that are most important to them (3 items). This tool can be used to inform treatment planning, thereby optimizing the positive impact that healthcare has on patients’ broader well-being. The WBB provides a more extensive but still relatively efficient evaluation of patient’s well-being across health, vocational, financial, and social domains and was developed to guide referrals to specific well-being promotion supports. Both measures have undergone psychometric evaluation and were developed with input from patients and providers. A final phase of psychometric testing is planned for the WBB, whereas the WBS is now finalized and available to the field.

A key direction for future work will be to identify and address barriers to the widespread implementation of these and other well-being measures in clinical care. Findings from an evaluation of WBS pilot implementation efforts within VHA suggested that lack of awareness regarding how to best apply well-being measures in clinical practice is a key barrier to use of these types of measures, which prompted the development of materials to support WBS implementation.¹² Findings from an initial examination of the value of WBB assessments in raising patients’ awareness of unmet needs and promoting their help-seeking suggested that this approach was effective in enhancing patients’ willingness to seek support for areas of low well-being.¹¹ An important next steps for this work will be to make this tool broadly available to patients within VA and to evaluate how it can be adapted for use in other healthcare settings. Although we have only just begun to explore how well-being measurements can be used in clinical care, we are optimistic that attending to the well-being of the “whole person” can better meet patients’ needs and improve healthcare outcomes.