liveWELL at the University of Iowa

The University of Iowa (UI), along with focusing on the growth and advancement of more than 31,000 students, employs and supports the health and development of its 14,500 staff and 2,600 faculty. With its own healthcare system, including a teaching hospital and clinics, UI formally launched a program called liveWELL as part of their integrated health management strategy for UI faculty and staff in 2006. liveWELL focuses on a healthy campus culture and improved organizational performance by making well-being part of the daily routine of UI faculty and staff.

Joan M. Troester, interim assistant vice president of Benefits, Health and Productivity, says UI was motivated to include mental health as an integral component of liveWELL because “well-being truly includes the whole person—mental and emotional.” UI has been reporting on liveWELL-related outcomes since the program’s inception. The behavioral/mental health components of liveWELL intersect with physical health and with UI’s centers for excellence, which are utilized to apply learning directly to the well-being support programs provided to UI employees.

Troester says that UI’s integrated health management strategy is informed by a large body of work pioneered by Dee Edington, founder of the University of Michigan’s Health Management Research Center and chairman of Edington Associates, who has focused on multiple ways of engaging employees in health. The four levels of UI’s strategy include: 1) managing chronic conditions, 2) lowering risk in the “at risk” population, 3) keeping healthy people healthy, and 4) environmental supports, such as benefit design, policy, physical environment, culture, and engagement.

Within this strategy, liveWELL activities are driven by data about UI faculty and staff collected through their personal health assessment and focus groups. The activities are focused on the lower three levels of this pyramid. Support programs—including health and wellness coaches, coordination with the UI employee assistance program (EAP), UI centers of excellence and advisory groups—all aim to assist employees reduce health risk factors.

liveWELL—Using Data

The mission of the liveWELL team is “to create and sustain a healthy campus culture at UI through the development and delivery of best-in-class health and wellness programs for faculty and staff” (UI, n.d.a). This mission is being accomplished by targeting efforts in response to what the liveWELL team found in their data. Troester’s team (see inset box) gathered and aggregated data on the UI employees to better understand the health concerns of the UI workforce through focus groups and through their personal health assessments. Together, the information has been the basis for reporting outcomes on liveWELL’s effectiveness. Troester said, “With my employer hat on, we measure organizational outcomes, but it is really about impacting people—making a difference in people’s lives.”

Employee Focus Groups

Early preparation for liveWELL included a number of employee focus groups. There were general sessions asking employees about various planned activities and which incentives, if any, were effective in motivating health behavior change. Other questions were vendor related in terms of whether program services would be provided by UI employees or external vendors. As UI is self-insured and has its own healthcare system, there were questions whether anticipated health coaches should be internal or external. The focus groups revealed that, if confidentiality was maintained, health coaches employed directly by UI were preferred. Focus group participants cited ease of accessibility and the unique ability of internal staff to tailor coaching to meet the needs of the campus community as their reasons for preferring internal on-site coaching.

Personal Health Assessment

Health risk appraisals and assessments (HRAs) are instruments and processes that are used to methodically collect data from individuals to ascertain risk factors that are reviewed to provide each individual with customized comments and suggestions “with at least one intervention to promote health, sustain function and/or prevent disease” (Centers for Disease Control and Prevention [CDC], 2010). At UI, the HRA is called a personal health assessment (PHA) and follows preferred guidelines provided by the CDC of being web-based and ensuring the confidentiality of the information collected (CDC, n.d.). The PHA is delivered online by the vendor Quality Health Solutions, with a tailored feedback report provided to each individual upon completion. The voluntary survey takes 10-15 minutes to complete and is accompanied by a one-time annual incentive for participation.

The PHA has been delivered to faculty and staff since 2006. While many wellness programs and HRAs originally focused on physical risk factors, the PHA instrument includes questions related to mental and emotional well-being. Questions about stress and depression have been present since the PHA’s inception. For depression, questions from the Patient Health Questionnaire-2 (PHQ-2) are used. For example: “Over the past two weeks, how often have you been bothered by . . . little interest or pleasure in doing things . . . or . . . feeling down, depressed, or hopeless?”

The PHA instrument continues to evolve, and additional questions are added on the basis of new research. For example, in 2011, two questions were added about employee sleep, as research findings increasingly suggested that sleep disorders are associated with incidence of mental disorders—particularly depression and anxiety (Taylor, Lichstein, Durrence, Reidel, & Bush, 2005).

In 2014, the PHA instrument added two additional questions that address culture and the work environment: 1) “I feel that my physical work environment provides opportunities for me to make healthy choices,” and 2) “My supervisor supports health and wellness in my unit.” Inclusion of these questions is supported by research by Gallup (2013) indicating that success in health and engagement is strengthened by positive work environments and wellness programs.

The participation rate in the PHA, although voluntary, has been substantial across UI faculty and staff. Participation is encouraged through an incentive of $65 for completing the PHA each calendar year. Since 2011, over 80% of faculty and staff have participated in the PHA at least once (UI, 2014). The rates of participation indicate the commitment to health by both UI leadership and employees.

Outcome Reporting

Information from the employee focus groups and the results of the PHA led the liveWELL team to focus on tracking six areas of health behavior improvements: healthy weight, good nutrition, regular exercise, stress management, nonsmoking status, and good sleep. Research compiled by the National Center for Complementary and Alternative Medicine suggests that interventions focused on physical factors such as healthy weight, good nutrition, regular exercise, and nonsmoking status also support mental and behavioral health (Casper, 2005; National Institutes of Health, n.d.).

In the nine years that the UI team has been tracking these metrics, they have witnessed an overall reduction of risk factors by 32% (UI, 2014). This represents faculty and staff who have moved from the high-risk category, of four or more risk factors, to lower risk categories. In addition, internally collected data indicated that high-risk participants, over a three-year period, “used approximately 16-28 hours more of sick leave as compared to lower risk participants.” The overall risk reduction and resulting lowered absenteeism translates into an estimated $3.28 million cost avoidance annually and contributed to a 0% increase in health insurance premiums in 2012 and 2013. Highlighted in Figure 3 are the results from the data collected since 2010.

liveWELL Support Programs

What lies beneath the data and numbers? The intentions behind the liveWELL programs seek risk migration from higher to lower health risk levels for UI staff and faculty, but how is it accomplished? The results from the PHA are self-reported from those who participate in the PHA. The liveWELL approach follows the Transtheoretical Model of stages of behavioral change (Prochaska, DiClemente, and Norcross, 1992). The model indicates that change is a process that takes time for individuals to advance through five stages of behavior change: precontemplation, contemplation, preparation, action, and maintenance. Although the questions in the PHA instrument may raise awareness, helping a person move from precontemplation to contemplation or preparation, they may not lead to the action stage of behavior change. Understanding this dynamic, the liveWELL team includes many programs to help individuals bring about healthy changes and reduce risk factors among their employees.

Health and Wellness Coaches

Recognizing that people often need help to move into the action stage of making healthy changes, UI provides employees access to the services of health and wellness coaches who are prepared at a master’s level. The UI coaches review individualized PHA reports with UI employees and help employees create personal improvement plans focused on reducing any existing health risk factors. This process generally includes meetings between the UI coaches and UI employees up to five times over the course of 10-16 weeks, predominantly face to face and by phone, Skype, or e-mail. The UI coaches are well versed in the various programs available at UI to complement and enhance the improvement plans they help to create.

UI coaches link to health programs that are available to UI employees through referral programs. UI will reimburse the program fee, upon successful completion, for UI employees who are referred to a number of programs based on their PHA results. Two such examples are a mindfulness-based stress reduction program and nicotine replacement therapy.

Mindfulness-based programs, directed by UI’s Bev Klug, MA, LMFT, are provided on the UI campus through Behavioral Health Services at UI Hospitals and Clinics. The services, offered since 1996, are available to employees as well as to the broader community. See www.uihealthcare.org/mindfulness. Providing supportive services for individuals to more effectively manage stress both improves individual health and positively affects the organization overall. UI recognizes that the practice of mindfulness meditation encourages “living a full life with greater balance and ease, even amidst the busyness of daily living or the challenges presented by physical or mental health limitations” (UI, n.d.b).

UI will reimburse up to $500 through liveWELL for nicotine replacement therapy and/or medications that support stopping smoking. The employee must be engaged with a health coach related to stopping smoking; the reimbursement is for nicotine replacement aids and medications that are not otherwise covered by the individual’s insurance. In relation to smoking cessation, although they are about twice as likely to smoke as people without mental illness and consume approximately 44.3% of cigarettes, people living with mental illness still have a substantial quit rate (Lasser et al., 2000).

For mental health concerns identified through the PHA, coaches refer participants to licensed counselors through the EAP, described in the following text. These onsite professionals provide in-person mental health counseling. In addition, the EAP provides supportive resources for addressing sleep—as well as an online evidence-based program called SHUTi (Sleep Healthy Using the Internet), an eight-week program based on cognitive-behavioral therapy to help participants improve sleep.

Leveraging Advisory Groups and the Centers of Excellence for Behavioral Health

Given the university setting, the UI health and productivity team is in the unique position to leverage resources and research on campus. Examples include the EAP, a behavioral health advisory work group, and a suicide prevention education program.

UI’s EAP works closely with the liveWELL program, providing behavioral health services to faculty, staff, and their family members. The services are provided internally, as part of UI’s human resources department, within the health and productivity unit. The EAP staff includes four master’s-level licensed social workers. The EAP includes many standard offerings, such as counseling (eligible employees may schedule up to four free in-person sessions per year), consultation, educational services, and critical-incident stress debriefings. If additional counseling is recommended, the EAP counselor assists individuals in seeking help through community services or their health plan.

Another way the EAP serves UI faculty and staff is through participation in and chairing of a behavioral health advisory group. The Behavioral Health Work Group is a subset of UI’s Integrated Health Management Advisory Group. Membership includes individuals from EAP, University Counseling Services (student focus), Student Health and Wellness, and UI Hospitals and Clinics behavioral health areas. The work group is focused on identifying population health strategies that positively affect the mental and emotional wellbeing of faculty, staff, and students. It was at the suggestion of this group that two sleep questions were added to the PHA and sleep resources were developed for campus employees.

The suicide prevention education program is a partnership with several on-campus and community resources. In connection with the College of Public Health and the Crisis Center of Johnson County (a local nonprofit organization), education in suicide prevention was delivered at UI in 2011 to teach about the impact of suicide interventions on a major university campus. The work helped equip the human resources professionals and managers at UI to better recognize the warning signs of suicide risk and respond through life-saving actions. Working with the local Crisis Center of Johnson County, faculty from the Department of Public Health and the EAP studied the use of QPR Gatekeeper Training for Suicide Prevention in the university setting (WozniakRebhuhn & Ramirez, 2014). QPR stands for the steps Question, Persuade, and Refer and is a suicide risk reduction and gatekeeper training listed on the Substance Abuse and Mental Health Services Administration’s national registry of evidence-based programs and practices.

Aligning Health Management With Organizational Goals

Sally Mason, president at UI, has said, “A supportive environment and a healthy campus climate create the foundation for members of our community to engage in positive lifestyles.” In response to this vision for a healthy, engaged culture, the liveWELL team includes training about the importance of managers and supervisors in well-being, resilience, and in productivity. Training by EAP and liveWELL professional staff includes a supervisor series and an advanced management series, each four hours in length, which support defining, teaching, modeling, and encouraging well-being and how these efforts encourage growth and productivity of teams.

Managers and supervisors also receive communication and reports on the health of their college/division in comparison with overall UI statistics. This information has been shared for about the past seven years and is reviewed individually with managers and supervisors. Information includes participation rates, aggregate health risk population health profiles, and recommendations for the upcoming calendar year. This information is used to help tailor communications and focus on specific health messages that will be most effective, a strong example of how data can be used to make informed programmatic decisions to influence the health of employees. Managers and supervisors find the tailored information valuable for developing their own plans in supporting employee health and leading participation in liveWELL programs.

UI integrated health management provides an environment where liveWELL can influence positive behavior change across program administrators, faculty, and staff alike to work together for the well-being of the whole campus. It is clear why Troester says that, at UI, “No matter what door our employee comes through, they get to the right place for help because we are not siloed.”

University of Iowa’s liveWELL and EAP Team:

• Joni Troester: Interim Assistant Vice President of Benefits, Health and Productivity

• Megan Hammes: Interim Director, UI Wellness

• Maggie Moore: Director, Employee Assistance Program, LISW

• Erin Litton: Health Coach/Wellness Consultant

• Ilona Lichty: Health Coach/Wellness Consultant

• Carla Melby-Oetken: Health Coach/Wellness Consultant

• Holly Reed: Health Coach

• Bronwyn Threlkeld-Wiegand: EAP Counselor, LISW

What Employers Can Take Away

Which of these programs might your organization adopt or adapt to fit your organization culture and the data you have available?

• Understand your workforce population. Consider what data you already have available to benchmark and measure the health of your employees. Whether you self-funded or have a third-party healthcare system, collect aggregate claims data. Work with your EAP to get information about the utilization of various programs. If these are not available, use state normative data and extrapolate what health concerns are at the highest incidence for your workforce. These data can focus your support efforts according to the greatest needs.

• Ask your employees what they need. Conduct confidential focus groups where employees can voice their needs and opinions in a safe way so you can glean ideas from the diverse perspectives in your workforce.

• Include questions related to mental health on your organization’s HRA. Plan a clear process for follow-up with the information collected to increase awareness of resources and help employees adopt healthy changes.

• Collaborate and use internal and community resources to develop programs and services.

About the University of Iowa

Founded in 1847, the University of Iowa, located in Iowa City, was the first university in the state. It includes 11 colleges and is a national public research university.

Health and wellness efforts were first implemented at the University in 1999 through a number of pilot programs. Based on the demonstrated success of these early endeavors, a comprehensive health management strategy was developed, and liveWELL was formally launched in 2006.

Nancy Spangler, PhD, 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: October 2015