Total Worker Health TM in the Real World: Innovations, Successes and Lessons Learned Robert K. McLellan, MD, MPH, FACOEM Medical Director of Live Well/Work Well Chief, Section of Occupational and Environmental Medicine Associate Professor of Medicine, Community and Family Medicine, and The Dartmouth Institute Geisel School of Medicine at Dartmouth 1
Creating a sustainable program Integrating services and programs Learning and Improving Evaluating Agenda McLellan et al.safewell Practice Guidelines, Version 2 at http://centerforworkhealth.sph.harvard.edu/images/stories/safewellpracticeguidelines&execsumm_sept2012. pdf
Dartmouth-Hitchcock Academic Medical Center 8600 employees 8,000 additional health plan members 900 physicians Multiple sites in NH and VT Self-insured for group health, short term disability, and high deductible WC Known for its innovations in health care delivery and population health management
Step 1: Build Sustainability for Generations to Come Create a sustainable culture of health that will support workforce health and safety improvement over the long haul Do not depend on current leadership, fads and budget opportunities
Align With Corporate Culture and Embed in Strategic Plan Live Well/Work Well becomes integral to Dartmouth- Hitchcock s corporate culture and business imperatives
Not a program at the core of our institutional vision of Achieve the healthiest population possible the way we do things at Dartmouth-Hitchcock Aligned with institutional strategic goals Prominent feature of the D-H population health strategy, routinely embedded as a Key Tactic in D-H annual operational plans Foundational for delivering services to other employed populations Tied to academic mission of investigating the science of health care delivery
Step 2: Communicate the Foundational Premise A healthier workforce will be a safer workforce A safer workforce will be a healthier workforce Live Well/Work Well
Communicate the Foundational Premise Improving individual and population health of workers and their dependents will be facilitated by Integrating occupational health protection with health promotion Integrating community and employer based services and environmental interventions
Step 3: Imagine A Healthy and Safe Place to Work and Live Community Based DH Healthy Workforce & Families Special Populations/Needs Employer Based IH & Safety Occ Medicine Primary Care Specialty Care Community Resources Dependents Behavioral Physical Wellness Retirees Employees Occupational Health and Work Ability Health coaching Care Coordination EAP/Behavioral Health Workability EE Medical Home Information Technology Measurement Benefits and Human Resource Policies Work Environment & Community Environment Health Plan & 3rd Party Vendors
Build A Healthy and Safe Work and Community Environment Physical environment Nutritional environment HR policies, benefit design, work organization Social environment Information Environment Community Environment
Assure Access to a Comprehensive Suite of Health Promotion and Protection Occupational medicine Safety and Industrial hygiene Health promotion Employee assistance program Workability program Primary care PCMH dedicated to workforce Embedded behavioral health, health coaching, care coordination svcs Care registries built with HWA and claims data Staff trained to address work/health issues Primary care other Services Employer services offered to bolster community and D-H practice resources
Integration?
Step 4: Create a Team It s not easy being a team! LWWW team meetings Discipline specific presentations Multidisciplinary case presentations Appreciative inquiry
Step 5: Align Effort Set high level team goals Manager meetings Align discipline specific goals Examples Reduce prevalence of employees with high lifestyle risk by x Reduce lost time days by y Each discipline develops tactics for the overall goals
Step 6: Partner in Health, Environment, Wellness, and Safety PHEWS reconfigure the safety committee to integrate health promotion, work environment, occupational medicine, and safety activities Include front line staff from high occupational risk departments with content experts and management
Step 7: Engage Employees The Number One Challenge Source: Towers Watson NBGH 2010 Survey
Since occupational health risks cluster (and interact) with personal health risks (Punnett 2010, Schulte 2012) Let s use reports of injury to identify and engage those departments and employees that would most benefit from integrated health protection and promotion
The EROI (Electronic Report of Injury) Web-based, intranet Available throughout system and offsite through VPN Completed by ee or supervisor Instant, auto e-mail alert to all employer stakeholders (occ med, safety, HR, Workability, etc)
Novel Approach: EROI as a Sentinel Event to Protect and Promote Health Use for just in time integration of occupational and personal health care Prompt not only safety intervention, but also Referral to individual and population health promotion Integrated comprehensive investigation of work environment and personal and organizational factors influencing workgroup health
Individual Response Management of workrelated exposure, injury or illness Identification of behavioral risk factors and/or comorbidities Referral to employer resources (EAP, Health coaching, workability programs) and as relevant to primary care/community resources
Identification of At Risk Departments 120 DH Incident Rates by Departments, 4/2013-3/2014 Rate per 100 FTEs per Year 100 80 60 40 Flex team, 109.5 Peds-General, 51.2 CSR, 51.3 MedSpec Unit, 78.0 MHO, 52.1 3 West, 50.3 Data Average 2SD limits 3SD limits Housekeeping, 56.3 Neuro/5W/NSCU, 42.3 Periop OR, 42.4 Food/Nutrition, 37.3 20 Avg 21.4 0 0 20 40 60 80 100 120 140 160 180 200 FTEs Note: Population is adjusted due to Standardization Calculations
Population Health Response: Safety Wellness Action Team (SWAT) To the rescue
SWAT Triggers Work Safety Outliers High ROI or Cluster of events or Critical event PLUS Wellness and Performance Indicators < 25%ile HRA participation or Low culture of health index or Low percentile nursing quality or Low percentile patient satisfaction
Integrated Work Environment Assessment Initial open ended safety and socioenvironmental health assessments Whole worker questionnaire Culture of health survey Self-Scored psychosocial and personal health Assessments Burn-out Depression and Anxiety Perceived stress Physical well-being
Integrated Interventions Stand-up local PHEWS committee Integrated team intervention (SWAT) may include: Ergonomic Supervisor training Behavioral health Team/resiliency building Chaplaincy Lifestyle coaching Environmental changes to better support personal health, such as healthier food options, staffing, scheduling
Gate Keeper: Safety and Environmental Programs Reviews EROI data (At Risk; cluster or sentinel event) Safety Wellness Action Team Process Flow Prevention Committee Meeting Discussion: SWAT appropriate? - Concerns related by employee health care provider Yes (Workability) SWAT Assessment Form (A) Meets intervention criteria? Yes No No Continue to monitor SWAT Convenes Meeting #1: Local PHEWS/Safety Group -Discuss results -Unit engaged? -Integrated approach appropriate? Distribution of surveys C&D to larger unit group -Collection box on unit -Scored by LWWW Admin No Yes Review qualitative response to surveys C &D SWAT Convenes Meeting #2 Local PHEWS/Safety Indentify target issues Identify resources Plan interventions ( J ) SWAT Unit/Work Group Dashboard Review Dashboard with Unit Leadership Interest? No Data analysis/scoring LWWW Admin Send out Initial surveys (C and D) Collection box on unit SWAT Unit/Work Group Dashboard Data analysis Intervention 90 days Meeting series Key to resources Yes Unit or Workgroup has PHEWS (safety) committee? Yes Yes Improvement? A. Action Triggers B. Unit Dashboard C. The Whole Worker Assessment D. Dimensions Survey J. Interventions Menu --------- Workability Care Manager No Work with PHEWS/Leadership to form local PHEWS (safety) committee Local PHEWS/ Safety Group - Continued monitoring - Provision of support Resources No
Nice Idea, but Pilot in an in-patient, at risk unit not successful Labor management issues identified outside of scope of LWWW Unit leadership overwhelmed by other priorities Staff not released for participation in psychosocial interventions Safety issues persisted
Work Culture Affects Participation in Employer Sponsored Health Promotion Participation highly correlated with attributes of workgroup culture Job satisfaction Perception of job safety Local leadership cares about me Able to express grievance McLellan et al. Impact of workplace sociocultural attributes on participation in health risk assessments. JOEM 2009
Step 8: Develop Leadership Competence and Accountability Establish performance expectations for all employees and leaders at every level for health protection and promotion Provide role based training Integrate health and safety performance with other aspects of performance review
Step 9: Integrate with Primary Care OEM: a parallel public health and health care delivery system? McLellan et al. Optimizing Health Care Delivery by Integrating Workplaces, Homes, and Communities. JOEM 2012
NCQA Recognition of OEM as a Patient Centered Specialty Practice Coordination of care between primary care and occupational medicine Improve quality and patient experience Reduce waste Create synergies using primary care and employer resources Address work/health issues D-H OEM clinic steps up as 1 of 2 early adopters in the nation and receives highest level (Level 3) of recognition
Step 10: Measure the Impact: An Integrated Value Chain Approach Work Environment Program delivery/utilization Program components Participation in assessments Engagement in programs Participant experience Health and well-being Job engagement Health culture index Readiness to change Lifestyle risk
Measure the Impact: An Integrated Value Chain Approach Occupational health eroi OSHA rates WC claim rates Personal clinical outcomes Biometrics Quality of care Disease burden Business outcomes PMPM health claims cost trends Lost productivity Return on investment vs cost effectiveness/utility analysis
Relevant data streams Claims HRA Biometrics WC STD/LTD Engagement Safety Aggregate reporting Group level correlations Individually linked data Creation of population registries with stratification of risk for care coordination outreach Step 11: Integrate Data
Step 12: Integrate Reporting
Integrate Health Protection and Promotion in the Real World Create a sustainable program integral to the company s business strategy Modify environment to protect and promote health Integrate a comprehensive suite of health and safety services and programs Develop integrated strategies for employee engagement Target highest risk populations with integrated interventions Align, train, and manage leadership at all levels to create a culture of health and safety Collect and report meaningful integrated data