Risk-Based Health Interventions Lead to Improvements - A Case Study
It's no surprise that chronic diseases such as asthma, diabetes, hypertension and severe obesity are the leading causes of death and disability in the United States. Together, they are responsible for seven out of 10 deaths and kill more than 1.7 million Americans every year. Yet, they are the most preventable diseases and can be delayed or prevented through interventions in diet and nutrition, physical activity and early detection through screenings.
The cost to employers for their workers with chronic illness is considerable. The healthcare expenditures for these employees is five times higher than those without a chronic condition; which equates to more than $6,000 additional costs annually. The financial impact of obesity alone is $13 billion annually for costs associated with sick leave, life insurance, disability insurance and lost productivity.
Optimizing Health in the Workplace
Research has shown that properly designed best-practice based health management programs can mitigate and reduce some of the cost and productivity losses resulting from chronic disease. It's been found that employing these best-practice programs lowers medical and absenteeism expenditures by 25 percent for program participants versus non-participants.
In addition, the medical costs for those participating in best-practice health management programs are $3.27 lower for every dollar spent on the program. The employer environment can be an ideal setting to support individuals in adopting healthy behaviors, as the majority of their day is spent in the workplace.
Employers also have the administrative bandwidth and infrastructure to support cultures that encourage healthy lifestyles. According to research on employee health management programs, there are six characteristics of successful programs to consider:
- Health education focused on lifestyle behavior change
- Supportive social/physical workplace environments
- Integration of the health management program into benefits and human resources infrastructure
- Links to wellness-related resources (employee assistance programs, diabetes prevention programs, etc.)
- Health screenings followed by counseling and education
- Individualized risk-reduction interventions and behavior change support
Employee Health Management at Eisenhower Medical Center
At the core of the Eisenhower Medical Center employee health management program is individualized counseling focused on risk-reduction and behavior change. This approach begins with assessing the health risks of the population and identifying those who are at low, moderate or high-risk for chronic conditions, and then offering accompanying levels of intervention, counseling, and support.
For example, for someone at low-risk, providing online wellness challenges or offering healthy food options in the cafeteria may suffice to help them maintain their low-risk status. For an individual with a chronic condition, higher risk individuals may require assistance from a nurse coach with managing their medications, working with their personal health care providers to control their condition, and helping them to self-manage their conditions and health-related behaviors.
In 2008, the Eisenhower Medical Center human resources department and its administrative leadership created a committee with the mission to enhance the well-being of employees and create a supportive wellness culture that includes resources and education. The result was the Five Star Wellness program. Five pillars of wellness were selected to address the areas of need:
- Pulmonary health
- Stress reduction
- Weight management
Two key aspects of the program have proven to be significant factors in its success. One is very strong support from administrative leadership from day one and the other is a commitment to a multi-year strategic plan.
Each year, Eisenhower Medical Center employees participate in a no-cost, onsite, biometric screening. Based on their screening results, as well as medical and pharmacy claims data, employees are stratified into three risk groups: low, moderate and high. Risk-specific interventions are then offered to individuals within each group who are assisted in choosing an action plan that fits with the goals for their health.
Employees can receive a $360 reduction in the employee medical premiums for the subsequent plan year when they participate in the program. To receive this incentive, they must complete the annual biometric screening, participate in their personalized risk-focused action plan and acknowledge that they are tobacco-free. The low-risk group, which consists of about two-thirds of participants, receives a letter congratulating them on being low-risk.
They also receive a no-cost, one-year membership to the Eisenhower Wellness Institute (EWI) that offers health coaching, continued health promotion support and educational opportunities. Moderate risk individuals work with an EWI health coach to develop a guided personal wellness action plan. The action plan includes approximately six hours of education or other activities that can range from yoga or stress management classes to educational interventions about nutrition or mindful eating.
Lastly, an exit interview the participant's health coach conducts an exit interview to assess their progress.Categorization into the high-risk group is determined using a claims-based diagnosis of chronic health conditions, such as diabetes, asthma, musculoskeletal problems or other chronic conditions.
For this group, the externally contracted telephonic condition management nurse coach develops a personalized action plan, which may include medication compliance, coordination of care with their physician, and pursuit of healthy behaviors. Monthly coaching calls and continuous adjustment of the action plan are needed to fit the individual's needs and help optimize condition management.
Evaluation Results and Implications
To gauge the effectiveness of this risk-focused intervention program, an evaluation study was conducted after Year 2 of the program through a pre-intervention, post-intervention cohort analysis. Eight biometric measures were analyzed: weight, body mass index (BMI), body fat percent, glucose, HDL cholesterol, total cholesterol, systolic blood pressure and diastolic blood pressure.
Data analysis was conducted for these measures within each intervention group using paired t-tests to determine whether there were statistically significant differences in biometrics between the groups from pre-intervention to post-intervention. The results, presented in Tables 1 through 3, indicated the following:
- The low-risk group, which was not required to take any further action following the biometric screening to receive the medical premium discount, had dis improvements in five biometric risk categories and improvements in three categories.
- The moderate risk group, which was required to participate in at least one session with an onsite EWI health coach and complete their personal risk-reduction action plan to receive the medical premium discount, achieved improvements in seven of the eight risk categories.
- The high-risk intervention group, which was required to participate in monthly telephonic sessions with the condition management nurse coach and complete their personal condition management action plan to receive the medical premium discount, achieved improvements in all eight categories.
Eisenhower's best-practice employee health management program, with its risk-stratified interventions, effectively reduced participants' health risks. While both the moderate and high-risk groups experienced a number of positive changes, the more intensive high-touch intervention provided by the condition management nurse coach working with individuals with chronic conditions was most effective in achieving significant biometric improvements.
Although the low-risk group made improvements in three biometric measures, their risk status for the other five biometric measures become worse, which indicates the importance of engaging this lower risk segment of the employee population in follow-up interventions after biometric testing not just those at moderate or high-risk to help control their health risk factors and maintain their good health status.
The positive improvements found in the Eisenhower Medical Center program support the growing research evidence that best-practice employee health management programs can be effective in improving employee health, especially when employees are directed to risk-focused plans of action.
Organizations seeking similar improvements in employee health should consider implementing comprehensive best practices like those implemented at Eisenhower Medical Center, including:
- Strong organizational and leadership support
- A multi-year strategic plan
- Annual biometric screening to assess health risks
- Risk-stratified interventions
- Online wellness challenges to address lifestyle risks
- Utilization of employee assistance program resources
- Program evaluation to assess effectiveness of interventions
About the Authors
Danielle Keenan, MPH - Danielle Keenan provides consulting to Keenan clients to design, implement and evaluate best-practice population health management programs. She provides her expertise in developing engagement strategies and programs to address lifestyle risk factors and improve management of chronic conditions to minimize avoidable health care utilization.
She holds a B.A. degree in Psychology from California State University - Long Beach and an M.P.H. degree in Public Health from the University of California, Los Angeles (UCLA). Additionally, she has earned the WELCOA Worksite Wellness Certification, is a continuing WELCOA Faculty Member, and was recognized as one of WELCOA's Top 50 Health Promotion Professionals.
Jeralyn Brossfield, MD - Dr. Brossfield's first step toward becoming a Board Certified OB/GYN occurred at age twelve. Kneeling on a concrete floor in South Sudan, she held a flashlight while her mother delivered a neighbor's baby. Service in medicine was inevitable. In studying medicine, her vision of impacting the health of her community expanded. As a student at Loma Linda University School of Medicine, Dr. Brossfield noticed that, although the school motto was to make man whole, there was no course training its students to do so.
She founded and co-created a new course focused on the comprehensive care of the patient's mind, body and spirit. At graduation, she was awarded the Whole Person Care Award by her class and professors. In 2002, Dr. Brossfield opened her practice in the Coachella Valley.
After pursuing her board certification in obesity medicine, Dr. Brossfield stepped into the Directorship of the Eisenhower Wellness Institute in 2013. There she has led employee-health initiatives that have made a measurable improvement in Eisenhower's employee wellness, and developed community health programs and Functional Medicine-based consultations for integrative health.