Hennepin County’s Emotional Health Team: Combining Awareness and Early Detection

Working on an emotional health initiative team was not part of the job description for anyone in the county workforce in Hennepin County, Minnesota. Several county managers, however, examined various data points related to emotional health within their own departments, and each saw the need for broader discussions with other professionals.

In 2008, a group formed to address emotional health. Team members included:

• Jim Ramnaraine, Americans With Disabilities Act (ADA) Coordinator within the Human Resources (HR) Department

• Jessica Huntington, a Recruiter in HR

• Tera King, Program Analyst in Health Works, the County’s Health and Wellness Program

• Jill Hamilton, Health Works Manager and Contract Manager for Employee Assistance Services

• Cathy Krepsky, Benefits Analyst and Contract Manager for Disability Insurance

• Meghan Quayle, Health Works’ Registered Dietitian

Assessing the Situation

By pooling their data, the team learned several things that concerned them. Among employee health assessment participants, 53% indicated emotional concerns. The prevalence of depression in the workforce of 8,000 employees was 2% higher than in comparable government jurisdictions. In addition, three of the top ten prescription drugs used by assessment participants were antidepressants. The team was also seeing higher disability claims and increased requests for workplace accommodations from employees with primary or secondary diagnoses of depression, as well as increased requests from supervisors for programs on emotional health topics.

The team investigated the issue further and identified several factors that were possibly contributing to the situation. For example, Hennepin County’s long-term disability benefit provided unlimited lifetime coverage for mental health claims, but there was limited return-to-work programming that could help ease transitions back into previous work roles following mental-health related leaves of absence. This limitation was particularly significant because research suggests that return-to-work programs and work task modification may help workers recover from depression (Brenninkmeijer, Houtman, & Blonk, 2008). Furthermore, the team sought mechanisms for enhanced mental health screening and appropriate referral to the County’s healthcare benefit, employee assistance program (EAP), and short- and long-term disability plans.

Screening and Providing Information

All of this information helped the team frame a presentation to top management requesting support and authority to work with vendors to negotiate more proactive approaches for identification of mental health conditions and for interventions to support employees. The team began working with Screening for Mental Health, an organization that provides telephonic and online screening and education on a variety of mental health problems. Issues addressed by the organization include depression, anxiety, bipolar disorder, post-traumatic stress disorder, and substance use disorders. Screening for Mental Health reported back to the team that online screening contacts far outnumbered telephone contacts, so the organization worked with the Sand Creek Group, the County’s EAP, to develop a web-based link for making appointments for additional assessment, information, and intervention. In the first two years of the screening program, 462 employees, or 6% of the workforce, completed the anonymous self-assessment. The percentages of people who had positive scores for depression and who said they would seek further evaluation were nearly identical year over year: on average, 43% of employees who completed the self-assessment had symptoms characteristic of depression and more than one-half of those employees indicated that they would seek further evaluation.

The EAPA Standards and Professional Guidelines for Employee Assistance Programs

(Employee Assistance Professionals Association, 2010) identifies essential and recommended components of EAPs:

“[EAPs] serve organizations and their employees in multiple ways, ranging from consultation at the strategic level about issues with organization-wide implications to individual assistance to employees and family members experiencing personal difficulties. As workplace programs, the structure and operation of each EAP varies with the structure, functioning, and needs of the organization(s) it serves.

In general, an EAP is a set of professional services specifically designed:

• to improve and/or maintain the productivity and healthy functioning of the workplace and to address a work organization’s particular business needs

• through the application of specialized knowledge and expertise about human behavior and mental health.

More specifically, an EAP is a workplace program designed to assist: (1) work organizations in addressing productivity issues, and (2) ‘employee clients’ in identifying and resolving personal concerns, including health, marital, family, financial, alcohol, drug, legal, emotional, stress, or other personal issues that may affect job performance.”

Manager Training

The emotional wellness team also worked to devise training programs for supervisors and employees. While EAPs often provide training services, in this case the team worked with consultants from Behavioral Medical Interventions (BMI) and the local chapter of the National Alliance on Mental Illness (NAMI) in developing a customized program. The four-hour supervisor program was piloted with two county departments: 1) Community Corrections & Rehabilitation and 2) Taxpayer Services. Employees and supervisors in both agencies regularly face numerous stressors in the course of their work, including interactions with aggressive, hostile, and abusive clients, residents, and inmates.

The supervisor training focused on the following topics:

• The importance of identifying and documenting performance issues in order to have a basis for dialogue with individual employees about how their mental health issue was interfering with their work.

• Resources for employees, supervisors, and work teams through the EAP, health and wellness, organizational development, ADA, case management, and critical incident teams.

• Constructive ways to confront the “troubled” employee (someone with frequent absences who appears to be struggling with a personal issue, behavioral health problem, or physical condition exacerbated by emotional problems).

• The business case for intervening.

• Guidance about roles and boundaries.

Regarding roles and boundaries, supervisors in the pilot training were told that effective intervention involved responding early, regardless of the cause. They were told that it is not their job as supervisors to figure out what is wrong, to attempt to diagnose the employee’s condition, or to advise employees on their personal lives. However, they should discuss the problematic change in the employee’s behavior (e.g., drop off in performance, attendance, or changes in mood) and point out the resources available to help the employee. The message to supervisors is that a situation involving mental health issues is no different from a situation requiring safety training or harassment prevention: it is important to address behavior before it becomes a serious problem.

In a 90-day follow-up survey with supervisors who attended the training, 49% said they had a performance issue with a troubled employee, and 96% said the tools and resources presented in the training were helpful when meeting with troubled employees. Based on feedback from supervisors, the team arranged for additional small group sessions facilitated by HR and a psychologist so supervisors may share and compare how they have handled various situations.

Early Intervention

The emotional wellness team also worked with the County’s disability benefit vendor, The Standard Insurance, to provide a return-to-work program using local on-site case managers (rather than telephonic short-term disability case management and return-to-work programming) and to include professionals with mental health backgrounds as disability case managers.

The team created a communication link between disability case management and the EAP for optimal collaboration and role definition. The external EAP fields employees’ inbound calls and provides information, support, and referral for difficulties with personal issues, such as relationship or financial problems. The disability case manager advises supervisors of employees who have work performance difficulties that are complicated by emotional issues. The case manager may contact the employee directly through an outbound call to inform the employee about the services of the Stay at Work/Return to Work program provided by case management as well as services available through the EAP or the health plan’s health coaches. Case managers often attend physician appointments with employees to help employees better understand their treatment and to advocate for and ask questions about potential work accommodations that may make return-to-work more successful. The case managers and the ADA Coordinator work together on weekly case reviews. The reviews have helped them intervene proactively with employees and supervisors and to close cases more quickly.

The anecdotal evidence on several complex cases suggests that the case managers have been able to help employees and have achieved better employment outcomes. The following case examples illustrate ways in which the extra support has been beneficial:

• An employee had major depression and vivid dreams involving acts of violence, which were later attributed to insomnia. The person had major work stressors and no current treatment. Following treatment for depression and reassignment to a job that was a better fit for the person, this employee had stable sleep patterns and was back to work in 90 days.

• An employee with bipolar disorder and borderline personality disorder left work after an incident with a county official. The case manager follow-along resulted in partial return to work after dialectical behavioral therapy (a modified cognitivebehavioral treatment that has been found effective for individuals with self-injurious or self-destructive behaviors; Linehan et al, 2006) and adjustment to medication after 45 days. After 30 more days, the employee returned to work full time.

In addition, the team negotiated case management services on a preventive basis with the County’s disability vendor so that case management may begin before there is a disability claim to manage. The goal is for the disability case manager, who is a licensed psychologist, to function like an extension of the EAP, as a confidential referral to help employees manage difficult situations or life changes.

The Standard reported that the County is the only employer among the company’s more than 30 clients using on-site case managers that also offers employees the services of a licensed psychologist as a case manager. While other employers may receive similar services through their EAP, especially internally managed EAPs, in this instance, providing case management and proactive outreach through disability management has been an effective arrangement. (See above for additional information on typical EAP services.) The Standard is looking at the County’s relationship with BMI as a pilot to determine whether providing specialized psychiatric support to employees is costeffective from the disability insurance side, and they are discussing appropriate metrics to capture this information.

Program Rewards

Working together on the emotional health initiative for employees of Hennepin County has been a rewarding experience for the professionals on the team, all of whom have an interest in the overlap between physical health, mental health, and the therapeutic value of work. While contributing to this team is outside of their job descriptions, these employees have received the support of their supervisors, who have allowed them time to work on the initiative. It appears the team’s efforts are paying off. The positive feedback from supervisors has been gratifying, and the financial return-on-investment (ROI) is substantial. After a one-year review, the new approach has realized an ROI of $81 to $1 on their reserve. This beats the disability insurance industry standard of $22 to $1 ROI for case management and $27 to $1 for comparable preventive case management programs.

Encouraging Collaboration and Awareness

This spring the emotional wellness committee provided a panel discussion to employees, supervisors, managers, and union stewards. Services of EAP, disability, ADA, health plans, wellness, onsite nutrition services, and mail-order pharmacy were represented. The panel helped employees better understand the benefits and support available to them, and the various providers became more aware of collaborative and cross-referral opportunities. In addition, handouts were developed to support the case manager and supervisor trainings. In the next year, Hennepin County plans to hold a conference on depression and integrated depression management. The training used in the pilot program will be extended to all supervisors using eLearning, and the County anticipates using Working Family Resource Center to present a web-based program to all employees.

About Hennepin County, Minnesota

Hennepin County is the largest of Minnesota’s 87 counties, with Minneapolis as its largest city and county seat. Hennepin County has a broad-based economy with sizable manufacturing, financial, governmental, trade, healthcare, and entertainment sectors. The mission of Hennepin County is to enhance the health, safety, and quality of life of residents and communities in a respectful, efficient, and fiscally responsible way.

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: July 2011