Forming effective alliances with IPPs: by working closely with impaired professional programs, EAPs can help health care practitioners receive the substance abuse treatment they need, thus improving the care their patients receive.

Nancy Smith, a nurse, completed the substance abuse treatment program to which her employee assistance program (EAP) had referred her six months earlier. It was now time for her to renew her nursing license. She completed her renewal application and indicated she had been treated for alcoholism. One month later, she was informed by the nursing board's impaired professional program (IPP) she would have to resubmit to an evaluation of their choosing, with possible additional treatment.

John Brown, a doctor, had a long history of substance abuse. He informed his supervisor of his problems and was referred to the medical board's IPP. Two months later he returned to work, but nothing was said about the referral to the IPP. The following year, one of his patients died, and the patient's family filed a malpractice suit.

During the investigation, Dr. Brown's treatment for substance abuse came to light. It was noted that the hospital's administrators had not referred him to the EAP, nor did they have any official documentation of the referral to the IPP. In addition, the hospital had not attempted to monitor his treatment compliance. Had the administrators referred Dr. Brown to the EAP and monitored his compliance, they would have discovered he had failed multiple drug screens and also been diagnosed with bipolar disorder. The patient's family filed suit against the hospital for neglect employment, along with the malpractice suit.

EMPHASIZING RISK MANAGEMENT

Alcohol use, abuse, and dependency impose a heavy burden on society. The costs for health care secondary to alcohol and substance abuse treatment, as well as for losses stemming from reduced workplace productivity, premature death, crime, and legal problems, number in the billions of dollars. (1) Workplace productivity losses alone are estimated to cost the United States $89.5 billion per year. (2) In addition, two million American workers report being victimized each year by workplace violence, costing employers billions of dollars. (3)

Behavioral risk management has become a major concern for both health care professional licensing boards as well as the health care industry in general. Multiple studies indicate many health care professionals are at risk of developing, or already are experiencing, substance abuse and dependency problems. McAuliffe and others, for example, reported that 59 percent of physicians had used psychoactive drugs in their lives, while one in four had abused prescription drugs and one in ten currently use drugs regularly. (4) Brown and others report that much remains to be done for the health care profession to both recognize and provide treatment for impaired health care professionals. (5)

A growing number of health care licensing boards are responding to substance abuse problems among health care professionals by establishing IPPs, while the health care industry is developing various internal programs. The impetus for these programs varies: The concern for public safety, for example, has pushed many licensing boards to increase the role they play in monitoring the treatment and care provided by their licensed professionals. While public safety is certainly a major concern, there are other issues that need to be considered, including increased litigation, liability risks, and costs resulting from the presence of impaired professionals in the workforce.

These issues have driven the development of many corporate risk management programs. Although the development of IPPs and internal risk management programs have run along parallel lines, limited attention has been paid to the need of these programs to interface and work together to meet the objectives of both. A primary challenge facing the health care industry and IPPs is to provide services that complement one another while also ensuring the professional's needs are met.

Employee assistance programs are in a unique position to interface between the workplace and the IPP, filling the gap in providing services and sharing information. Additionally, the EAP can monitor the effectiveness of the IPP as well as the quality and type of services provided to the health care professional. It is with these concepts in mind that we offer the following guidelines for the effective interfacing of EAPs and IPPs.

FINDING COMMON GROUND

For EAPs and IPPs to interface effectively, they must resolve issues pertaining to intervention, referral, return to work and fitness for duty, disciplinary action, and monitoring of aftercare treatment. An effective collaborative effort requires the programs to broaden the scope of their intervention processes, extend their referrals to include one another, and coordinate their evaluation, treatment, and return-to-work plans.

Communication. The EAP and IPP need to establish a formal line of communication that goes beyond simply becoming acquainted with each other's programs. A protocol needs to be established so that each program communicates with the other throughout the intervention, treatment, and case management phases. Information that is shared can be invaluable in improving the quality of the assessment, ensuring that adequate treatment is received, evaluating return-to-work restrictions, and monitoring the case. All of these benefits contribute to the safety of the overall workplace as well as that of the health care professional.

Common ground. It is important for the EAP and IPP to establish common ground on treatment philosophy, treatment providers, costs for treatment, and drag-testing procedures. This will prevent health care professionals from having to undergo repeated evaluations and treatment, reduce the need for services that are not covered by insurance providers, and ensure the best outcome possible. The EAP can help the employer reduce health care costs by identifying needed changes in insurance coverage and ensuring the provider list meets the requirements of the IPP In addition, the EAP can assist in the return-to-work process by modifying work schedules (to enable the individual to attend treatment) and offering needed supervision.

Licensed health care professionals have unique treatment needs related to confidentiality, time schedules, and specialized care that need to be addressed. These issues often pose distinct challenges for treatment providers. IPPs are in an excellent position to evaluate the effectiveness of treatment providers who serve their licensed professionals.

Supervisory dual referral. Collaborative interventions and referrals have several advantages for both the IPP and the EAP The control that an IPP wields over the health care professional's license is a critical motivation for impaired professionals in denial. A mutually-agreed-upon recommendation not only sends a strong message to the impaired health care professional, it also adds support to each program when these cases go to court or in front of a licensing board.

Although EAPs often are not directly responsible for referring health care professionals to IPPs, they are in an excellent position to educate workplace supervisors and administrators and staff of the IPPs in their state. The requirements for reporting an impaired or potentially impaired health care professional to licensing boards run the gamut, from no reporting obligation in some states to mandatory reporting in others. Additionally, given that IPP policies vary from profession to profession and state to state, EAPs can be invaluable in helping new employees from other states obtain services required by the IPP in their new state.

Drug testing. Many IPPs and health care facilities have mandatory drug testing programs. Procedures to share drug test results can be established to prevent duplicate testing. This reduces the cost to the company and/or the individual.

IPPs and EAPs often test for more than the so-called "DOT 5" (marijuana, cocaine, amphetamines, opiates, and PCP). In health care settings it typically is necessary to test for several controlled substances, given the easy access many health care professionals have to controlled substances. The Department of Transportation (DOT) has developed drug-testing standards that have stood the test of the legal system. Following these standards as closely as possible minimizes the possibility of lawsuits and/or reversals of drug-testing results.

While many workplaces and most IPPs follow the DOT guidelines, some do not. To avoid ending up in court without a defense, accept only drug test results that meet your program standards. Before you agree to share drug test results, ask the following questions:

1. Are DOT guidelines being followed, except possibly for the number and/or type of drugs being tested for? If not, why not?

2. What is the collection process?

3. Is a chain of custody used?

4. What laboratory is used?

5. What types of screening tests are performed?

6. What drugs are targeted by the test?

7. Are positive test results being confirmed through gas mass spectrometry (GC/MS)?

8. Is there a Medical Review Officer? If so, do all positives go through the MRO?

9. What is the random selection process for monitoring?

10. How often are health care professionals tested for drugs?

11. How soon after receiving notification of the need to undergo drug testing must a health care professional be tested?

12. What is the process for dealing with prescriptions for controlled substances written by "helpful colleagues" or received through "doctor shopping?"

13. What is the process for appealing drug test results, and what is the health care professional's status during the appeal process?

14. Is the EAP notified when an appeal is taking place?

The EAP can serve multiple roles in the drug-testing process, including interpreting the significance of positive or negative tests. The EAP also can (1) facilitate communications with a firm's substance abuse professional, (2) ensure that drug panels include the drug(s) the health care professional is known to abuse and those readily available to him/her at work, and (3) help develop a "stand down" procedure for health care professionals whose positive drug test results are being appealed.

Policies and procedures. EA professionals should sit down with IPP representatives in their states and compare policies and procedures. Significant elements to review include the following:

1. Is there a return-to-work or fitness-for-duty policy? Do these policies and procedures complement one another, or do they conflict?

2. With respect to the Americans with Disabilities Act (ADA), what is the policy if a health care professional needs the employer to make reasonable accommodations so s/he can perform essential job functions? The IPP is in an excellent position to assist the EAP in gathering the needed documentation that will help the professional. The EAP, on the other hand, can serve as an internal advocate for reasonable accommodations or employee benefits.

3. Are procedures in place for coordinating return-to-work plans and making any needed modifications for the work setting? If treatment is ongoing, are recommendations concerning the work setting listed as part of the treatment plan?

4. If both the EAP and IPP have return-to-work contracts with the impaired professional, do they support one another or impose conflicting requirements? Is there a procedure for the two programs to share this information with each other?

5. What plans are in place for monitoring treatment compliance? What is the protocol for sharing information and procedures should the health care professional fail to comply with the treatment program?

SUPPORTING PROPER TREATMENT

When patient safety is at issue, the margin for error is minimal and the liability risks are great. Multiple problems can arise in case of a failure to establish a formal relationship between a health care workplace setting, the EAR treatment providers, and the IPP. These problems include duplication of services, competing or conflicting treatment recommendations, missed information, inadequate case management, and risks to patients and employees.

Employee assistance programs and impaired professional programs are in a unique position to form an alliance to support proper treatment of health care professionals and ensure their safe return to work. Collaboration in the areas of intervention, referral, return to work, disciplinary action, and monitoring of aftercare treatment is imperative. This alliance will improve the effectiveness of their respective programs, enhance the quality of care for the identified health care professional, and reduce the liability risk for all.

The authors wish to thank Barbara McGill, R.N., director of the Recovering Nurses Program and a member of the Louisiana State Board of Nursing.

References

(1) U.S. Department of Health and Human Services. 2000. "Economic Analysis Aids Alcohol Research." Alcohol Research & Health. Bethesda, Md.: National Institute on Alcohol Abuse and Alcoholism.

(2) Fitzgerald, S.T., S.C. Hammond, and K.A. Harder. 1989. "Role of the Employee Assistance Program in Helping the Troubled Worker." Occupational Medicine, 4 (2): 233-243.

(3) Injury Prevention Research Center. 2001. Workplace Violence: A Report to the Nation. Iowa City, Iowa: University of Iowa.

(4) McAuliffe, W.E., M. Rohman, S. Santangelo, B. Feldman, E. Magnuson, A. Sobol, and J. Weissman. 1986. "Psychoactive drug use among practicing physicians and medical students." New England Journal of Medicine, 315: 805810.

(5) Brown, M.E., A.M. Trinkoff, A.G. Christen, and E.J. Dole. 2002. "Impairment Issues for Professionals: Review and Recommendations." In M.R. Haack and H. Adger (eds.), Strategic Plan for Interdisciplinary faculty Development: Arming the Nation's Health Professional Workforce for a New Approach to Substance Use Disorders. Providence, R.I.: AMERSA.

Stanley Denton is an assistant professor of psychiatry and director of the Louisiana State University Health Sciences Center's Campus/Employee Assistance Program.

Martha Brown is an associate professor of psychiatry and director of the Division of Addiction Medicine and Professional Health Services in the University of South Florida College of Medicine.