PROGRAM FUNDAMENTALS

A first consideration, McLellan said, in a theme that recurred in subsequent discussions, is to build a set of integrated activities that are not attached to a particular leader, leadership team, or budget cycle. Instead, he said, the initiative should grow from a sustainable culture of health that will support worker health and safety in the long term. To put this another way, the initiative needs to be aligned with the corporate culture of the particular business and embedded it its strategic plan, and McLellan believes building a healthier culture is Dartmouth-Hitchcock's most important prevention activity.

Dartmouth-Hitchcock's institutional vision, McLellan said, is to achieve the healthiest population possible, which is highly congruent with the Live Well/Work Well concept. Because of that tight fit, the initiative is routinely embedded as a key tactic in Dartmouth-Hitchcock's annual operational plans, including the way in which the institution delivers services to other employed populations and their dependents. Live Well/Work Well also aligns with Dartmouth-Hitchcock's academic mission of investigating the best ways of delivering health care and creating a healthy community. As a result, and because of the significance of the medical center's local presence, “The community is us,” McLellan said.

According to McLellan, not only do institutional leaders need to communicate effectively and consistently what their worksite wellness initiative is about in general terms, perhaps with message maps to guide them, they have to communicate how specifically they plan to achieve the integration of occupational safety and health protection with health promotion for workers, families, and retirees. This requires reaching out into the community where health promotion and environmental intervention opportunities may exist, and using information technology to inform, motivate, and provide feedback, he said.

Specific and easily understood examples of using the work environment to promote health that can communicate the integration concept effectively include encouraging staff to use the stairs or take a walk on campus; providing healthy foods in the cafeteria and vending machines; and improving work organization (such as clinical flow), which not only supports good patient care, but also reduces employee stress. Another example, said McLellan, is Dartmouth-Hitchcock's focus on safe patient lifting, which involves an active group that helps staff with everything from ergonomic assists, to training in safer lifting techniques, to access to floating help when a staff member needs another person to help lift a patient safely.

Despite the anticipated benefits of integrating health protection and safety with wellness activities, employee engagement is “the number one challenge,” McLellan said, no matter which health-related issue is under consideration. He pointed to 2010 data from an annual national employer survey on purchasing value in health care that showed “lack of employee engagement” to be an issue for 58 percent of employers (National Business Group on Health and Towers Watson, 2010). However, he noted that the use of social media, health ambassadors, and various colloquia have helped to build a “buzz” in the community. McLellan said that in the most recent Dartmouth-Hitchcock engagement survey, employees gave their highest scores—86 percent support—for the center's health promotion and safety efforts.

PROGRAM ELEMENTS AND TEAMS

At Dartmouth-Hitchcock, occupational medicine, safety and industrial hygiene, disability prevention and treatment, health promotion, and employee assistance services are augmented by primary care services. Primary care is offered through a patient-centered medical home and supported by behavioral health, health coaching, and care coordination services. Primary care clinicians are trained to address work-related health issues, which means they know what employees' jobs are, how to take a basic occupational history, and basic stay-at-work and return-to-work strategies. Nevertheless, some tasks—such as “fitness for duty assessments” or U.S. Department of Transportation examinations for professional drivers—may require specialized occupational medicine expertise outside of the primary care practice, McLellan said.

In addition, Dartmouth-Hitchcock followed the lead of the National Center for Quality Assurance (NCQA) in establishing the concept of a patient-centered specialty practice³ to coordinate care between primary care and occupational medicine, in order to improve quality and the patient experience, reduce waste, and create synergies (McLellan et al., 2012b). The approach builds on the long-term experience of occupational health nurses who have followed employees' blood pressures or glucose levels, providing flu shots, and the like, then providing that information to primary care providers. This original approach was “not a very robust integration,” McLellan said. However, now, employer-based services are more integrated and no longer merely parallel community-based public health and the health care delivery system.

Even for employees who seek primary care outside Dartmouth-Hitchcock, the institution provides care coordination and behavioral health services. The initiative compiles care registries, built through health and wellness assessments and claims data, and staff members ask injured or ill employees whether they have a primary care physician and, if not, help them obtain one, if they desire.

True integration requires a thorough and thoughtful approach to team creation, McLellan said. Early in Dartmouth-Hitchcock's program, staff made discipline-specific presentations to the team, so all professional groups clearly understood what an occupational health professional or a disability specialist or a health coach does—including the various professional groups' different terminologies and ways of working. Over time, these presentations evolved into case examples of an individual with a lifestyle or occupational health issue, with all those involved in caring for that person participating in the presentation. Finally, the team employs a discussion method called “appreciative inquiry,” in which team members tell stories about what is going well, as opposed to the usual focus on what is going badly.

However, assembling a team is not enough. “You cannot just put everyone in the same boat and give them an oar,” McLellan said. The next stage of team development involved setting high-level team goals, aligned with the organization's goals. As an example, the team might want to reduce the number of employees who have a specific lifestyle risk. All team members have tactics they can use to contribute to achieving this integrated team goal.

Large organizations typically have a number of committees involved in health, safety, wellness, and benefits. Dartmouth-Hitchcock disbanded those groups and instead assembled an integrated committee called Partners in Health, Environment, Wellness, and Safety. Core content experts attend every meeting of this committee, but frontline staff rotate through, depending on the specific issues the committee will address. An important part of the committee's role is to ensure that the integration is proceeding smoothly.

THE OCCUPATIONAL HEALTH–LIFESTYLE LINK

Research findings suggest a clustering of occupational health and personal lifestyle health risks, McLellan said (Punnett, 2007; Schulte et al., 2012). Based on this insight, Dartmouth-Hitchcock is using injury reports to identify departments, workgroups, and employees likely to benefit most from integrated health protection and promotion efforts. Essentially, McLellan said, it is treating injury reports as sentinel events. The reporting system has revealed units with rates of injury three or more standard deviations above those of other departments. These present opportunities for intervention that would reduce overall institutional injury rates significantly.

Injury reports, which Dartmouth-Hitchcock personnel can generate electronically, trigger an e-mail message about the incident to all the key personnel who need to be involved, McLellan said. While the injury reports prompt treatment referrals, they also can stimulate an integrated, comprehensive investigation of the work environment and the personal and organizational factors that may be influencing workgroup health. Similarly, in the occupational medicine clinic, clinicians not only manage illnesses or injuries that result from work-related exposures, they also identify any behavioral risk factors or co-morbidities that might benefit from referral to in-house or community-based resources.

Although these occupational-lifestyle risk clusters have been observed in the workers' compensation arena for some time, McLellan said, “It is frustrating as a physician who wants to take care of a whole person” when workers' compensation does not pay for services related to co-morbidities or lifestyle. Similarly, in some settings, if a company physician denies a compensation claim, private insurance may not cover the costs of care sought privately, giving employees an incentive to conceal the possible occupational origin of an illness or injury. This skews data and may stall remediation efforts, McLellan said. Moreover, there are privacy issues to consider when including information on behavior and co-morbidities in employees' workers' compensation records, he said, even though these conditions may substantially affect the outcome of the claim.

Dartmouth-Hitchcock has pulled together a Safety Wellness Action Team (SWAT), triggered not just by units that are work safety outliers, he said, but also by other evidence of problems: critical or clustered events, plus some combination of poor participation in some of the employer-sponsored health promotion activities or indicators of lower-quality care provided by the unit, for example. SWAT interventions begin with an open-ended, integrated work environment assessment intended to prompt discussion, as well as a “culture of health” survey. Workers complete a self-scored psychosocial and personal health assessment that helps individuals recognize whether they have burnout, compassion fatigue, depression, or other factors inhibiting performance.

The next step is to work with a local unit committee to discuss potential interventions. In practice, this approach has encountered some difficulties, McLellan said, such as the presence of labor-management issues outside SWAT's scope of authority, lack of clarity regarding the team's role, and, in one instance, a profusion of priorities on a unit that overwhelmed the manager. One unsuccessful application of the SWAT method revealed that management would not release staff to attend psychosocial interventions. McLellan said this underscored the importance of micro-level work cultures on staff participation in health promotion. Broad institutional participation rates hid some of these pockets of poorer performance, he said.

The institution's Job Satisfaction Survey revealed a strong correlation between job satisfaction, employees' perceptions of job safety, belief that local leadership cares about individuals and their well-being, employees' sense they can express grievances, and the likelihood that they would participate in employer-sponsored health risk assessment and biometric screening campaign (McLellan et al., 2009). These psychosocial attributes of a workgroup culture are closely tied to leadership competence, McLellan said, noting that Dartmouth-Hitchcock's next step is to create performance expectations for health protection and health promotion not just for employees, but for leaders at every level, as well. To help leaders meet these expectations, the organization will develop a curriculum about how to create work environments that are safe and health promoting. At the higher levels of the organization, leaders are expected to create supportive policies and practices and incorporate relevant messages in public communications.

MEASURING RESULTS

Dartmouth-Hitchcock's integrated approach to measurement employs the concept of a value chain. This value chain begins with creating a work environment that is safe and health promoting (and documented with audit tools), then proceeds to assess the comprehensiveness and performance of individual program components, based on external judgment, internal assessment, and employee participation.

Another link in the value chain is reflected in a variety of measures of employee health and well-being, satisfaction, and retention. The final step in the chain relates to the traditional occupational health measures, personal clinical outcomes, and business outcomes (e.g., claims, direct costs, productivity measures, and, ideally, return on investment).

In other parts of the medical field, return on investment is not the measure of interest, McLellan said; instead, the analytic approach usually used is cost-effectiveness or cost–benefit analysis, with the measure of effectiveness often expressed as quality-adjusted life years (QALYs). This more usual approach may suggest another approach to measuring the impact of integrated programs, McLellan said, perhaps in parallel with assessments of return on investment. An alternative measure would reflect the impact of an intervention on quality of work life. Some potential contributors to that analysis (e.g., retention) and some approaches used in more traditional health care quality effectiveness assessments, so far have not been applied to integrated health protection and health promotion services.

Larger employers, especially, collect information relevant to workforce health from a great many data streams, either in-house or from external vendors. The challenge is to aggregate and integrate these, McLellan said. Workers' compensation and disability data, for example, may be hard to integrate with the organization's own information; employee surveys may not be online or may be externally managed.

As primary care providers move toward an accountable care organization model, under which they assume responsibility for managing the health of a population, they will be increasingly interested in how employer-based health promotion and protection can synergize with community-based health services to improve population health, McLellan said. As well, Dartmouth-Hitchcock is creating an integrated scorecard to report in easy-to-understand, actionable format data along its value chain, compiled from many sources. In the scorecard's current state of development, it includes these domains of wellness: health promotion, health protection, engagement, and care management. Total costs are also reported. For each domain, specific metrics are used to monitor progress toward established targets. Once the scorecard is further refined, it will be made widely available within the organization.

Footnotes

1

See more about Live Well/Work Well at http://employees​.dartmouth-hitchcock​.org/livewellworkwell​.html (accessed July 17, 2014).

2

The SafeWell Practice Guidelines were created through a collaboration between the Dana-Farber Cancer Institute; Harvard School of Public Health Center for Work, Health, and Well-Being; and Dartmouth-Hitchcock Medical Center.

3

See more about NCQA's Patient-Centered Specialty Practice Recognition program at http://www​.ncqa.org/Programs​/Recognition​/Practices/PatientCenteredSpecialtyPracticePCSP.aspx (accessed July 17, 2014).