Presenteeism: taking an integrated approach: by integrating the efforts of disability management and employee assistance programs, employers can form a solid foundation for an early-return-to-work program that reduces the impact of presenteeism.

A supervisor notices that a valuable longtime employee has missed several project deadlines, appears distracted, and has begun arriving late to work and leaving early. Another employee, recently diagnosed with diabetes, has returned to work after taking a short-term disability leave of absence but is having difficulty coping with the effects of the illness on her life. A third employee harbors lingering feelings of anger about an on-the-job injury that are interfering with his successful return to work and is also struggling to care for an aging parent recently diagnosed with Alzheimer's disease.

These employees are exhibiting "symptoms" of presenteeism, a term used to describe the phenomenon of employees showing up for work but not performing to their full potential. Although presenteeism is familiar to many employers as a concept, it is still considered the next frontier among workplace issues, and relatively few work organizations--mostly large employers--are taking steps to address it (see "The Presenteeism Mindset").

Presenteeism shifts the focus of employers, human resources professionals, and others interested in workforce performance from employees who take unscheduled absences from work (a problem known as absenteeism) to employees who are present but not as productive as they could be. There are many drivers of presenteeism, including (but not limited to) chronic health issues or episodic illness, difficulty returning to work after an illness or injury, personal or family problems, and child care or elder care needs.

To address presenteeism and its multiple causes, some employers are making use of their workplace benefits, including disability management and employee assistance programs (see "An Integrated Approach to Presenteeism"). As this article will discuss, an integrated approach to combating presenteeism leverages the strengths of multiple programs to address the physical, mental, emotional, vocational, and practical needs of employees.

AN EMERGING AWARENESS

On the surface, employee presenteeism may not appear to be a serious problem. From an employer's perspective, having an employee on the job would seem preferable to having him or her miss work due to an unscheduled absence, whether from illness, injury, or other cause. In addition, the impact of presenteeism is difficult to gauge on a case-by-case basis--unlike disability cases such as workers' compensation claims, which are easier to measure in terms of cost of benefits and duration of time off.

Nonetheless, research indicates that presenteeism can have a significant effect on productivity and on a work organization's bottom line. Wayne D. Burton, M.D., employee wellness and productivity executive for JP Morgan Chase, says that presenteeism is estimated to account for two-thirds of total direct and indirect costs (such as lost productivity) stemming from medical care, absenteeism, short- and long-term disability, and presenteeism. The remaining factors together account for about one-third.

A small but growing number of employers are beginning to consider presenteeism from the perspective of performance and productivity management. They are starting to ask themselves a question: When my employees are not able to focus on their tasks and responsibilities, when they are distracted by problems and concerns, when the quality and consistency of their work suffers, what is the impact on my company's performance and productivity?

"The awareness is beginning to emerge at all levels," says Ronald Loeppke, M.D., chief health officer and senior vice president of integrated solutions for CorSolutions Inc. "What we have seen is that the 'C-suite' level in the company--the executive team--does grab onto this issue of managing total cost by recognizing the business value of health in the workforce."

A GLOBAL APPROACH

Disability managers and EA professionals can play a major role in helping companies understand the importance of addressing presenteeism and utilize existing tools and services more effectively to help improve employee productivity Disability managers know the importance of early-return-to-work programs that help ill and injured employees transition back to the workplace. Employee assistance professionals, meanwhile, understand the value of addressing the emotional, mental health, and work/life needs of employees.

By integrating their separate but complementary perspectives, disability management and EA professionals can develop a global solution to both absenteeism and presenteeism. Indeed, disability management and employee assistance professionals are at the heart of a team approach that can also encompass the wellness, work/life balance, and human resources functions and meet the needs of supervisors and managers as well as employees. Adopting a global view of health, wellness, and productivity enables companies to begin breaking down the "silos" of medical and pharmacy benefits, disability management, employee assistance, and wellness and work/life programs.

"There is a tremendous opportunity if the head of health benefits, the head of the EAP, the head of disability, and/or the corporate medical director would aggregate this information and begin to show the business case of why an integrated health solution is critical to the bottom line of the company," Loeppke says. "Then, executives would really 'get it,' if they don't already. In fact, I have had corporate executives ask why their people have not brought this total cost perspective and the business value of integrated health strategies to their attention. The opportunity is ripe for those within organizations to bring this forward to their executive teams."

Traditionally, EAPs have focused on non-disability-related issues like personal or family problems and work/life concerns, such as child care and eider care referrals. The EAP often operates separately from disability management, which focuses on returning employees to work after an illness or injury. Disability management and employee assistance programs, whether internal or provided by third parties, usually do not integrate their services very much, and direct referrals between programs are often difficult because of confidentiality issues.

Many employers view their EAPs, disability management programs, and other workplace benefits separately, but in so doing they fail to recognize the complementary strategies underlying them. This can be seen most clearly, perhaps, in the link between returning an employee to work after an absence (whether covered by workers' compensation or short-term disability) and addressing any lingering presenteeism/productivity issues.

Some companies may be successful in developing early-return-to-work programs for employees who suffer occupational or non-occupational illnesses or injuries. They may not enjoy as much success, however, administering the necessary follow-up activities, including monitoring returning employees to ensure they are adjusting emotionally and psychologically to the workplace. Offering various types of support, include counseling through the EAR can help early-return-to-work programs achieve more productive outcomes.

IMPROVING EAP UTILIZATION

Clearly, using an integrated benefits approach to assist employees who have been off work and are transitioning back into the workplace is one way employers can target presenteeism and show significant gains in productivity Such an approach can also help companies increase utilization of their EAPs.

Carol A. Harnett, assistant vice president and national practice leader of group disability and life practice for The Hartford, says employers generally expect 4-6 percent of their employees to use the EAP each year. Some studies, however, indicate that utilization is typically lower, around 1-2 percent annually. By involving EAPs in early-return-to-work programs, employers may see increases in their medical and pharmacy costs. While employers might consider this a negative development, Harnett believes it is a positive turn of events.

"When you have good utilization of your EAP, it means your employees are dealing with their issues, particularly depression and anxiety disorders, which are two of the main things we see," she says. "As workers visit their doctors and take their medications, medical/pharmacy costs may go up a little bit, but the hope is that this will change the presenteeism problem. If employees deal with issues appropriately, they will not leave the workplace. They'll be at their jobs and they'll be more productive."

To increase EAP utilization, companies should make sure that employees and supervisors alike understand how the program operates, the benefits it provides, and the fact that it is free and confidential. Supervisors can be an important source of referrals to EAPs for employees who exhibit signs of stress or presenteeism problems. At the same time, supervisors themselves may need EAP support as they face the pressures of maintaining and/or increasing the productivity of their units and managing employees, including those who are coming back to work after an absence.

"Companies may spend a week giving two-hour training sessions each day on new software that may affect productivity by a certain amount," says David Whitehouse, M.D., M.B.A., corporate medical director of CIGNA Behavioral Health. "Yet when it comes to employees understanding how to use their benefits, which are at least of equal importance to productivity as new software, how much time do they spend training them how to use it? Usually, it's minimal."

In addition, as employers look at integrating EAPs with wellness and, increasingly, disability management programs, there is an even greater opportunity to help employees access these services, both for practical concerns and for emotional/behavioral reasons. For example, an employee who has been on disability leave may be physically ready to return to work, but child care may have become an issue in the interim. Another employee may be seeking information about nursing homes for an elderly parent living in another state and may also need emotional support to deal with his or her feelings surrounding this issue.

ELEMENTS IN PLACE

The first step in addressing presenteeism is to realize that the problem exists in all companies. Chronic illness, disability, personal/family problems, and other issues can diminish the productivity of the most highly trained, experienced, and valued employees. By understanding that work and life issues are inextricably linked, employers can offer resources to their employees and assist them in being as productive as possible.

The elements of an effective presenteeism strategy may already be in place through existing benefits and programs. Many companies have EAPs, work/life initiatives, and wellness, prevention, and disability management programs. What's required, however, is a team approach.

Loeppke advises not to tackle presenteeism through a sole source but rather through a corporate health team that spans health benefits, disability management, employee assistance, behavioral health, occupational health, health promotion, and wellness. "Bring it together so that the executive team will see there is a dialogue and an interest in an integrated approach," he says.

As an integrated approach is developed, companies will begin to understand that there is no hard boundary between disability management, employee absence, and productivity/presenteeism. "You can't see where disability ends or presenteeism begins," Burton says. "It's a continuum."

Presenteeism strategies begin with the acknowledgement that work/life issues can affect the performance of even valued employees. With this understanding, employers can explore workplace strategies that can help employees come back to work, stay at work and be as productive as possible.

RELATED ARTICLE: The presenteeism mindset.

presenteeism is currently beyond the scope of focus of many employers, who typically are more concerned about employees who are absent than those who are on the job.

"Most definitely there is the buy-in from the very large employers, but we don't see interest yet from the middle market and the small companies," says Carol A. Harnett, assistant vice president and national practice leader for group disability and life at The Hartford. "Some of those employers are still struggling with whether absenteeism is really an issue."

There may be another underlying reason why presenteeism isn't capturing the attention of employers. Although some research indicates presenteeism is a major drain on workplace productivity, presenteeism requires companies to look at employees from the perspective of human capital, a valuable asset in which to invest not only training but also resources to develop and maintain productivity.

"You really have to place a value on the employees and their being fully healthy and productive," says David Whitehouse, M.D., M.B.A., corporate medical director at CIGNA Behavioral Health. "This is another approach to performance management that says, 'If you are functioning at 75 percent, I can give you support to get you to 100 percent.'"

RELATED ARTICLE: An integrated approach to presenteeism.

At JP Morgan Chase, disability management and EAP professionals work side-by-side to handle the company's internally managed short-term disability program, focusing on both physical and mental health issues, depending upon the employee's needs.

"The partnership between the EAP and short-term disability management was one I set up over 20 years ago," says Wayne Burton, M.D., employee wellness and productivity executive for JP Morgan Chase. "We realized that not only is a significant portion of our short-term disability caseload related directly to mental health, but in many short-term disability cases, mental health issues are in part a co-morbidity. Someone starts out having a heart attack, but we know that a large percentage of people who suffer heart attacks have depression afterwards."

If the co-morbidity (or secondary medical condition) of depression is not diagnosed and addressed, the employee is far more likely to be away from work longer on disability leave. If the employee does return to work, the underlying depression may result in another absence or short-term disability, as well as presenteeism issues when he/she is on the job. By integrating disability management and EAP, however, JP Morgan Chase is able to assign the right professional--whether an occupational health nurse or a registered nurse who specializes in mental health nursing--to manage the employee's case.

"Rather than mental health being carved out, if the mental health profession would work part and parcel with physical medicine, then a person could be treated in total," says Daniel J. Conti, Ph.D., first vice president and EAP manager for JP Morgan Chase. "We have nurses who are professionals in case management and know how to introduce the idea of behavioral medicine, to help employees take some steps to live in a healthier way and learn how they can manage their emotions to do better with their physical conditions. In the vast majority of cases, it's done very easily and is seen as a source of additional support. Pushback from employees isn't an issue here, and it's a free and confidential service."

Marybeth Stevens is immediate past chair and Norman Hursh is chair-elect of the Certification of Disability Management Specialists Commission (CBMSC), the only nationally accredited organization that certifies disability management specialists. Ms. Stevens is also the delivery leader of Workplace Absence and Disability Management Programs for General Electric. Dr. Hursh is an associate professor in the Rehabilitation Services Department of the Sargent College of Health and Rehabilitation Sciences at Boston University.