Center for Integrated Behavioral Health Policy

Department of Health Policy, George Washington University Medical Center

Eric Goplerud, Ph.D., Tracy McPherson, Ph.DNIATx Webinar

November 18, 2010

Alcohol Screening, Brief Intervention, and Referral to Treatment (SBIRT) in the

Workplace:

Connecting with the “BIG” EAP Industry Initiative

Seed Funding: NHTSA CSAT SAMHSA NETS Alkermes

Corporate SponsorsPilot Sites:

Aetna OptumHealth ValueOptions

Trainer: Denise Ernst PhD

Workplace Alcohol SBI Project: The BIG (Brief Intervention Group)

Initiative

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Historical Context of EAPs in US Began in 1950’-60’s with a primary focus on Alcohol and Substance

Abuse/Addiction among workers. Originally programs were internal to organizations, known as Occupational

Alcohol Programs and staffed by recovering substance users. Interventions focused on medical withdrawal, 28 day inpatient treatment and

mutual support group involvement (Alcoholics Anonymous). In the early 90’s EAP service delivery moved from internal programs to

external managed care driven programs using large networks of general mental health providers resulting in reduced focus on substance use intervention and identification.

The qualifications and professional training of general mental health provider professionals had with regard to alcohol use focused primarily on addiction and not inappropriate use interventions.

Increased adoption of EAPs

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http://www.shrm.org/Research/SurveyFindings/Documents/08-0335_BenefitsSR_FINAL_.pdf

Percentage of workers with access to EAPs is growing

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Stoltzfus E (2009) Access to Wellness and Employee Assistance Programs in the United States. Bureau of Labor Statistics, 2009. http://www.bls.gov/opub/cwc/cm20090416ar01p1.htm

Overall Aim: Adapt alcohol SBIRT approaches developed in medical settings for work-related settings:

EAP Occupational health & safety Health promotion and wellness Disease management

NHTSA/CSAT Workplace SBI Project (2006-2010)

Conduct extensive literature review, surveys and interviews

Convened Workplace SBIRT Product Development Work Group.

Developed a model of workplace SBI.

cont…

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80% binge and heavy drinkers are employed.1 9% heavy drinkers work full-time.1

Young adult workers (age 18-25) have highest rates of SU disorders2

9.2% worked with a hangover in the past year.3 Heavy drinkers are more likely to have worked for 3+ employers in the past year.4 Heavy drinkers are more likely to have skipped work 2+ days in the past month.4 Workers reporting alcohol dependence/abuse more likely to have missed 2+ days of work due to illness or injury .4 9 in 10 heavy drinkers work for small and medium sized firms.5

1Substance Abuse and Mental Health Services Administration, Office of Applied Studies (2008). Results from the 2007 National Survey on Drug Use and Health: National Findings (NSDUH Series H-34, DHHS Publication No. SMA 08-4343). Rockville, MD. 2Substance Abuse and Mental Health Services Administration. (2006). “Substance Use Disorder and Serious Psychological Distress, by Employment Status” The NSDUH Report Issue 38. 3Frone, M. R. (2006). Prevalence and distribution of alcohol use and impairment in the workplace: A U.S. national survey. Journal of Studies on Alcohol, 76, 147-156. 4 Larson, S.L., Eyerman, J., Foster, M.S., and Gfroerer, J.C. (2007). Worker Substance Use and Workplace Policies and Programs (DHHS Publication No. SMA 07-4273, Analytic Series A-29). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies. 5Larson, S.L., Eyerman, J., Foster, M.S., and Gfroerer, J.C. (2007). Worker Substance Use and Workplace Policies and Programs (DHHS Publication No. SMA 07-4273, Analytic Series A-29). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies.

U.S. Workplaces at Risk

A Feasible Workplace SBIRT Approach

(telephonic or face-to-face)

Developed protocols that could be seamlessly integrated into existing EAP practice. Conducted “proof of concept” studies to pilot test approaches and protocols in EAPs. Launched “BIG Initiative” to facilitate EAP adoption of alcohol SBIRT through dissemination of materials and pilot test findings, and training.

cont…

EAP industry-wide campaign kicked-off in Dallas at EAPA to adopt alcohol SBIRT as routine practice of US and Canada EAPs by October 2011.System change campaign, similar to NIATx Action CampaignLearning collaborative facilitated by GW which brings together 100+ organizations in the workplace SBIRT “supply chain”.

What is “BIG”?

EAPs/MBHOsEmployersProfessional Associations CliniciansSBIRT/MI ExpertsResearchers and ConsultantsPharmaceutical CompaniesFederal Agencies

“BIG” Members

National Highway Traffic Safety AdministrationSubstance Abuse and Mental Health Services AdministrationNetwork of Employers for Traffic SafetyAetna Behavioral Health/EAPOptumHealth/UBHValueOptionsOffice of Drug and Alcohol Policy and Compliance, Department

of Labor Office of Demand Reduction, Office of National Drug Control

Policy, Executive Office of the PresidentU.S. Nuclear Regulatory CommissionDepartment of DefenseMaine State Government Federal Occupational Health (FOH)University of Maryland School of Social Work Chestnut Behavioral HealthFirst Sun EAPSELECT, IncCIGNAMagellanAnthem/WellPointMasi ConsultingBurke Consulting

Caterpillar Northrup Grumman Johns Hopkins University and Hospital JP Morgan ChaseHawaii Business Health CouncilNational Business Group on HealthUPSAmtrakContinental Airlines RAND CorporationBaltimore Gas & ElectricHalliburton 3MEAPAEASNACenter for Clinical Social WorkNAADACAssociation of Flight AttendantsAONSt John’s MercyFirst AdvantageThe Rainier GroupReckitt-Benckiser

Brief Intervention Group (“BIG”)

Four Committees Board of Directors – thought leaders,

industry decision-makers provide direction of BIG strategy

Clinical – change EAP provider and network affiliate practice

Systems and Operations – change call center and internal EAP practice

Quality Improvement – identify common metrics (program performance, client outcomes)

What does “BIG” do?

www.EAPBIG.orgShare experiences, materials, support, competition with others in industryGain attention of purchasers and internal organizational leadershipReverse trend towards commodity pricing of EAPs by demonstrating valueReceive free SBIRT Training, Resources, CEUs

How do participants benefit from “BIG”?

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Prescreening = AUDIT-C (items 1-3)1. How often do you have a drink containing alcohol?

Never Monthly or less 2-4 times a month 2-3 times a week 4 or more times a week

2. How many drinks containing alcohol do you have on a typical day when you are drinking? 1 or 2 3 or 4 5 or 6 7, 8 or 9 10 or more

3. How often do you have five or more drinks on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily

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Full Screening = AUDIT-C + 7 Remaining AUDIT Items4. How often during the last year have you found

that you were not able to stop drinking once you had started? Never Less than monthly Monthly Weekly Daily or almost daily

5. How often during the last year have you failed to do what was normally expected from you because of drinking? Never Less than monthly Monthly Weekly Daily or almost daily

6. How often during the last year have you needed a first drink to get yourself going after a heavy drinking session? Never Less than monthly Monthly Weekly Daily or almost daily

7. How often during the last year have you had a feeling of guilt or remorse after drinking? Never Less than monthly Monthly Weekly Daily or almost daily

8. How often during the last year have you been unable to remember what happened the night before because you had been drinking? Never Less than monthly Monthly Weekly Daily or almost daily

9. Have you or someone else been injured as a result of your drinking? No Yes, but not in the last year Yes, during the last year

10. Has a relative or friend or doctor or another health worker been concerned about your drinking or suggested you cut down? No Yes, but not in the last year Yes, during the last year

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Based on risk level

RISK Normative Feedback

ETOH Education

BI using Motivational Interviewing

Appropriate Referral(s)(counseling,

DM, community, other treatment)

Follow-up (Admin, Clinical)

Low(0-7)

(EAP Standard)

Moderate(8-19) or

High (20-40) (30/60 days)

Brief Intervention

Aetna / GWUAlcohol SBIRTPilot Research Findings

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Site Characteristics: Large U.S. Employer (Financial Services Industry) 147,000 employees 33% young adults(≤30 yrs), 53% adults(31-50),14% older adults(≥51) 70% female, 30% male 93% self- or management referrals Non-emergent, self-referral cases

Design: Pre-test Post-test One Group Pre-experimental

Training: Face-to-Face and Telephonic Coaching

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Pilot: Initial Results @ 5 months 295 employees offered SBIRT 93% (n=274) completed AUDIT-C (7% ineligible/refused) Prescreen Results (n=110 positive)

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Pilot: Initial Results @ 5 months 87% (n=96) prescreen positives completed full AUDIT Screening Results (n=50 positive screens)

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Pilot: Initial Results @ 5 months

IDENTIFICATION RATE (Aetna) 18.23% based upon standardized screening for

hazardous/harmful drinking or alcohol dependence 6% based upon presenting problem while using SBIRT protocol

IDENTIFICATION RATE (prior vendor data) < 1%

78% agreement to follow-up (members offered SBI at intake)

72% set an appointment for face to face counseling (members offered SBI at intake)

EAP Return On InvestmentUsing SBI and The Work Limitations QuestionnairePreliminary Findings

Work Limitations Questionnaire -SFDeveloped and well validated tool by Dr. Debra Lerner (Tufts University) to measure

productivity and presenteeism

Generates -A summary score of productivity loss due to presenteeism

Productivity Loss Score - estimated percent difference in an employee’s at-work productivity compared to employees who do not have health-related work limitations (a healthy benchmark group).

Degree of Impact of Health Problems (Physical & Emotional Health) on Work

Four scale scores (4 work limitation scales) Time Management Physical Mental-Interpersonal Output

Past 2 Weeks Self Report

rate the frequency of difficulty (or, on one scale, ability) performing specific job demands persons who are currently employed

Suitable for Repeating at Multiple Time Intervals

WLQ Levels of Data

Summary Score

% Productivity Lost Compared to Benchmark

Job Level

% Time with Impaired Job Performance

Task Level

% Time with Impaired Task Performance

Time Management

Physical Demands

Mental-Interpersonal Demands

Output Demands

25 Items

Average Audit Score: All Cases

10.62

5.01

0

2

4

6

8

10

12

Audit Score Average

IntakePost Intervention

Average AUDIT Score: Moderate and High Risk at Intake

16.81

9.44

02468

1012141618

Average Audit Score

IntakePost Intervention

40.7

19.423.8

11.9

40.4

18.6

32.5

15.3

9.54.7

.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

WLQ Scales

Job Performance Deficits Underlying Productivity Lost

Initial Score

Discharge Score

Most

Limited

Least Limited

WLQ Productivity Loss Due to Overall Presenteeism

8.89%

4.50%

0.00%1.00%2.00%3.00%4.00%5.00%6.00%7.00%8.00%9.00%

Presenteeism Score

Intake Post Intervention

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  Initial Productivity Loss

Discharge Productivity Loss

Productivity Cost Savings Impact

Population 343 343  

% Productivity Loss

8.89% 4.50% 4.38% gain in productivity

Average Productivity $/EE

$2,878 $1,458 $1,420

Total Productivity Cost

$987,207 $500,086 $487,120

WLQ EAP Participant Productivity Loss and Estimated Cost Impacts

0

100

200

300

400

500

600

9-Jun 9-Jul 9-Aug 9-Sep 9-Oct 9-Nov 9-Dec 10-Jan Feb (est)

ValueOptions EAP SBI Pilot

alcohol screens

alcohol positives

audit completed

Pre-SBITime

Period(n=681)

Post-SBI Time

Period(n=383)

p-value

EAP Alcohol Identification Hazardous alcohol use 7.5% (51) 20.1% (77) <0.0001 Alcohol abuse/dependence 7.1 (48) 10.4% (40) 0.0536 EAP Telephonic Alcohol Interventions Alcohol education & risk reduction

9.8% (67) 13.3% (51) 0.0465

Alcohol intervention options 9.5% (65) 10.7% (41) 0.5442

OptumUnited Alcohol SBI Pilot

Greenwood G, Goplerud E, McPherson T (2010) Delivering brief alcohol-related interventions with a telephonic EAP. Journal of Employee Assistance. 16-18.

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What comes next? The BIG Initiative Strategic Plan

Wider and deeper penetration of EAPs to deliver alcohol SBIRT

Broad, ubiquitous training of office-based clinicians in SBIRT. EAPA, EASNA, NAADAC, CCSW common SBIRT training

plan.

Outcomes evaluations, especially business relevant outcomes

Extension of BIG to additional conditions Broadening financial base for sustainability

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Workplace SBIRT Resources World Health Organization’s SBI Manuals:

AUDIT: http://whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6a.pdf Brief Intervention: http://whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6b.pdf

SAMHSA SBIRT Initiative: http://sbirt.samhsa.gov/

Motivational Interviewing: www.motivationalinterview.org/ TIP 35 Manual: www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.61302

Workplace SBIRT Toolkit: www.ensuringsolutions.org/solutions/solutions_show.htm?doc_id=450551

Alcohol Education/Self-Help: Rethinking Drinking: www.rethinkingdrinking.niaaa.nih AlcoholScreening.Org

Workplace SBI Publications: What Employers Can and Should Do About Excessive Alcohol Use:

www.ensuringsolutions.org/resources/resources_show.htm?doc_id=673239&cat_id=963 Literature Review www.ensuringsolutions.org/allies/allies_show.htm?doc_id=431629&cat_id=969 McPherson, T.L., Goplerud, E., et al. (2009). Workplace alcohol screening, brief intervention, and

referral to treatment (SBIRT): A survey of employer and vendor practices. Journal of Workplace Behavioral Health, 24(3).

EAPA Learning Center (Free session) New Tools for EAPs to Deliver Higher Levels of Value (2009 World Conference)

http://www.softconference.com/eapa/sessionDetail.asp?SID=184750

THANK YOU!