Integrating Employee Health A Model Program for NASA (2005) / Chapter Skim
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5 Implementing Integrated Health Programs
5 Implementing Integrated Health Programs
Pages 102-149
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. Following the management systems approach described previously, this chapter provides an overview of the characteristics of effective integrated health programs and approaches to setting program priorities; examines strategies for program implementation and evaluation; and explores implications for NASA.
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In their research, this team of investigators has applied this model to the design interventions for working class and multi-ethnic populations, aimed at health behavior changes such as tobacco control, diet, and physical activity. By applying this model in behavior change strategies, it may be possible to change some elements of the workers' social context, and also to enhance the quality and relevance of interventions through an understanding of the social realities of workers' lives.
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Leaders can become role models, uniting the organizational vision for health with its mission, as well as providing support and encouragement for employee participation. Programs at the individual or interpersonal level focus particularly on educating individual workers and building social norms supportive of worker health, through mechanisms such as educational classes or one-on-one training programs (Refer to Chapter 2 for a description of NASA's preventive health programs, the NASA Occupational Health website, and the NASA Health Promotion
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NASA's health benefits are provided under the Federal Employee Health Benefits Program, which, in 2004, included over 350 different plans covering more than 9 million employees, retirees, former employees, family members, and former spouses (Tingwald, 2004)
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For example, early worksite health promotion programs often consisted solely of HRAs combined with screening, apparently under the assumption that medical or risk information as such would motivate large numbers of participants to reduce their health risks. Subsequent experience showed that effectively supporting risk reduction required integration of the HRA into a comprehensive health promotion process that would include follow-up education and behavior-change components (Schoenbach et al., 1987; Terry, 1987; Anderson and Staufacker, 1996; Edington et al., 1999)
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Tools for Assessing Mental Wellness As a part of the HRA, an assessment of stress experienced by employees may be of value. Ideally, the impact of stress would also be assessed via stress-related risk factors for chronic disease, such as high blood pressure, as well as the influence on performance of acute stress.
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Alternatively, health and wellness committees may take the lead in planning health promotion programming, and may coordinate with occupational health and safety committees to design integrated health efforts. In considering the composition of these committees, it is important to provide equal representation and voice to workers from diverse groups.
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and initiating health improvement behaviors (such as tobacco cessation, weight loss and increased physical activity) , incentives are effective and important (Isaac and Flynn, 2001; Ozminkowski et al., 2002)
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. Barriers Health Disparities Health risks are not evenly distributed among workers, and for this reason, it is important that integrated health programs consider the particular needs and concerns of diverse groups of workers.
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(2004) examined barriers and facilitators to physical activity perceived by underserved, ethnically diverse older adults in a community.
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Opportunities for Integration As described in Chapter 3, to create and support a healthy and productive workforce, integrated health programs must move toward programs that are integrated across multiple functions in the work organization rather than segregated within "silos," and that are employee-centric rather than driven by employer priorities. Figure 4-2 illustrates the functions within the organization that can be integrated in order to promote and sustain worker health, ranging from health risk appraisals to behavioral health programs, disease case management, and occupational safety efforts; examples are given in the figure legend.
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. For example, the WellWorks-2 study, a randomized, controlled study comparing the effectiveness of an integrated health promotion/occupational health program with a standard intervention, asked the question, "Does the integration of worksite health promotion and occupational health and safety programs increase program effectiveness over and above health promotion alone?
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Such approaches build on opportunities for synergism across risk areas. PREVENTION PROGRAMS Prevention efforts include those aimed at health behaviors (such as nutrition, physical activity, tobacco use, and stress and mental wellness)
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. Several studies of worksite nutrition interventions have been offered across multiple levels of influence.
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The nutrition activity scores were indicators of change at the worksite, or organizational level; that is, organizational changes sustained over time. There were no measures in this study of whether or not health behaviors were sustained over time.
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The program outcome was a significant increase in fruit and vegetable intake and increased use of informational materials, compared to control sites, at a 2-year follow-up. Physical Fitness Programs Trends in Physical Activity.
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. Worksite social support systems can also be set up to facilitate activity groups to form, such as walking and sports clubs that promote physical activity.
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Fitness facilities at the worksite are an important component of Occupational Health programs. However, published data on workplace fitness center utilization shows that overall utilization rates tend to be low relative to total worksite populations (Shephard, 1992; Lewis et al., 1996; Crump et al., 2001)
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Additional programming to encourage utilization of this valuable NASA resource could increase employee physical activity. The Task Force on Community Preventive Services has found a multilevel approach for increasing physical activity to be supported, for the most part, by research (http://www.thecommunityguide.org/)
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provide a standard of care for all tobacco control interventions, and recommend brief counseling with pharmacological treatment. Many worksites offer the same types of smoking cessation programs originally developed and offered in clinical settings, or, in some cases, provide referrals to clinic- or community-based programs, such as those of the American Cancer Society or the American Lung Association; for-profit programs (e.g., Smoke Enders)
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. As noted above, studies by Sorensen and colleagues have found that programs which integrate occupational health and safety and tobacco control are able to increase smoking quit rates for blue-collar workers (Sorensen et al., 1998, 2002)
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Factors such as poor communication and interpersonal difficulties at the workplace can foster a chronic exposure to acute stress. The pattern of physiological reactions induced by these chronic stressors has been conceptually related to cardiovascular disease by Krantz and Manuck (1984)
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Addressing stress factors is appropriately done at a programmatic level through restructuring of the environment and training of individuals and groups, using a top-down process designed to create a work environment that eliminates unnecessary workplace stress and improves productivity. A current emphasis is to integrate health programs to yield a healthy individual that is resilient and ready to face the challenges of everyday, and more significant, mission stress.
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state that "...the simultaneous focus on employee healthrelated productivity (well-being) and performance recognizes the practical reality that having happy and satisfied staff is of little value to an organization unless staff are also performing efficiently and productively." The most relevant form of chronic stress is worksite stress created by a perceived imbalance between the demands of a position and the control over the work (Karasek, 1979; Bond and Bunce, 2001; Polanyi and Tompa, 2004)
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Occupational medicine and EAP then become partners with managers in the integrated health and performance focus. The primary role for occupational medicine is to develop, in conjunction with other NASA staff, the training program for managers (i.e., a program developed by and for NASA is advocated rather than use of contractors; see Chapter 4)
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In industry, engineering controls are being put in place that may mitigate the need for surveillance exams, as exposures in the workplace are lowered. When non-mandated examinations are performed, these are frequently initiated by an employer's occupational health and safety staff based upon local practice or "expert opinion." Unfortunately, many such discretionary periodic examinations are initiated based on good risk assessments, but are rarely re-evaluated, resulting in an ever-expanding set of examinations, at least some of which may no longer be warranted.
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The panel, consisting of private-sector experts, regularly reviews and grades the evidence of effectiveness for clinical preventive services based upon age, gender, and risk status and uses a consistent and rigorous hierarchy of evidence in deriving its recommendations. Periodic health examinations represent "teachable moments" to not only identify risk factors for morbidity and premature mortality but also to educate and promote primary preventive behaviors.
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DISEASE, DISABILITY, AND INJURY MANAGEMENT PROGRAMS On-Site Medical Clinics Acute Care Acute care onsite occupational health clinics traditionally provide treatment for injuries or illnesses occurring due to a work experience or exposure. Most onsite clinics also provide basic treatment for minor nonoccupational illnesses, such as headaches, gastrointestinal distress, and blood pressure monitoring.
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Although clinical and functional benefits have been demonstrated for many of these condition management programs, few organizations have capitalized on this vast opportunity. Adverse morbidity and productivity impacts of prescription drug utilization such as antihistamines or migraine medications have been shown to be substantially reduced by aggressive workplace health initiatives that integrate health benefits utilization experiences into their worksite health processes.
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These signs are self-evident-e.g., lost work time, marital difficulties -- but require reinforcement so the employee can recognize and ideally admit to having a substance abuse problem. As part of an integrated health program, maintenance of a healthy social environment at work should remove some of the incentives for abuse, e.g., drinking to alleviate experiences of stress and anxiety.
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Employees with drug abuse or dependence problems also benefit from a comprehensive program that includes treatment, self-help such as NA, and urine monitoring. Disability Management Programs Disability Management Another component of employee integrated health programs is disability management across both occupational and nonoccupational settings.
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This type of evaluation will indicate, for example, that the numbers of risk factors present in the population have improved over the course of the year due to the integrated health program, or that physical activity levels have increased in response to all programming that was made available throughout the course of the year. However, these data are not specific to individual program effectiveness.
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. To illustrate the PIPE Impact Metric using an example, consider a physical activity program designed to increase walking behavior among all NASA employees being announced and communicated to all employees.
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to steps of is of for the the invited related example, 8 of invitations prior of that score which according and signed mail-based For benefits program a set 10,000 week with to created successful is directly of Definition program the (e.g., via of activity in be health impact Metric end proportion degree proportion rate success objectives. achieved reached the Variable The is walking The implemented specifications The enroll protocol specifically enrolled The for should and who at physical achieve Overall Impact PIPE 2003b.
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However, a common finding among large, decentralized organizations that also appears to be true at NASA is the development of communication gaps between the centers and Headquarters, as well as between managers and employees, which has an impact on the effectiveness of these programs. The Committee's specific findings, based on observation of NASA programs and characteristics of established integrated health programs, encompass four general areas as follows: (1)
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from this report is that NASA adopt a mission-driven vision for an integrated health program for all employees. The foundation for such a program is acquisition of evidence-based knowledge of the current health status of health program participants and appropriate metrics to define and predict participant needs.
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All programs should include program promotion strategies as well as financial and benefit-designed incentives to foster program participa tion across the diverse NASA workforce. Examples of policies and programs include: · Developing policies for making healthy food options avail able throughout the workplace, for all shifts, through a combination of cafeteria and vending options, and offering a variety of nutrition education programs targeting both healthy workers and those with nutrition-related diseases; · Ensuring a physical-activity-friendly atmosphere and environment that is supportive of employees' efforts to achieve physical activity guidelines for health benefits as outlined by national policy, including Healthy People 2010 and the Dietary Guidelines for Americans; · Providing support for non-smoking employees by uniform adoption and enforcement of tobacco control policies, and through a broad spectrum of tobacco use cessation programs for tobacco users at varying stages of readiness for change.
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To achieve this goal requires a clear rationale, policy, and practice that drive accomplishment and resource allocation at the center level. The Committee recommends the following strategy: · Establish appropriate databases to provide health metrics to inform the evaluation process; · Define desired goals for periodic health examination pro grams and medical surveillance data requirements; · Stratify health and safety requirements into occupationally mandated standards; · Link health promotion and disease prevention examinations, if and when uniformly performed, through a standardized process, to the employee's primary health provider and the Health Risk Ap praisal.
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1996. The integrated model: Implications for worksite health promotion and occupational health and safety practice.
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2005.Presenteeism and its role in worksite health promotion. American Journal of Health Promotion 19(Suppl 4)
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2002. The long-term impact of Johnson & Johnson's Health & Wellness Program on employee health risks.
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2005. Process evaluation of an integrated health promotion/occupational health model in WellWorks-2.
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2001. Using theory to understand the multiple determinants of low participation in worksite health promotion programs.
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2001. Getting closer to the truth: Overcoming research chal lenges when estimating the financial impact of worksite health promotion programs.
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In: Glanz K, Lewis FM, Rimer BK, eds. Health Behavior and Health Education.
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workforce: Integrating occupational health and safety and worksite health promotion: State of the science. Paper presented at the Na tional Institute of Occupational Safety and Health (NIOSH)
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. Federal Employee Health Benefits Program (FEHB)
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Journal of Physical Activity and Health 1(3)
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