Your Guide to Workforce. May 26, Milwaukee, WI. Presented by Brian J. Thomas and James O. Prochaska, Ph.D.

Transcription

1 Wellness That Works: Your Guide to Workforce Health Promotion Presented by Brian J. Thomas and James O. Prochaska, Ph.D. May 26, : :30 030a.m. Milwaukee, WI

2 Today s Presenters Brian J. Thomas Founder, President & CEO Quality Health Solutions, Inc. Nationally recognized as one of the thought leaders in the health promotion and wellness industry QHS has been honored as one of the best wellness vendors in the nation three years in a row by the Health Industries Research Companies, an independent organization that conducts healthcare market research.

3 Today s Presenters James O. Prochaska, Ph.D. Collaborative Partner Quality Health Solutions, Inc. Founder of Pro-Change Behavior Systems, Director of the Cancer Prevention Research Center and Professor of Psychology at the University of Rhode Island Named one of the five most influential authors in Psychology by the Institute for Scientific Information and the American Psychological Society, Dr. Prochaska is one of the originators of the Transtheoretical Model of Behavior Change and the author of more than 300 papers on behavior change for health promotion and disease prevention.

4 Presentation Overview Transtheoretical Model of Behavior Change State of Health Effective Program Design How is Health Promotion Evaluated? Case Study Questions and Answers

5 The Transtheoretical Model of Behavior Change: Theory, Research and Practice

6 Stages of Change

7 Precontemplation: Not Ready Have no intention to start taking action in next 6 months

8 Characteristics of Precontemplation Ignorance Demoralization Denial

9 Contemplation: Getting Ready Intend to start in next 6 months

10 Characteristics of Contemplation Doubt Delay

11 Preparation: Ready Practicing the behavior Intend to start in next 30 days

12 Characteristics of Preparation Fear of failure Be prepared

13 Percent of Smokers by Stage Sample Precont. Cont. Prep. N Rhode Island ,144 4 Worksites ,785 California ,534

14 Clinical Guidelines for Treating Tobacco Use Fiore et al., 1996: 3000 studies on tobacco Fiore et al., 2000: 6000 studies Many evidence-based treatments for motivated smokers (i.e. those in preparation stage). No evidence-based treatments for unmotivated smokers. > 80% of all U.S. smokers > 90% of daily smokers

15 Action: Recently Started to Change Consistently for less than 6 months

16 Action Characteristics Most demanding Most regressive

17 Maintenance: Has Overtly Changed Behavior Consistently for 6 months or more

18 Maintenance Characteristics Preventing relapse Managing distress

19 Termination: Sustaining ggoals For more than 5 years

20 Characteristics of Termination: Home Free Preventing relapse Managing distress

21 Behavior Controls and Stages of Change Precontemplation Contemplation Preparation Action Maintenance Termination Stimulus Control Decisional Control Rule Control Stimulus Control

22 Intervention Issues Reach Retention Progress Process Outcomes

23 Engagement Challenge Engagement Involves behavior change through a series of interventions Challenge Most employees are not intending to participate in health promotion programs

24 Proactive Engagement Proactive Engagement Communication Campaign Incentives

25 Communication Programs have to communicate that they are tailored to needs of each employee: Wherever you are at, we can work with that! Traffic light: Red light not ready; Yellow light getting ready; Green light ready.

26 Proactive alone will not work Kaiser example with smoking

27 1 st Principle: Increase the Pros of Change How much: One standard deviation Increasing your Change IQ by 15 points

28 Stage Transitions Pros Cons PC Cont PR Action Maint The pros and cons of changing across stages of change for 48 behaviors Hall, K. L. & Rossi, J. S. (2008). Meta-analytic examination of the strong and weak principles across 48 health behaviors. Preventive Medicine, 46,

29 Programs have to increase the Pros Medicare example Health Plan example

30 Social vs. Self When social controls (including incentives) are used, programs have to help transform social controls into self controls. Air Force example with smoking

31 2 nd Principle: Decrease The Cons How much: one-half standard deviation Emphasize the pros twice as much as the cons.

32 Programs Have to Decrease the Cons

33 Programs have to have easy access: Home or work based rather than clinic or group based. Weight management example

34 Third Principle: A Positive Balance When the balance goes negative: e regress When the balance goes positive: progress

35 55 53 ores T Sc Premature Termination 45 Appropriate Termination Continuers 43 PC C A M

36 Stages by Processes PRECONTEMPLATION CONTEMPLATION PREPARATION Consciousness Raising i Dramatic Relief Environmental Reevaluation Self Reevaluation The processes listed above are most relevant in the early stages of change.

37 Stages by Processes PREPARATION ACTION MAINTENANCE Self Liberation Reinforcement Management Helping Relationships Counterconditioning Stimulus Control The processes listed above are most relevant in the later stages.

38 Treatment Groups Action-oriented Manuals Stage-Matched Manuals Stage-Matched Computers & Manuals Counselors & Stage-Matched Computers

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41 Pe ercenta age Action Manuals Stage Manuals Computers+ Counselors+ 0 Pretest Assessment Periods

42 Computer vs. Counseling Percentag ge Baseline 6 Months 12 Months 18 Months Assessment Periods Computer Counseling

43 Gender 30 bstinence e P oint Prev valence A Assessment (Month) Male Female

44 Age 40 Point Pre evalence Ab bstinence Assessment (Months) <=

45 Proactive Cessation With Adolescents in Primary Care Tailored Intervention Assessment Only 23.9% 11.4% Hollis, JF, Polen, MR, Whitlock, EP; Lichtenstein, E., Mullooly, JP, Velicer, W.F., & Redding, C.A. (2005). TEEN REACH: Outcomes from a randomized controlled trial of a tobacco reduction program among teens seen in primary medical care. Pediatrics, 115,

46 Race 30 bstinence t Prevalence A Point Assessment (Month) White Black

47 Hispanic 40 Point Prevalence e Abstinen ce No Yes Assessment (Month)

48 Proactive Cessation with Depressed Patients Abstinence at 18 Months Tailored Intervention + Assessment Only 24.6% 19.1% Hall, S. M., Tsoh, J. V., Prochaska, J. J., Eisendrath, S., Humfleet, G. L., Gorecki, J. A. et al. (2006). Treatment for Cigarette Smoking Among Depressed Mental Health Outpatients: A Randomized Clinical Trial. American Journal of Public Health, 96,

49 Proactive Cessation with Patients Hospitalized for Mental Illness Tailored Assessment 31% 11%

50 Percentage in Action/Maintenance for Stress Management Treatment Control Baseline 6 month 12 month 18 month 2 significant (p <.001) at 6, 12, & 18 months (Pre-Action at Baseline Only) Evers, K.E., Prochaska, J.O., Johnson, J.L., Mauriello, L.M., Padula, J.A., & Prochaska, J.M. (2006). A randomized clinical trial of a population- and Transtheoretical model-based stressmanagement intervention. Health Psychology, 25,

51 Smoking Point Prevalence % in Action and Mai intenance e Baseline 12 Month 24 Month Treatment Control

52 Diet Point Prevalence % in Actio on and Ma aintenanc ce Treatment Control Baseline 12 Month 24 Month

53 Sun Point Prevalence % in Action and M aintena ance Treatment Control Baseline 12 Month 24 Month

54 Two Years of Primary Care Counseling No effects on any of the four target behaviors No increased effect on four behaviors treated effectively with TTM-tailored interventions

55 Two Years of Worksite Campaign No effects on any of the multiple targeted behaviors No increased effect on multiple behaviors treated effectively with TTM-tailored interventions

56 Number of Risk Factors in Preparation Among 3,616 Current Smokers 63% 27% 8% Number of Risk Factors % Risk Factors: Smoking, High Fat Diet, Sedentary, Not Using Sunscreen

57 Multiple Behavior Change Strategies Sequential Simultaneous: Modular Simultaneous: Co-variation Simultaneous: Integrative Bullying Prevention Proactive Health Consumer

58 Co-variation The increased probability of progressing to Action on a second behavior (e.g. diet) when individuals have progressed to Action on an initial behavior (e.g.smoking). Co-variation in Odds Ratio Control Group.85 TTM Intervention Group 3.44

59 ADHERENCE Regression from A/M by Group Post-action at Baseline 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% Baseline 6 mo 12 mo 18 mo

60 Exercise Staging Adherence Group Progression to A/M by Group (pre-action at baseline) % in A/M 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Baseline 6 mo 12 mo 18 mo

61 Dietary Fat Staging Adherence Group Progression to A/M by Group (pre-action at baseline) 30% 25% A/M % in 20% 15% 10% 5% 0% Baseline 6 mo 12 mo 18 mo

62 ORIGINAL IMPACT EQUATION IMPACT = REACH X EFFICACY IMPACT = (5% REACH) X (30% ABSTINENCE) = 1.5% IMPACT = (75% REACH) X (20% ABSTINENCE) = 15%

63 GOAL Help employees become more proactive about their health and healthcare

64 NEW IMPACT EQUATION IMPACT = REACH X EFFICACY X ( BEHAVIORS CHANGED)

65 Inclusive Care Inclusive Research + Inclusive Practice = Inclusive Care

66 State of Health

67 The State of Health Today Despite the steady increase in healthcare costs, there is no evidence that the health of Americans is improving Without healthy work forces, organizations are unable to compete locally, nationally, or globally Failure to control healthcare costs, may lead to government mandates and oversight of our healthcare system Health does not occur without changes in behavior on the part of individuals and organizations

68 Current Environment: Population Trends Smoking - 21% smoke; results in more than $193 billion in costs annually, based on lost productivity ($97 billion) and health care expenditures ($96 billion) (CDC. Annual smoking attributable mortality, years of potential life lost, and productivity losses United States, MMWR November 14, 2008 / Vol. 57 / No. 45) High-fat Diets 77% of Adults eat fewer than 5 servings of fruits and vegetables each day Sedentary Behavior - <1/3 of all adults engage in regular physical activity

69 Current Environment: Population Trends Stress health care expenditures are nearly 50% greater for workers who report high levels of stress (Journal of Occupational and Environmental Medicine) Alcohol Abuse excessive alcohol use is the 3 rd leading lifestyle-related cause of death for the nation Depression depressed employees use, on average, more than $4,000 per year in medical services versus less than $1,000 per year used by employees without depression (Cigna Behavioral Health, 2006) Multiple Health Risk 47 million adults are classified as metabolic syndrome (insulin resistance, obesity, high blood sugars and triglycerides).

70 Current Environment: Population Impact Blood Pressure 30% of the population has high blood pressure, 1/3 don t know they have it Cholesterol 17% of adult Americans aged 20 years and older have high total cholesterol; 1/3 don t know it Blood Sugar 78% 7.8% of fthe population has diabetes; 1/4 don t know they have it Obesity 67% are overweight or obese

71 Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes Obesity (BMI 30 kg/m 2 ) 1994 Diabetes Missing Data <14.0% % % % 26.0% Missing data <4.5% % % % 9.0% CDC s Division of Diabetes Translation. National Diabetes Surveillance System available at

72 Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes Obesity (BMI 30 kg/m 2 ) 2008 Diabetes Missing Data <14.0% % % % 26.0% Missing data <4.5% % % % 9.0% CDC s Division of Diabetes Translation. National Diabetes Surveillance System available at

73 Obesity (BMI 30 kg/m 2 ) Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes No Data <14.0% % % % >26.0% Diabetes No Data <4.5% % 59% 6074% % 7589% % >9.0% CDC s Division of Diabetes Translation. National Diabetes Surveillance System available at

74 Effective Program Design

75 Program Design: Incentives Trinkets don t work Cash prizes don t work Plan design works

76 Program Sequencing Planning Implementation Evaluation 1. Project Initiation 1. Program Go Live 1. Program Evaluation 2. Needs Assessment 3. Eligibility & Reporting HRA Biometric Screenings Participation Reports 4. Program 2. Baseline Analysis Health Coaching Components Risk Stratificationtifi ti 3. Health Coaching 5. Incentive Design Enrollment Aggregate Report 6. Communication 4. Lifestyle Management Strategy Program Enrollment 2. Year Two Planning 7. Vendor Integration 5. Targeted Campaigns 8. Program Logistics

77 Program Design: Integration Benefit Plan Resources Disease management Case management Health Plan EAP Data Management Eligibility data Incentives

78 How is Health Promotion Evaluated?

79 How is Health Promotion Evaluated? Process Program delivery milestones met according to timeline? How many people participate? Are participants satisfied? Outcome Does the program change behavior? Does the program change biometric measures? Does the program save money, increase productivity, reduce healthcare utilization?

80 Key Findings of the HPBS 10 Employer Study On average, every $1 of medical and pharmacy costs is matched to $2.3 of health-related productivity costs = 23:1 2.3:1 (with some conditions as high as 20:1) Health-related presenteeism has a larger impact on lost productivity than absenteeism, with Executives/Managers suffering high loss. Evidence based medicine should go beyond clinical outcomes or financial outcomes and include functional outcomes. Source: Loeppke, R., et al., Health and Productivity as a Business Strategy: A Multi-Employer Study, JOEM, 51:4, April, pp National Business Group on Health: Key Findings of the HPBS 10 Employer Study

81 Biggest Health-Related Cost is Presenteeism Source: Cisco Systems, Inc.: 2007 incurred medical claims and STD, LTD claims National Business Group on Health: Key Findings of the HPBS 10 Employer Study

82 Behavior Change Outcomes Focus Starting With the End in Mind Changing Health Behavior Risks Enhancing Health Impacting Healthcare Costs

83 Quality Health Solutions: A Case Study

84 Company Demographics 14,000 lives 26 states 53% male Average age 44.3

85 Program Design Employees were provided with two plan options: Option I high deductible $1,000 deductible $1,050 placed in HRA (HRA rolls over; when employee retires they keep and use for medical expenses such as Medicare premiums) When employee retires the Client pays 75% of health care costs Option II low deductible - $300 deductible At end of year if health care premium cost of employees in the low deductible is higher than the high, the employee pays the increase When employee retires Client pays 50% of health care costs

86 Program Design Program participation p is voluntary To participate in Plan Option I, employees have to actively participate in the health management programs Active participation is defined as: Annual biometric screening At a minimum, annual completion of the Quality Health Survey Enrollment and active participation in the appropriate care management program (lifestyle management and/or condition management)

87 Program Impact (Partial Sampling) Smoking: Between Year 1 and Year 5, 35% of smokers quit smoking. Alcohol: Among those at risk for Alcohol, 73% began limiting iti their intake between Year 1 and Year 5. Stress and Depression: Among those at risk for depression, 79% showed improvement. Similarly, 68.0% reduced their risk for stress between Year 1 and Year 5. Health Screenings: 99% of participants had their cholesterol l and blood pressure checked.

88 Program Results 92% of the employees actively participate p in 2005, 88% in 2006, 91% in 2007, 92% in 2008, 95% in Client expected an increase of $140mm for 2008 Actual healthcare cost increase came in at 0% No other changes in the plan to account for this leveling trend Client attributes this outcome to QHS services 2008 was the first year in company history where healthcare costs were held flat

89 Questions? s