An integrated approach to behavioral health: more employers are recognizing behavioral health as a workplace productivity risk and are creating teams of diverse professionals to address this risk.
These costs and the related losses in employee productivity, health, and well-being point to a critical need for behavioral health solutions, particularly those that can be integrated with other health, disability, absence management, and wellness programs. Fortunately, good news is emerging in the workplace, particularly from large employers that are integrating disability management, EAP, work-life, wellness, and even group health offerings to better address the mental and physical needs of employees. In addition, health risk assessments, which many employers use to assess existing and potential medical conditions, often include a behavioral health component, while wellness programs may provide employees with tools such as a "depression calculator" to raise mental health awareness and signal a need for treatment.
Another positive development is that the stigma surrounding mental health conditions has lessened somewhat, thereby encouraging more individuals not to hide their symptoms but instead seek treatment. Meanwhile, anecdotal evidence suggests that television and print advertisements for medications that treat various mental health conditions have also helped increase awareness and removed the perceived taboo of discussing these issues.
GREATER WORKPLACE ACCEPTANCE
Among the major forces contributing to more openness around behavioral health in the workplace is increased understanding and acceptance by employers of the prevalence of mental health issues and their impact on employee absenteeism. Evidence of this growing understanding and acceptance was revealed by a February 2006 member survey by the Disability Management Employer Coalition (DMEC). The survey assessed the need to review, analyze, and implement processes to prevent and limit workplace losses from claims, absences, and reduced productivity related to psychological issues.
The survey found evidence of a clear trend that appears to be a new employer best practice. Of those who responded to the survey, 82 percent said they thought behavioral risk was emerging as an area of concern for employers, while 53 percent said management's opinion regarding the need to review behavioral issues has changed in the last five years. Of those who answered affirmatively to the latter question, roughly nine in 10 said management was "more open" to this concept, which illustrates a shift toward fuller acceptance of behavioral risk. (For more information or to request a copy of the survey, please send an e-mail to firstname.lastname@example.org.)
This change in employer attitudes creates an important opportunity for disability management and absence management programs to incorporate behavioral health components. As this occurs, there will be greater collaboration and cooperation among disability management, employee assistance, occupational health, and related fields. For example, the DMEC survey found that one-fourth of companies use EA professionals as members of a disability management team, and another 11 percent are considering taking this step.
Another factor contributing to greater employer awareness of mental health issues is the link between physical disability and behavioral health. Research has shown that in a significant number of cases, depression accompanies a chronic health condition such as heart disease, diabetes, or asthma. For example, 15 to 20 percent of heart disease patients meet the criteria for major depression (and many more suffer from milder forms of depression), (2) while comorbid depression affects an estimated 20 to 50 percent of individuals with asthma (with higher percentages attributed to those in inner city areas). (3)
Depression and other underlying mental health issues often prolong recovery and prevent employees from returning to work in a reasonable time frame. Further, there is a noticeable increase in the use of antidepressants for pain management modalities or to minimize the behavior issues that may impede a person's full recovery.
Another factor that has crossed into this domain is the possibility of a traumatic event (on either a large or small scale). The attacks of September 11 affected people across the United States and demonstrated that post-traumatic syndrome could be accepted as a work-related condition. Plans for crisis intervention and counseling are now part of many companies' disaster response programs.
Although employers historically have shied away from linking employees' professional and personal lives, many companies are more proactive today, offering assistance for behavioral health issues. Further, disability managers are referring individuals to EAPs in recognition of the fact that counseling, support, and other services (whether delivered in person or via the telephone or Internet) can help promote success in returning employees to work after an illness or injury as well as encouraging them to stay at work. Increasingly, disability managers are engaging in "warm transfers" of employees, contacting the EAP with the worker's permission to help him/her obtain assistance.
ADDRESSING BEHAVIORAL RISK
The most important stakeholders in addressing behavioral risk in the workplace are employers. Management must understand the link between mental health and workplace performance and the risks of lost productivity from (1) employees who receive inadequate treatment or none at all and (2) co-workers who assume work on behalf of a misdiagnosed colleague. To optimize productivity, employers should develop integrated health solutions that address not only physical issues but mental and psychological ones as well.
Greater integration of health, wellness, and work-life programs will require more coordination and cooperation among many parties, from disability managers and EA professionals to human resources and benefits managers, treating physicians, and insurance companies. Aetna, for example, has begun offering a program to improve the delivery of mental health care services by focusing on identifying and treating depression at the primary care physician (PCP) level. The company says its "Aetna Depression Management" program integrates medical and behavioral health care at the PCP level in order to "diagnose depression early and to help doctors better manage health problems related to depression." (4) In a similar vein, Kaiser Permanente assigns a mental health aide to each of its primary care physicians in Northern California. (5)
Behavioral risk needs to be treated like any other risk in the workplace, with a thorough analysis and understanding of the implications. Employers need to measure the specifics of behavioral risk within their employee populations, then offer programs to mitigate or eliminate the risk. As employers become more sophisticated, programs and initiatives will shift from treatment alone to include prevention. These efforts have the potential to lessen the cost and duration of employee absences, including workers' compensation and disability claims in which depression or other mental health issues are co-morbid complications.
Addressing behavioral risk also allows employers to look more deeply at workplace issues, using integrated teams that bring together disability managers, EA professionals, human resources specialists, and employee relations and labor relations personnel. These teams may find, for example, that a higher incidence of behavioral risk in a certain department is attributable to a "toxic supervisor," meaning a supervisor's personality issues are triggering conflicts and raising the stress level of employees.
The behavioral health approach also acknowledges that an EAP can be a management resource by offering services to executives who may themselves be facing behavioral health issues. An emerging use of EAPs as a management resource is coaching and training to help managers and supervisors understand employees who have personality disorders. Training can help supervisors separate a disability issue from a performance issue and understand the behaviors that can be expected from an employee who, for example, has been treated for cancer with chemotherapy.
As employers recognize behavioral health risks and bring together the necessary resources, integrated teams will be formed by disability management, employee assistance, occupational health, benefits, human resources, and other professionals. By working collaboratively, these specialists will be the key players in addressing the impact of behavioral health in the workplace. Their goal will be to implement solutions to measure and manage behavioral risks and keep employees on their jobs, working with greater productivity and enjoying better health and improved physical and mental wellness.
Addressing Mental Health Disability and Helping Employees Return to Work
Working and recovering from a mental health disability go hand-in-hand, according to the Partnership for Workplace Mental Health, a program of the American Psychiatric Foundation.
In a March 2007 white paper on psychiatric occupational disability, Assessing and Treating Psychiatric Occupational Disability: New Behavioral Health Functional Assessment Tools Facilitate Return to Work, the Partnership emphasized the value of work and called its role in recovery "the missing piece in the mental health disability puzzle."
"Work is central to a person's identity and social role," the paper states. "It provides income but, more than that, is often an important source of self-esteem. For many people, lack of work equates with lack of meaning. Thus, loss of work capacity is a life crisis, one that demands an immediate and focused response."
The report advances "Principles of Treatment" to help improve outcomes for many patients with psychiatric impairments that lead or contribute to occupational disability. These principles include the following:
* Early assessment to prevent or minimize loss of function;
* Intensive treatment for persons with mental health conditions and loss of work function;
* A focus on return to function and work as part of treatment;
* Active collaboration and communication; and
* An understanding by clinicians that illness and impairment can co-exist with adequate occupational performance.
The report also recommends employer practices to promote return to function and work. For example, employers should establish policies and procedures to ensure that employees receive an accurate diagnosis and appropriate treatment plan, with an emphasis on an objective assessment of the scope, range, and severity of functional impairment. Benefit plans should be designed in conjunction with medical and disability providers to ensure that psychiatric conditions and disabilities are treated by appropriate mental health professionals. The report also emphasizes a team approach to return to work, including the employee, the treating physician(s), the employer, the EAP, and health and disability plan representatives.
"It is critically important that the U.S. employer-supported healthcare system promote accurate diagnosis and effective treatment with a focus on return to work, and employers adopt policies that facilitate early return to work," the report concludes.
Case Study: Pitney Bowes
For Pitney Bowes, intervening early to address behavioral health is crucial to ensuring that employees obtain access to mental health professionals as soon as possible.
"Access is what comes first," says Hilary Mitchell, director of employee health operations for Pitney Bowes, a $5.7 billion company that offers hardware, software, and other solutions to create, produce, distribute, and manage mail, documents, and packages.
To facilitate early access, Pitney Bowes made a change a few years ago from its original model of having internal personnel manage mental health claims to partnering with its vendor, ValueOptions, one of the largest behavioral health care providers in the country. Now, every mental health or substance abuse claim that comes into the disability department is referred to ValueOptions for case management, with the employer retaining the ultimate decision on whether to allow the claim.
Through ValueOptions, Pitney Bowes employees are able to access a network of mental health care resources, including an EAP (Pitney Bowes also uses Ceridian Corp. for certain EAP services). EAP services are available onsite at company facilities and where Pitney Bowes has employee medical clinics, as well as through EAP providers in the community. If employees wish, they may access services at a location that is different from where they work.
"An onsite EAP is a convenience, but employees don't have to use it. Some may want to use EAP services in their community," says Christine Berman, manager of benefits strategy for Pitney Bowes.
The company also recognizes that there is a large mental health component tied to disability management. For example, depression is often a co-morbid (or secondary) health issue when employees have an injury, illness, or other medical condition, such as a cardiac event. In response, the company is launching a pilot program with ValueOptions that asks screening questions to detect depression when employees miss work due to disability.
Addressing behavioral health and disability requires a team approach by disability management and EA professionals who have the same objectives and work closely together. "Having us in one department was instrumental in on-boarding this program and implementing these goals," Berman says.
(1.) Finch, R.A., and K. Phillips. 2005. An Employer's Guide to Behavioral Health Services: A Roadmap and Recommendations for Evaluating, Designing, and Implementing Behavioral Health Services. Washington, D.C: National Business Group on Health.
(2.) National Heart Blood and Lung Institute. 2004. Working Group Assessment and Treatment of Depression in Patients with Cardiovascular Disease. Washington, D.C.: National Institutes of Health.
(3.) Tousman, Stuart. 2003. Asthma and Depression. Washington, D.C.: American Academy of Allergy and Asthma Immunology.
(4.) Aetna Inc. 2005. Aetna Depression Management: Strengthening the Early Identification and Treatment of Depression. Accessed at www.aetna.com.
(5.) Freudenheim, Milt. 2005. Aetna to Pay for Programs to Manage Depression. The New York Times, November 2.
by Pamela Caggianelli, RN, CDMS, and Marcia Carruthers, M.B.A., CPDM
Pamela Caggianelli is chair of the Certification of Disability Management Specialists Commission (www.cdms.org) and manager of corporate health for Bausch & Lomb in Rochester, N.Y.
Marcia Carruthers is chief executive officer of the Disability Management Employer Coalition (www.dmec.org).