As wellness and chronic disease initiatives mature, employers are shifting their programs' focus from rewarding basic participation to encouraging outcomes-based goals. To move the needle on improving employees' health, savvy benefits and HR professionals are implementing member advocacy programs and other techniques to engage individuals and tailor the program to their specific needs.

The wellness program that serves Manatee County, Fla., employees, for example, features an entire staff of experts in physical and behavioral health to respond holistically to the individual's needs.

"In-house, we have a very integrated team of people," says Kim Stroud, benefits manager for Manatee County. "We've got nurses, a clinical pharmacist, a registered dietitian who is a certified diabetic educator, [as well as] behavioral health staff, fitness and wellness specialists. This crew of specialists works together to create integrated programming. Our philosophy is we want to deal with the whole person."

By providing integrated care and having all experts and resources under one roof, "we've eliminated that silo effect," says Stroud. "Our wellness program is much more than a wellness program, probably. It really has incorporated a lot of those pieces that a carrier or third-party administrator would do for employees and their covered dependents."

The wellness coordinators conduct regular outreach to a caseload of members. For example, employees and spouses who seek out a fitness trainer receive advice and follow-ups regarding their exercise regime. With members' permission, the diabetic educator has access to lab results and diabetes monitoring results, so they can monitor spikes in blood pressure during the night and reach out to the employee and their doctor to fix the problem.

Stroud believes the county's success comes from the plan's design: "For employees to get a low out-of-pocket cost plan for themselves, they need to engage in preventive care and evidence-based recommendations for preventive care," she says.

The program is customizable to each employee after a one-on-one interaction with a health expert. For example, the diabetic manager can easily introduce a member also suffering from depression to a mental health professional. The staff uses case management and serves in a triage role to hook up members with the services they need.

Biometric screenings also are an effective way to spark employees' interest in their personal health.

"We typically like to use either a health assessment or a biometric screening as a trigger point for those downstream programs," explains Karl Ulfers, vice president of consumer solutions at OptumHealth Care Solutions.

Erin Gerred, wellness chairperson, Fond du Lac County, Wis., agrees: "If you don't know where you are personally, you don't know what issues you need to focus on, what programs you need to participate in, and what you need to improve on."

Fond du Lac also recently introduced a member advocacy component, where health coaches call employees who have a score of 20 or higher on their HRA. The coach walks employees through their score, helps them set up an appointment with their physician and can forward their results to their doctor or the nurse practitioner at the company's onsite clinic.

After employees set a goal, the coach explains how they can achieve it in relatable, everyday terms, as well as suggests available tools and resources that could help them improve their score.

Coaches also "help them develop an action plan based upon specific results of their HRA, such as a reduction in cholesterol," says Gerred. Coaches follow-up every three months to offer support and encourage accountability.

The lab-based medical histories help coaches tailor the program to each individual - assisting in setting health goals for next year and maintaining high engagement. Interactive Health Solutions, a wellness and health coaching firm, claims onsite testing, coupled with interactive coaching, sustains employees' engagement level at over 60%.

According to IHS, 63% of people that participate in its health evaluation haven't seen a physician in five years. Once the health data is front and center, they find 58% of participants have an undiagnosed or untreated chronic issue - meaning they may not have significant health claims yet, but are trending in that direction. Further, IHS catches 3% of employees with a serious or critical problem during the first onsite evaluation.

Timing outreach to spur and maintain employee engagement with health is critical. Ulfers insists employers take a thoughtful approach to make the program fun throughout the year. He adds that a high-profile program promoted through a comprehensive marketing and education campaign makes employees aware of the services available so they can call into the program. According to an Optum survey, 55% of employees didn't feel wellness programs were appropriate or relevant to them.

"If you just have a model in place where you're calling people and semi-harassing them with phone calls, that's not a model that's attractive to the consumer value proposition," warns Ulfers. He advises employers to avoid "coming across as telemarketing to employees."

IHS leaders don't perceive the firm's phone-based member advocacy program as harassing because the coaches are trained in motivational interviewing. Further, if a coach calls a member three times without reaching him or her, the coach sends an email the fourth time and will follow up six months later.

"We start working with the individual on their time frame," says Joseph O'Brien, president and CEO of IHS. Plus, he adds, "we create reasons that are non-obtrusive to [check in with] the employee, [in order to be] collaborative and make them feel comfortable."

Gerred agrees, having received very positive feedback from the county employees in their first year using the IHS service. "Sometimes all you need is a phone call," she says. "If someone cares enough to call and follow up [with you], I think that's where you start seeing behavioral change and more engagement."


Carrots first, then sticks

Experts recommend employers begin rewarding employees who complete a health assessment or biometric screening, or who visit the wellness website to grow the initial engagement. Then, they can add outreach throughout the year with onsite health fairs and specific pushes around challenges. Employers should keep activities new and locally relevant to workers, such as announcing a community 5-km race.

A common mistake among employers is "to just tie the incentives to the initial launch of their benefits, and not have a calendar-based approach for their incentives," explains Ulfers.

For example, Manatee County's weight program featured a weigh-in at the end of 2011, where employees set goals to maintain healthy weights or lose 5% of their weight before the weigh-out in July 2012 to receive a maximum reward of $400.

"It's a progressive program. When they weighed out in July that became their new baseline and the same criteria applies to the next year, except the incentive goes up [to] $500," Stroud says. So far, more than 2,000 county employees have participated in the program, which is over half the adult population eligible. In all, 70% of participants earned the incentive and they have lost a combined 10,000 pounds.

"Our philosophy is that obesity is a crisis in our nation and 75% of [Americans] are overweight or obese, so we didn't want to single out people," Stroud says. "We don't expect everybody to get to a body mass index of 25 or below; we want people to engage in slow, progressive weight loss."

Stroud believes the wellness success of Manatee County stems from their progressive approach.

"I feel strongly that the success we've seen with our health plan is because we spent several years simply educating and using a pure carrot approach with no sticks," she explains. "When we started introducing more accountability and more sticks, it was more accepted," especially since the county provides employees with the tools they need.

Stroud concurs with this approach: "Spend the time rewarding for participation and rewarding for good choices [already made], before you start to lay the hammer down because I think it's better received."



VIP treatment

Today's average primary care practice has 2,400 patients, condensing the average doctor visit to an average of eight minutes or less. MDVIP, a wellness plan founded by two primary care doctors frustrated by the new realities of doctor-patient care, caps practices in their network at 600 patients. These doctors seek the root causes of ailments to address them proactively and help the individual develop a personalized wellness plan.

Patients spend over an hour annually with their doctor in a physical exam that is a comprehensive assessment of the individual's medical history, family history, and diagnostic tests. With a smaller patient pool, individuals can schedule same-day care to see the doctor when they need to, as well as reach their physician any time by calling their cell phone.

"The program is all about designing a personalized health and wellness plan based on your unique needs," explains Mark Murrison, president, MDVIP. "Regardless of where you fall on that health continuum, your plan is personalized to your specific needs, whether it's programs you need to be a part of, medications you need to be compliant with, nutrition or diet counseling. Our doctors provide a much broader level of care than what you get from a traditional primary care doctor today."

The plan has 185,000 members and is approaching 600 physicians in 40 states and Washington, D.C.

Not only do doctors provide ongoing support for employees keeping up with a personalized diet and exercise plan, for example, they go out of their way to customize support to fit the patient's everyday life.

Many doctors will organize weekly walking, hiking, or biking trips with patients. One doctor in Texas hosts weekly Tai Chi exercise classes with patients.

In addition, numerous physicians take patients to their local grocery store to demonstrate how they can shop for the right foods and make better nutrition decisions. One suggestion is to shop on the outskirts of store where the fresher foods are, and avoid the aisles when possible.

"They really give basic fundamental tips that people can simply and easily employ in their everyday lives," Murrison adds.

MDVIP members who are commercially insured (that is, employees) are hospitalized up to 72% less than non-MDVIP members "because you are able to get the care that you need when you need it from the doctor," believes Murrison. If someone does go to the hospital, MDVIP patients have a 2% or lower re-admission rate, significantly below the normal rate of 15% to 20%. Often doctors will visit patients in the hospital and follow up afterwards to educate individuals about how to avoid returning there.

Further, satisfaction scores among patients are in the 90th percentile and 92% decide to renew participation in the program each year on average.

Employers can offer the plan in three ways: As an executive wellness plan, an employee wellness plan either fully or partially subsidized or available on a pretax basis through a flexible spending account or health savings account, or as a plan that focuses on employees with chronic conditions.

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