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Caterpillar Builds Healthy Employees: Practical Applications that Integrate Health Promotion, EAP, and Disability Management
When the public thinks of Caterpillar, visions of high-quality heavy machinery and engines are likely to come to mind. Behind the scenes, a well-honed machine is also operating to support the health and well-being of Caterpillar’s nearly 95,000 employees worldwide through a spectrum of integrated tools and services provided by several complementary areas of human resources, including health promotion, an employee assistance program (EAP), and disability management.
Integrating Internal Management
John Pompe, PsyD, SPHR, Caterpillar’s Manager of Behavioral Health Programs, describes the company’s comprehensive approach to mental health as one that has evolved over several years because of a close collaborative relationship among the internal managers responsible for health and productivity initiatives and their various vendors. “Integrated internal management helps Caterpillar build benefits and programs that have a long-term comprehensive care orientation, that can integrate service delivery, and that are able to collect data for process and outcomes evaluation,” notes Pompe.
For example, the company’s managers of health promotion, employee assistance, occupational health, and disability management programs meet routinely to integrate their efforts. All are housed in the Corporate Medical Department within the Human Resources organization at Caterpillar (Human Services Division), which allows cross referrals between programs while protecting employee confidentiality and privacy as mandated by the Health Insurance Portability and Accountability Act (HIPAA).
Caterpillar’s Manager of Behavioral Health Programs and the Medical Director for Health Promotion track a variety of metrics related to these programs. These data are collected and analyzed for purposes of assuring program quality,making process improvements, and developing new benefits and programs.
In general, Caterpillar’s approach is aimed toward preventing illness when possible, identifying conditions early, and encouraging evidence-based treatment when needed. The managers can use data from many sources (i.e., healthcare plan, EAP utilization, health risk appraisal data, and disability data) to drive program planning for health promotion, EAP, and disease management. Conversely, data from each program can be pooled by the internal team to indicate the need for changes in healthcare plan design,with the ultimate goals of enhancing benefit value, providing evidence-based benefit designs, reducing barriers to care, and incentivizing proactive and healthy behaviors.
Caterpillar has devised and manages its own health risk appraisal (HRA) to better understand the population served by its health initiatives, to provide an educational experience for participants, and to drive the use of intervention programs. The detailed data from the HRA also help document the value of the supportive programs. In addition to the robust, customized content on a wide range of health topics, the HRA includes questions on depression and alcohol use.
Prior to participating in the health promotion physical exam, employees sign a consent to release their biometric information to the health promotion program. The health promotion program is a part of the Corporate Medical department, thus the information collected is considered at the same level of privacy as an employee’s medical record (i.e., neither HR nor Benefits has access to the information). Employees receive a copy of the data privacy notice, which describes how data collected by the health promotion program will be used and confidentiality will be protected. Any updates to the privacy statement are posted through the Caterpillar communication network. The program has a 10-year record of operation with no breach of confidential information, and there is participation across all employee groups.
With the help of incentives in the form of healthcare premium reductions, Caterpillar typically achieves a 94% participation rate with its HRA, which employees complete every six months. The HRA data help stratify participants’ health risks. Those who are at low risk for health problems are provided health information to help them maintain their low risk status. Those at moderate to high risk receive more personal attention and the opportunity for more intensive intervention.
Caterpillar recently offered employees the opportunity to participate in the Healthways Well-Being Assessment, a survey that collects and measures well-being in cities and workplaces across the United States daily. About 50% of all eligible employees participated in this survey.
Employee Assistance Program
Caterpillar’s behavioral health strategy aligns with a health continuum model to provide mental health promotion and early intervention to the majority of the population who are currently healthy with no or few risk factors, while increased support and care is made available for the remainder who experience chronic or recurring conditions. It is this group with chronic and recurring conditions group that is more likely to drive increased costs and productivity decline.
The EAP is designed (a) to help employees resolve personal and work related problems before they affect work performance, personal lives, or health and (b) to support supervisors and Human Resources entities in managing performance and behavior and in mitigating risks. The EAP is a hybrid model with an internal manager and a team of eight internal mental health and EAP professionals who provide nearly 200 hours of on-site services per week. Internal EAP staff provide counseling, case management, and monitoring to individuals, as well as training and consultation to Caterpillar organizations. Internal staff members devote 150 to 200 hours per year to supervisory training and consultation on managing employee performance and behavior. Supervisors are trained to look for (a) changes in workplace performance, (b) patterns in behavior changes, and (c) severity of deterioration in work performance as signals of behavioral health difficulties. They are encouraged to use the EAP as a resource for themselves and a referral resource for their employees.
Process metrics: Demographics, job status, presenting problem, web traffic, usage on-site vs. off-site (by business unit), utilization rates (locations and trends), and training and consultation.
Performance metrics: referral sources, supervisory referral rate, length of services, medium of service (phone vs. in-person), costs (total, per case, per session), satisfaction surveys, and Workplace Outcomes Suite (a validated scale for measuring EAP effectiveness).
Workplace violence and suicide awareness trainings are a standard part of all EAP supervisory training and have been integrated into the mandatory Human Resources anti-harassment training. Internal EAP professionals are housed at on-site health clinics in 12 locations in the United States and one location in India, where they are involved in case management and are able to assist the occupational health physicians with fit-for-duty assessments.
The internal EAP staff members are backed up by a single external vendor, who has served Caterpillar internationally since 2003. In addition, the external vendor provides assessment, counseling, and referral through a short-term EAP intervention model. Long-term intervention is provided through Caterpillar’s integrated health plans. Work-Life services offer employees unlimited access to consultation and referral services by phone,Web, or live chat, as well as self-assessments, interactive on-line trainings, and monthly webinars on a wide range of topics.
Caterpillar takes pride in the close, collaborative relationship with its external vendors. The EAP vendor communicates daily with Pompe, who manages the internal EAP program, and has regular contact with the Caterpillar Medical Director of Health Promotion,Michael Taylor,M.D. To support the disease management programs, which are also provided through the EAP vendor, a Caterpillar nurse program manager holds an office at the EAP vendor’s facility.
Since 2003, Caterpillar and its global EAP vendor have focused attention on expatriates (or employees assigned to work in locations outside of their home country) to minimize risks of family adjustment and personal problems while on an international assignment. The effort includes proactive outreach by phone and e-mail, a pre-departure meeting with new expatriates and their families, face-to-face or telephonic counseling, a professional coach or counselor while on assignment, and educational support through teleconferences, webinars, and a website. Spousal support groups are also available.
The proactive outreach dramatically increases utilization of clinical services where expatriates can seek support for a wide range of personal concerns during their assignments. Since implementation, utilization has steadily increased year-over-year, and a broader representation of the global employee population has begun using the services. Surveys indicate significant improvement in employees’ satisfaction related to their jobs and the relocation experience in general. Self-reports also suggest some reduction in absenteeism.
Disability Case Management
Caterpillar’s disability case management team reports directly to Pompe. The team consists of a licensed clinical social worker who acts as a full-time psychiatric disability case coordinator, a nurse manager, and six nurse case coordinators.
The psychiatric case coordinator works closely with the general disability case coordinators, the EAP staff, the occupational health professionals and Caterpillar’s Human Resources professionals. These efforts are aimed toward identifying individuals in need of medical leave due to a primary or secondary psychiatric illness. Such problems may interfere with the employees’ ability to perform their work or may complicate a timely return to work.
“Staying in contact with employees on leave helps to keep the employee engaged with the workplace and stay focused on both getting healthy and returning to work,” explains Pompe. The case coordinators serve as a liaison to help the employee navigate a highly complex system of care, completing leave documentation, and reviewing provider claims and restrictions. Coordinators evaluate quality of care, assess for comorbid conditions, and make referrals to appropriate specialists. They also encourage treatment compliance and empower employees to be critical consumers of healthcare.
Disability Management Metrics
General program metrics: incident rate, total lost work days, average lost time, top diagnoses driving disability, diagnoses with the longest duration, disability rate by location, early return-to-work rate, cases with duration over the national average, percentage of employees with multiple disability claims, percentage of cases transitioning from short-term to long-term disability, response time to new cases.
Psychiatric disability management metrics: percentage of all cases that are psychiatric diagnoses, average lost work time, total long-term cases, cost savings compared to pre-program benchmarks.
In addition, the case coordinators may involve HR personnel to help in instances where illness recovery and return to work are complicated by relationship problems, workplace conflicts, or other work-related and performance problems. Case managers are able to interact with the health promotion and prevention efforts to reduce recurrence of conditions. Recent efforts focus on using the disability management program as a tool to engage employees on medical leave by sending individualized health promotion messages (e.g., information on postpartum depression). For employees on medical leave due to a chronic or recurring illness, the disability management program is also an obvious entry portal to the disease management programs.
Around the year 2000, Caterpillar began offering an internal diabetes management program based on the knowledge that improving clinical outcomes in diabetes would translate into improvements in cardiovascular disease, a costly area for Caterpillar’s heavily male workforce. Approximately 2,000 employees have participated in the diabetes management program.More than 3,500 have participated in the company’s Free and Clear smoking cessation program.
A growing body of literature indicates that depression has a significant effect on employee health, productivity and benefit cost (Kessler et al., 2006; Loeppke et al., 2007). In addition, research findings suggest that disease management programs may be able to positively affect clinical outcomes and productivity for persons with depression (Rost, Smith, & Dickinson, 2004;Wang et al, 2007). Caterpillar,meanwhile, discovered that many participants in the diabetes management program struggled with comorbid depression, which interfered with employees meeting diabetes and cardiovascular clinical goals. As a result, Caterpillar developed an internal depression care management program in 2008, then leveraged an existing vendor relationship by transitioning the process to the company’s EAP vendor in 2009. In the first three months of 2010, an average of more than 200 employees participated in the depression care management program.
Many participants in the diabetes management program struggled with comorbid depression, which interfered with employees meeting diabetes and cardiovascular clinical goals.
The program is based on telephonic care management delivered by coaches with a behavioral science background, as opposed to a nursing background, which Medical Director of Health Promotion Taylor suggests is “a good fit for the highly dispersed Caterpillar workforce. It enables access to workers across a wide geographic range and multiple time zones, and it has a number of other advantages for employees over face-to-face or electronic delivery systems.” For example, Caterpillar’s production workers have limited access to phones and computers at work. The call-center based service allows greater flexibility in order to match their schedules. Caterpillar employees also have a variety of health plan options, so centralizing the program helped drive standardization and quality control, an improvement over primary-care-based models.
To begin enrollment in the program, the internal psychiatric disability case manager referred and transitioned active depression cases into the new program. In addition, the company added the Patient Health Questionnaire, 2-item scale (PHQ-2), to the biannual HRA. If an employee scores positively on the screening tool, a counselor attempts to call and engage the individual in completing the longer version of the scale, the PHQ-9, which goes beyond the PHQ-2 screening by asking about sleeping patterns, appetite, concentration, energy levels and feelings about oneself. Employees with a score suggesting depression are recruited into the telephonic depression management program that is staffed by the EAP vendor.
The trained disease management counselors use a semi-structured interview and motivational interviewing techniques to help participants obtain and comply with evidence-based treatments. They also help participants set lifestyle goals that are likely to help reduce depression and explore deterrents to reaching goals. Interviews are not scripted, but they are taped to allow counselors to review and improve their approaches. Call frequency, content, and treatment standards are based on severity of depression symptoms. Participants of the depression care management program are followed until they have reached 18 months of continuous remission of symptoms.
If an employee has a very high PHQ-9 score, the counselor suggests that the employee consider a variety of treatment approaches and educates the employee about evidence-based treatments. Calls focus on empowering the participant to be informed and engaged in his or her treatment plan.When depression is severe or is not improving, the participant is encouraged to discuss more intensive counseling and/or medications with treatment providers. Employees may also receive referrals for additional services. The phone support is ongoing in order to increase treatment engagement and compliance and to facilitate long-term outcomes.
Referrals into the depression management program come from the HRA, health promotion staff, occupational health nurses, EAP staff, and the disability management team. Screening for depression and referrals into the depression care management program also occur through the 6,000 to 7,000 physical examinations provided through Caterpillar’s occupational medicine staff. The internal EAP manager works regularly with the occupational medicine physicians and nurses to provide information and training, encouraging them to be attuned to employees’ psychosocial health issues and reinforcing available support and lifestyle services.
Depression Care Management Metrics
Primary metrics: medication compliance, percentage engaged in counseling, clinical outcomes, absenteeism/presenteeism.
Secondary and additional metrics: activities of daily living, stress management skills, social support, work functioning, physical activity, alcohol intake, body mass index, program’s impact on medical and pharmacy utilization, inpatient admissions, read missions to inpatient care, rate of follow-up with medical care after inpatient discharge.
With a program that is already comprehensive, where does Caterpillar plan to head next? Pompe reports that Caterpillar’s integrated team will continue to innovate. “Just like our product groups, innovation, quality and sustainability are fundamental principles that will drive us toward finding new ways to support the health and well-being of employees and their families. However, while expanding our areas of focus will be important, we have to continue to improve our programs and demonstrate that we are providing value for both the individual customer and Caterpillar.” For example, enhancing data integration to better tie EAP, disability, and absence data together is a future goal.
Caterpillar is the world’s leading manufacturer of construction and mining equipment, diesel and natural gas engines, industrial turbines and diesel-electric locomotives. Caterpillar is also a leading financial services provider through Caterpillar Financial Services.
Nancy Spangler, MS, OTR/L, president of Spangler Associates, Inc., and consultant to the Partnership for Workplace Mental Health, is a prevention and health management specialist in the Kansas City, Missouri area.
Last Updated: July 2010
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Rost, K., Smith, J.L., & Dickinson,M. (2004). The effect of improving primary care depression management on employee absenteeism and productivity: A randomized trial. Medical Care, 42(12), 1202–1210.
Wang, P.S., Simon, G.E., Avorn, J., Azocar, F., Ludman, E.J.,McCulloch, J., Petukhova,M.Z., & Kessler, R.C. (2007). Telephone screening, outreach, and care management for depressed workers and impact on clinical and work productivity outcomes: A randomized controlled trial. Journal of the American Medical Association, 298(12), 1401–1411.