Health Alliance Addresses Behavioral Health-Related Leaves through Disability Management Practices

In 2006, the employee population of the Health Alliance in Cincinnati decreased from 14,000 to 9,000 employees after two health care facilities left the organization. The company is self-insured for short-term disability. The leave of absence department was noticing that the incidence of Family & Medical Leave Absences (FMLA) for behavioral health issues was increasing. Nine percent of FMLA absences were related to stress disorders, and the average duration was 58 days. In 2007, the Employee Health department implemented a requirement to see a mental health specialist (psychiatrist, psychologist, mental health nurse practitioner, master-level social worker, or chemical abuse counselor) if a leave of absence was longer than 30 days for a behavioral health issue in order for the employee to receive short term disability pay. Prior to this time, employees could submit documentation from primary care physician alone to certify the leave of absence. With the mental health requirement, claims decreased by 1% in incidence and by 7 days in duration.

In 2007, the EAP Director and the Employee Health Director began benchmarking and attended a conference where they were introduced to the Partnership for Mental Health and their trial disability management program. After learning about that and other programs at this conference, they decided to work on a new behavioral health initiative. This initiative requires any employee signed off for a behavioral health issue to be seen by an Employee Assistance counselor within the first week of the leave. The EAP counselor assists the employee with a referral to a mental health specialist and treatment if needed. The counselor acts as a case manager for the associate during the leave, as well as a (short-term) therapist until an appointment in the community is secured. No short-term disability pay is granted unless the EAP counselor verifies that the employee is getting an appropriate level of treatment. The Primary Care network was contacted and easily supported the program as most employees were initially signed off by their Primary Care Physician.

In 2008, the Health Alliance’s Director of Benefits and Compensation connected the internal EH and EAP departments with Unum, their long-term disability carrier. Unum helped build a corporate strategy for addressing employees on short-term disability leaves of absence who have difficulty returning to work. In many cases, these employees have physical, psychosocial, and motivational issues that play a role in developing ambivalence about returning and resistance to change. The carrier also helped the organization formulate assessment plans to track variables such as: 1) work time lost due to disability, 2) disability costs, and 3) cost savings attributed to the new approach.

Before finalization of these changes requiring EAP involvement for disability payment, the EAP counselors had concerns. The EAP has always been voluntary and confidential. This new program was not voluntary if the employee wanted disability benefits. Confidentiality was limited, as EAP and EH coordination is required on all cases. Employees were required to come to an office for a face to face appointment. There was concern that “push back” would be strong. To date, there have been no employee complaints and no grievances from unions following the change. They attribute this to employees recognition that they were getting valuable and needed treatment—and feeling better! Complaints from EAP staff and occupational health case-facilitators were not anticipated, but were initially very strongly felt. EAP felt frustrated with some aspects of case management and felt they were no longer being therapists. EH case facilitators were often more directive in their helping role and were not accustomed to some of the therapeutic aspects expected of them. Some of the staff struggled to suspend their own frustrations and beliefs that disability patients were not motivated or non-compliant with treatment. Their interactions with clients often felt confrontational or ineffective.

The LTD carrier consulted with the Alliance and provided training with the staff to serve two roles—to help build a team approach between the EAP and EH departments and to build skills in working with clients applying tenets of motivational interviewing and the readiness to change model.1,2 EH case facilitators and EAP therapists were encouraged to use motivational interviewing to help clients reflect on and explore their own ambivalence about their disability, their resistance to returning to work in the same capacity or in a modified way, and the multiple perceived barriers. Rather than simply collecting information, providing supportive listening or attempting to rush prematurely to solutions, EAP and EH staff are trained to actively listen to clients, reflect back their description of ambivalence, and to focus on change talk (weighing of pros and cons of changing the status quo in their situation).

Unum has continued to provide periodic boosters to the staff for skill building, practice, and mentoring in this non-directive, non-confrontational therapeutic strategy. Dianne Carroll, MSW, Director, Employee Assistance, and Shirley Kendall, RN, MBA, Director, Employee Health, both believe the training has helped their departments come together as partners to help their clients identify values and fears of change in their work situations and to solve potential problems. The staff feels more comfortable with silence, more open to their clients’ choices and decisions, and better able to find common ground for possible workplace solutions.

The staff also feels better prepared to use these motivational interviewing skills with workplace managers who may not be supportive of the employee’s eventual return to work. Asking questions about barriers and possible solutions may help uncover unspoken difficulties and pave the way for improved communication between manager and employee.

Outcomes

In 2008, 134 employees went through the disability management program. There were no complaints from employees or union officials. Lost days, referral to long term disability and cost impact were significantly reduced. Savings from 2006 to 2008 were tracked at over $800,000. (Measurements, Courtesy of Unum)

Lost Work Day Impact

A. Number of Claims (paid claims)
B. Average Duration (days)
C. Total Lost WORK Days (A x B x .7123) Full Time Equivalent Impact
D. FTEs (C/260) Indirect Productivity/ Cost Impact
E. Average Salary
F. Indirect Cost @ 100% (D x E) G. Direct Cost (D x E x 70% Benefit. Replacement.)

(1. Rollnick, S., Miller, W, Butler, C. (2008). Motivational interviewing in healthcare. New York: Guilford Press. 2. Prochaska, J., Norcross, J., DiClemente, C. (1994). Changing for good. New York: William)

Other

For a number of years, the Health Alliance provided financial assistance for rent and utilities to employees through payroll deduction loans. While this helped some employees avoid evictions, there were many repeat requests, and managers felt that the program was not successfully changing behaviors in financial responsibility. Payroll loans were eliminated in 2007 and replaced with SmartMoney Community Services, a non-profit that provides financial services and economic education in Cincinnati. Initially, SmartMoney set up a satellite office on the Health Alliance campus and provided onsite individual counseling and group education sessions for all employees. SmartMoney had permanent office hours once a week for half a day. During these office hours, 47 Health Alliance employees took advantage of individual counseling sessions. According to Dionne Owens, Financial Education Director at SmartMoney, the greatest success was found in the group counseling sessions. There were 8 workshops conducted with a total of 58 participants in 2008. The workshops provide participants with tools and techniques to help control spending, increase savings, identify financial goals, and further align income with expenses.

Following the recession, organizational budget cuts put a financial strain on the company, threatening to de-fund these financial support services. Thankfully, the Health Alliance utilized The Partnership's publications on the positive work performance impacts of financial education programs in order to justify the retention of the group counseling element of the program.

Last Updated: August 2009