Work site partnerships improve health
Patient satisfaction with managed care soars
American consumers generally are frustrated and dissatisfied with managed care, but one Utah health plan found that those feelings vanish when managed care plans partner with employers and bring health care to the workplace. In fact, the program has been so successful that the employer now pays the salary of the nurse case manager who runs the on-site clinic.
"If you’re a managed care company, primary customers are employers. It makes sense to partner with your local employers to improve the health of their employees and your members," says Jill Hoggard-Green, RN, PhD, assistant vice president of clinical support systems for Intermountain Health Care (IHC) in Salt Lake City.
Becton Dickinson, a manufacturing company in Salt Lake City, came to IHC in the mid-1990s seeking ways to keep their employees healthy. "The company was very proactive," Hoggard-Green says. "Becton Dickinson realized that we have very low unemployment in our area, about 3%, and very low turnover. The company looked at its aging work force and realized that it had better keep that work force healthy to avoid heavy costs down the road."
IHC agreed to partner with the manufacturing company by bringing health services to the work site. "We really believed we could best improve the health of the employees by understanding how and where they worked and by making access to care as convenient as possible," she says. "However, we insisted that Becton Dickinson agree to our rules."
Those rules were:
• The program had to be voluntary.
• The data gathered had to be confidential.
• The health plan had to ask for and receive permission before sharing aggregate data.
• The employer had to agree that IHC would not share information about individual employees without specific consent.
Becton Dickinson agreed to all those conditions and provided clinical space at the manufacturing plant for IHC. "We’ve had an employee assistance program [EAP] on-site since 1993. We also have a physical therapy clinic on-site. It’s a plant with a lot of hand injuries, so we have a therapist that specializes in hands. In 1996, we added a nurse case manager to the services we offered and also started distributing self-care books to employees," adds Hoggard-Green.
The nurse case manager’s first responsibility was to conduct an annual health needs appraisal for employees. "The needs appraisal is a very short, 32-question tool with a regression formula which scores it. It’s one way for us to . . . see that an employee is sick and go to work improving their health before they are hospitalized," she says. "It also has a health risk component that looks at health behaviors, such as smoking, so that we can design health promotion programs appropriate for the population."
Word of mouth
The first year, 350 of Becton Dickinson’s 1,000 employees participated in the voluntary program. This year, 950 employees participated.
"I think a couple of things have driven that participation rate upward," notes Hoggard-Green. "First, during the first year the nurse case manager worked with a couple of employees who were in danger of losing their jobs because of health issues. They were diabetics who had trouble managing their care because they worked the night shift and couldn’t regulate their insulin levels."
The nurse case manager, with the employees’ permission, talked to the supervisor and had the employees moved to the day shift and their hours scheduled around their insulin schedules. Those employees started talking to their friends, and the staff began to see the benefit of working with the nurse case manager. After all, says Hoggard-Green, the service was free and confidential, and the benefit was visible.
Becton Dickinson also allowed staff paid time off from their jobs to attend health education and health promotion classes taught by the nurse case manager. "They get paid while they attend diabetes management classes. The employer is truly putting its money where its mouth is," she says.
The nurse case manager works with any employee who walks in the clinic. The primary services the nurse case manager provides are health assessment, education, coaching to encourage self-management skills, and coordination of care.
"The work site case manager can put a care plan together, and they are fiduciarily responsible for our health plan members," she notes. "The care plan the nurse case manager puts into the health plan computer becomes the authorized care plan. No one else can alter it. However, the nurse case manager is clinically and fiscally responsible for the care delivered to the employee. They follow the patients when they become patients in the hospital and wherever else they go in the health care delivery system."
In addition, the nurse case managers also do workers’ compensation case management for the employees at their sites. "Employees who file a workers’ comp claim are assessed by the EAP social worker and the nurse case manager. By working in tandem, a return-to-work plan is developed that addresses both medical and psychosocial issues. I’m a firm believer in blending those lines between mental health and medical care management," she notes.
Since the nurse case manager went on-site at Becton Dickinson in 1996, health appraisal scores have made a consistently upward turn. More important, a qualitative research study conducted by a nursing graduate student found that of 85 employees interviewed, not one would recommend discontinuing the program. "She interviewed 40 employees who had participated in the program and 40 who had not," Hoggard-Green says. "Overwhelmingly, they said the program had value. They also said that their health improved."
Cost-neutral’ program
At a time when most American consumers are complaining that managed care is denying them access to care, the Becton Dickinson employees said the nurse case manager program created better access to services. "Think of this on a national scale. Nationally, we have most Americans saying that managed care keeps us away from our doctors and provides us with less care. Here employees are saying just the opposite: that we’ve improved access to care and provided valuable education."
IHC found that the nurse case manager program decreased total medical costs at Becton Dickinson by about $300,000, says Hoggard-Green. After adjusting for the total costs of running the program, including the nurse case manager salary, researcher’s time, and other resources, she says the program broke even. "What I have is a program that is cost-neutral. How many of you can say that your case management services are cost-neutral? We have fundamentally improved health at no cost."
The success of the Becton Dickinson program caused the employer to volunteer to pay the nurse case manager’s salary just to make sure the program continues. In addition, other area employers have asked IHC to start similar programs at their work sites and have agreed to pay the nurse case manager’s salary in order to bring the service to their employees. "Employers are winning here," Hoggard-Green says. "The program says, My employer cares about me.’ When you have 3% unemployment, keeping your employees happy is very important."
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