Overview
The Network of Employers for Traffic Safety (NETS), through a Cooperative Agreement with the National Highway Traffic Safety Administration (NHTSA), contracted with Ensuring Solutions to Alcohol Problems at The George Washington University Medical Center from January 1 - December 31, 2007 as part of the Alcohol Screening and Brief Intervention (SBI) in the Workplace Project.  This period of performance constitutes the second year of a two year effort. This Executive Summary summarizes the activities and findings from Year Two of the project. Year Two activities are a continuation of those conducted in Year One. An Executive Summary of the Year One final report can be found on the Ensuring Solutions to Alcohol Problems website at http://www.ensuringsolutions.org/usr_doc/NETS_Year_One_Summary.pdf.

The purpose and highlights of Year Two are described below:

• Conduct employer-based SBI process development workgroups with employers, vendors, and experts to create feasible and testable approaches to worksite alcohol SBI.
  

• Develop a Workplace SBI guide containing information, materials, and resources employers and vendors can use to implement and evaluate workplace SBI approaches.
  

• Recruit potential employers and vendors for Year Three pilot tests of SBI approaches.

Highlights of Year Two:

• Assembled a team composed of representations from the entire “supply chain” necessary to deliver workplace SBI:  “suppliers” (vendors) of SBI (e.g., employee assistance programs (EAPs), corporate medical directors, occupational health and wellness staff, bioassay testing vendors, health plans including behavioral health service providers); “purchasers” of SBI (i.e., employers); representatives from federal agencies, business coalitions, and professional organizations; and SBI researchers, experts, and clinicians.  This team comprised the “Workplace SBI Product Development Work Group”.

• Convened quarterly meetings of the Workplace SBI Product Development Work Group to determine how SBI processes developed for use in medical settings needed to be adapted to be feasible, practical, and testable in workplace settings.

• Worked with Product Development Work Group to identify and collect numerous sample materials and resources that could be used in (or adapted for) a workplace SBI program.

• Developed the “Workplace SBI Toolkit” which houses SBI sample materials and resources http://www.ensuringsolutions.org/solutions/solutions_show.htm?doc_id=450551&cat_id=963. This site served as a vehicle for communicating key information and findings and sharing sample materials with members of the Product Development Work Group.

• Analyzed and summarized qualitative and quantitative data collected as part of conducting modified-Delphi assessments and Work Group meetings. The findings were used to further refine the components of a workplace SBI program.

• Developed a draft prototype guide called the “SBI Guide and Resource Manual for Workplace Practitioners” containing information, materials, and resources employers and vendors can use to implement and evaluate workplace SBI approaches.

• Enlisted interest from a number of employers and vendors as well as obtained letters of support to participate in pilot test studies in Year Three.

• Presented Year One findings at the 135th Annual Meeting of the American Public Health Association (APHA) in Washington, DC in November 2007. 

• Developed Year Three proposal to pilot test employer-based SBI approaches.

• Prepared Year Two Final Report to NETS and NHTSA summarizing activities and findings, including final recommendations on feasible and testable SBI approaches to be piloted in Year Three and prototype implementation, training and evaluation materials and resources.

Brief Summary of Major Activities and Findings
A description of the two primary project activities and findings is presented below.

Conducted an employer-based SBI process development workgroup with employers, vendors, and experts to create feasible and testable approaches to worksite alcohol SBI.

The Workplace SBI Product Development Work Group consisted of vendors (potential suppliers) of SBI (e.g., EAPs, corporate medical directors, occupational health, worklife and wellness staff, bioassay testing vendors, health plans including behavioral health service providers); purchasers of SBI (i.e., employers); representatives from federal agencies, business coalitions, and professional organizations; and SBI researchers, experts, and clinicians.

The project team and Work Group worked together to develop and refine prototype SBI approaches and identify and adapt implementation materials for work-related settings. Multiple methods (in-person meetings, conference call discussions, quantitative assessments) were used to elicit input from the Work Group on the specific components of an SBI program, potential challenges and barriers to adopting them, and necessary adaptations for them to be feasible for the workplace.
 
The process by which the development and refinement of the SBI approaches occurred was primarily through the use of Delphi assessments.  The assessments took the form of rating scales that generated quantitative data on Work Group members’ judgments of the importance, relevance, and feasibility of specific components of an SBI program. Mean ratings were calculated for all items. A modified-Delphi method is defined as a systematic interactive method for obtaining forecasts (opinions, judgments) from a carefully selected independent panel of experts (i.e., members of the Work Group). The iterative process is stopped after some predetermined criterion (e.g., group consensus was reached, the range of responses stabilized, or a specific number of rounds were completed). The process is used to reduce the range of responses from members of the group and encourage the group to converge on the “correct” responses.

The summary of the Delphi results was presented to the Work Group during the follow-up conference call to generate discussion about the findings and assess the extent to which consensus was reached. The discussions yielded qualitative data that was summarized and disseminated to the Work Group.

A summary of the findings from the kick-off meeting and Delphi/conference call process are discussed below.

Findings from Kick-off Meeting:

Work Group participants  engaged in a discussion about each component.  Discussing a range of issues and concerns around feasibility, adaptability, and practicability of implementing SBI components and monitoring and evaluating the program processes and outcomes.

Work Group participants agreed that more work needs to be done to determine how to incorporate components of SBI in workplace settings and what work-related programs are the best vehicles for delivering SBI. The Work Group identified five potential vehicles. There was consensus that, at least initially, the focus for this project should be on the first three.

• Employee Assistance

• Occupational Health

• Health Promotion and Wellness

• Disease Management

• Life Coaching

From the discussion emerged a number of common themes, key concerns and interests around SBI, including:

• Incorporating SBI methodologies for increasing identification and early intervention at all levels of risk, in particular alcohol misuse and not just abuse/dependence.
  

• Incorporating education and outreach into existing programming.
  

• Increasing identification in various settings that workers encounter that present opportunity for SBI (e.g., EAP, community centers, medical clinics, primary care providers, trauma centers).
  

• Developing an EAP approach to SBI that (particularly, from an employer perspective) demonstrates improvements in performance outcomes at the network and individual practitioner level.
  

• Developing an EAP approach that integrates routine, systematic SBI and follow-up practices.
  

• Incorporating SBI into an integrated model of disease management.
  

• Conducting alcohol and drug testing at all levels within a company, not just segments of the workforce (e.g., random testing only for workers who operate motor vehicles) and providing treatment (e.g., BI and intensive) for workers that screen positive.
  

• Integrating an SBI approach that conforms to drug testing and other regulatory policies that are written by various groups (government level, workplace specific, union, etc.).
  

• Integrating an SBI program that compliments union DFWP training and wellness programs for union workers; increasing early identification and in turn increasing safety but without punitive consequences.
  

• Getting union representatives’ perspective on DFWP programs that include an SBI component before rolling it out to union worksites.
  

• Getting managers/leadership at all levels need to be involved.
  

• Getting the word to employers that alcohol misuse is an issue of safety and productivity.
  

• Inclusion of substance use-related incidents in accident, injury and other safety reports presented to management.
  

• Implementing SBI on a large scale/national level.
  

• Identifying opportunities to leverage contact with employees to ensure SBI occurs as soon as possible.
  

• Integrating SBI into current EAP outreach and services and marketing SBI and wellness services to employers and supervisors.
  

• Implementing a proactive SBI approach in cooperation with medical and wellness department staff.
  

• Incorporating SBI into a broader health promotion/wellness and behavioral health context.
  

• Integrating screening in health risk assessments or appraisals (HRAs)
  

• Identifying the best approach for integrating SBI in post military deployment screening (medical and psychological/emotional).
  

• Identifying mixed messages in the workplace- what promotes alcohol misuse in the work environment (e.g., business events).
  

• Motivating employees to do something about their drinking.
  

• Encouraging more self-referral without fear of punitive action (e.g., job loss in accident/injury cases).
  

• Identifying ways in which employee peer support groups for different segments of the workforce (e.g., physicians, nurses, management/leadership, and union workers) can be effective in a worksite with an SBI program.
  

• Developing web-based training and health education programs (e.g., for impaired driving).
  

• Need for professional training and continuing education opportunities, specifically in SBI.

Findings from the Modified Delphi-Conference Call Process:

Alcohol Screening and Promotion/Outreach Delphi.  Work Group participants rated 15 items related to the alcohol screening and promotion/outreach (e.g., service promotion, educational outreach) components of a workplace SBI program. Items were rated on a scale from 1 to 5 (1=Nice to have, 3=Important, 5=Essential) on how essential it would be in developing an effective Workplace SBI Model. They were also asked to rank the five most important from “1” being the most important to “5” being the least important. Results showed 14 of 15 items were rated as “important” to “essential”. Based on inspection of mean ratings, the item rated as least essential was “alcohol and drug testing for all employees”. The six items rated as most essential were:

• Health education about alcohol misuse and related issues (e.g., stress, impaired driving) *
  

• Inclusion of alcohol as part of addressing issues such as depression, anxiety, or stress*
  

• EAP/MBHO service promotion/marketing to supervisors*
  

• EAP/MBHO service promotion/marketing to employees*
  

• Assessment of suspected alcohol use with signs & symptoms recognition approach
  -Alcohol/drug testing of specific employee groups (e.g., DOT regulated, safety sensitive)

Moreover, there was consensus on which were among the five most important. These included the first four most essential items listed above(*) and “routine alcohol screening by EAP/MBHO provider”. There was less consensus on the order of importance. There was also some consensus on which items were not among the five most important, i.e.,:

• Alcohol/drug testing for all employees

• Indirect alcohol screening as part of life coaching

Key Messages:

• Alcohol education, outreach, and screening should be part of addressing other mental health, medical, and life issues of the employee and their family.
  

• Alcohol education should convey the relationship between alcohol use and other health issues.
  

• Alcohol misuse can affect health.
  

• Dealing with health and life issues may result in alcohol misuse.
  

• Supervisors play a key role in identifying workers through signs and symptoms recognition.
  

• Service promotion/marketing to both employees and supervisors is important.

Brief Intervention, Referral, and Follow-up Delphi.   Work Group participants rated 27 items related to the brief intervention, referral, and follow-up components of a workplace SBI program. The 20 brief intervention items fell into seven groups – who should receive an alcohol BI, availability of BI, provider of BI, BI approaches/techniques, BI tools, BI measures, and BI sessions. Three referral items focused on the need for and timeliness of linkages between employees and treatment resources. The four follow-up items focused on timeliness and who should provide follow-up.  These items were rated on a scale from 1 to 5 as described previously.

The results of the Delphi assessment discussion yielded several messages:

• BI should be received by employees who test positive for alcohol or drugs, or otherwise identified by on-the-job incident (e.g., supervisory referral) or sought treatment for a mental health and substance use problem.
  

• BI should be available off the worksite at a medical or behavioral health/EAP counselor’s office.
  

• EAP counselors should be available to provide BI.
  

• Motivational interviewing/cognitive behavioral BI techniques should be aimed specifically at changing alcohol use behavior, or alcohol use in context of other mental health problems.
  

• A standardized screening tool should be used to guide the counselor in determining level and focus of BI. 
  

• A single BI session should be offered following screening to motivate workers to reduce drinking, set achievable goals and connect with a counselor.
  

• A referral resource network and the ability to link employee with treatment resource within 24 hours are necessary.
  

• Clinical and business outcomes (e.g., reduced risky drinking, clean alcohol/drug tests, productivity, and absenteeism) must be used to measure the impact of using BI.

One additional item asked participants to rank from 1 (most important) to 10 (least important) the importance of using BI to address 10 mental/behavioral health (e.g., alcohol use, depression) and physical health conditions (e.g., diabetes management). The results of the ranking were as follows: 

• Alcohol

• Depression

• Drug Use

• Stress

• Tobacco Use

• Marital/Family Issues

• Anxiety

• Weight Management/Obesity (diet and exercise)

• Diabetes and Cardiovascular Disease Management (tied for least important)

SBI Training Delphi.   Work Group participants rated 16 items related to the SBI training component of a workplace SBI program. The items fell into four groups – the focus of SBI training, where SBI training is offered, continuing education/competency certification, and monitoring quality of SBI training. These items were rated on a scale from 1 to 5 as described previously. 

The results of the Delphi assessment, yielded several messages:

• The focus of SBI training should be alcohol problems and also mental health problems (e.g., depression, stress) in addition to alcohol (note - alcohol problems often co-occur with other mental health problems).
  

• Various mechanisms should be used to provide training including webinars, conference calls, conference workshops, and off-site training.
  

• Continuing education credits for SBI need to be offered and practitioners should obtain competency certification in SBI. The Work Group felt CEUs and certification were essential, that SBI needs to be built into the CEAP and CADC specialty training programs, and certification/licensing exams need to include questions that demonstrate SBI competency. EAPA, EASNA, NASW, APA, and state government agencies (as part of licensing requirements) were suggested as organizations that the project team should work with in the future to develop continuing education and certification programs. Other key recommendations included working directly with medical directors to educate them about SBI and gain an understanding of the importance of SBI so that, in turn, medical directors will convey to the providers that it’s a priority. Use data (process, outcome) resulting from the implementation of SBI to get stakeholder ‘buy in’. This could be leadership in the “C-Suite”, clinical supervisors, or counselors. Use relevant data about outcomes that are meaningful to leadership (e.g., use productivity data to compare performance with competitors in same industry or geographic region) to present a more convincing case.  Vendors should leverage their influence with providers and gain “buy in”. Use a “push model” - communicate to network providers that SBI is a priority and they need to get training. Educate providers on reimbursement and coding issues (e.g., CPT and HCPCS codes) with private and public payers. Offer training to EAP/MBHO providers who offer employers telephonic only services.
  

• Both counselors and clients should use BI checklists for monitoring quality and fidelity. Work Group participants indicated BI checklists completed by counselors are feasible in the real-world (but needs to be brief). Use of standardized patients, evaluating audiotaped sessions and providing feedback, and telephonic coaching are easier to do as in-service trainings in call centers and much harder to do with network affiliates who conduct face-to-face. Clients could complete BI checklist too (e.g., take home checklist or web link).  This type of process requires competitors to come together and encourage (or require) provider panels to use quality monitoring techniques (e.g., BI checklists after a session). Quality of training can be monitored if collection of relevant data were built into software technologies that make it a standardized, routine process. This may be easier in telephonic call centers than in face-to-face settings.  Contracts should require SBI be measured - data collected, analyzed, and reported with a performance feedback loop to providers. Employers need to demand SBI in RFPs. Sample RFP and SPD language/statements about what needs to be done/measured around SBI would be useful to employers. The CDC Purchaser Guide may have sample language to draw from.

Performance Measurement and Evaluation Delphi.   Work Group participants rated 20 potential performance measurement targets for SBI that might be collected to examine the value of an SBI program. The targets fell into three broad groups - utilization (e.g., identification rates for hazardous use, behavioral health/EAP service utilization rates, supervisor referral rates), employee/workforce outcomes (e.g., human resource/administrative outcomes such as absenteeism, employee outcomes such as changes in alcohol consumption), and cost (e.g., unit of cost for delivering SBI). Performance measures vary in terms of their importance/relevance as well as differ in terms of the feasibility of implementation. Thus, participants were asked to rate each one twice on a scale from 1 to 5 (1=Not at all, 5=Very) on how “important” in terms of how these measures would be supportive in stimulating and directing quality improvement efforts and how “feasible” in terms of logistical practicability of implementing it in their organization.

The results of the Delphi assessment yielded a number of key finding and messages:

Utilization –

• The three most “important” measures related to utilization were hazardous alcohol use identification rates, supervisor referral rates, and alcohol treatment rates.  However, only supervisor referral rates were rated among the top three most “feasible”. The two most “feasible” were overall utilization rates of the SBI service and behavioral health/EAP services utilization. The least feasible was NCQA HEDIS Chemical Dependency Measures. The findings and the conference call discussion suggest there may be logistic/feasibility issues with collecting specific types of data that are deemed important for evaluating an SBI program. And, furthermore, there are significant challenges with clearly operationalizing the constructs being measured. The Work Group agreed that a list of key metrics and algorithms with more precise definitions would be important and useful to workplace practitioners.

Employee and Workforce Outcomes -  Two types of employee and workforce performance measures were rated - human resource/administrative outcomes and employee (individual level) outcomes.

• The three most “important” measures of human resources/administrative outcomes were self-reported absenteeism, HR record absenteeism, and safety (i.e., on the job injuries/accidents).  The three most “feasible” were self-reported absenteeism, safety (i.e., on the job injuries/accidents) and disability claims. The least “important” and “feasible” was grievances. The findings and conference call discussion suggest self-report absenteeism and safety are both “important” and “feasible” and there may be logistic issues with getting HR absenteeism data. Work Group participants indicated the need for this type of data must be anticipated in advance of implementing an SBI program. Data collection/warehouse infrastructure and processes may need to be modified during the program planning stage. Participants indicated  it may be easier and just as valid to collect self-report administrative data directly from the employee. Participants also noted this has been done in workplaces for years through surveys and health risk assessments.
  

• The two most “important” measures of employee outcomes were positive alcohol/drug tests and productivity. The least “important” was employee satisfaction with the service delivering SBI.  The two most “feasible” were positive alcohol/drug tests and employee satisfaction with the service delivering SBI. The least “feasible” was productivity.  These results and the conference call discussion suggest positive alcohol/drug tests are the most important and feasible measure. Moreover, productivity is very important, but there may be logistic issues such as the lack of an instrument to measure productivity and ability to collect the data. Work Group participants recommended the use of two scales. The Work Limitations Questionnaire (WLQ) developed by Debra Lerner is a measure of productivity as a function of “presenteeism”. Specifically, it measures the impact of chronic diseases and treatment for on-the-job work performance using four demand scales: time, physical, mental-interpersonal, and output. Ron Kessler’s Health and Performance Questionnaire (HPQ; http://www.hcp.med.harvard.edu/hpq) is a measure of the impact of health on four aspects of work functioning: time missed from work, performance while at work, injuries or illnesses at work, and job turnover. 
  

• Both of the cost measures they were asked to rate were highly “important” and “feasible”, i.e., the unit cost of delivering SBI and unit cost of the service delivering SBI.  This suggests  both are viable measures for evaluating cost of SBI program.

Assessing the Balance between Quality and Cost for SBI Services -

• Participants were asked to think about the components that go into an alcohol SBI program that would fit into work-related programs such as employee assistance, occupational health/wellness, and drug-free workplace programs. A description of each component they had shaped over the previous months was provided (screening, brief intervention and referral, promotion/outreach, training, and monitoring and evaluation). Participants were then asked about how their organization might think about the value of SBI services in terms of cost - what their organization would pay or need to receive as payment to implement these components. The amounts participants were most willing to pay (or be paid) for an SBI service ranging from “Free” to “More than $1.00 PEPY” (per eligible employee per year, presented in increments of $0.10) were $.40 to .50 PEPY and more than $1.00 PEPY. All other increments of .10 PEPY were endorsed equally. Respondents reported having difficulty responding to this question. The Work Group agreed we don’t have enough data from studies in the field to get a hold of what is the “value” of SBI, and we need more evidence of effectiveness in workplace settings and studies on costs/economic benefit.
  

• An alternative approach to assessing the value of SBI was also used. When the Work Group was asked to indicate which of the following elements of an SBI service they would expect to see delivered (holding the dollar amount constant) for an additional cost (or payment) of $0.70 PEPY (e.g., for a company or health plan covering 1,000 employees, this rate would be $700), almost all expected the following:

• Routine alcohol screening questions asked

• Referral to alcohol treatment as needed

• Brief intervention for those who screen positive

• Standard SBI service utilization reports

• Active outreach to workforce about hazardous alcohol use

• Quality Monitoring

Some expected these services but others saw these as externalities:

• SBI outcome and cost reports

• Training programs for SBI service providers (e.g., EAP counselors, occupational health nurses)

Assessing Persuasive Statements for Getting Employers and Vendors to Implement SBI -

Work Group participants were asked to rate on a scale from 1 to 5 (1=Not at all Persuasive to 5=Completely Persuasive) each of seven statements two times on how “persuasive” they would be at getting a) employers and b) their work-related vendors (EAP, occupational health, wellness, disease management, drug-free workplace) to implement SBI programs. The three most persuasive statements for both employers and vendors were:

• “SBI is state-of-the-art for early and effective intervention for workplace alcohol problems. SBI is part of the services employers generally, and in my industry (or geographic area) in particular, expect.”
  

• “SBI is an investment in employee health and productivity that produces a ROI at least as great as disease management program for diabetes, asthma, or depression.”
  

• “SBI is an investment in a healthier workforce. SBI is a health and wellness benefit employers should offer just as they offer weight management, smoking cessation, or other prevention programs.”

Also rated high for vendors:

• “The science supporting SBI is convincing. SBI is a proven approach to reducing the human and business costs associated with problem drinking. AMA, medical professional guidelines, and the federal government’s science panels recommend routine SBI.”

The least persuasive for employers:

• “SBI is already being done on an informal basis by EAPs and other work-related health programs. A formal SBI program will simply standardize the approach and make it more effective.”

The least persuasive for vendors:

• “SBI will solve problems before they get out of control and cost the company a lot of money in lost time, healthcare costs, and injuries.”

Developed Workplace SBI guide containing information, materials, and resources that employers and vendors can use to implement and evaluate workplace SBI approaches.

Over the course of Year One and Year Two of the project, an ongoing review of the SBI literature was conducted and SBI experts were consulted about the nature and quality of materials and resources available in the field and Work Group members contributed sample materials and resources related to each component of the model.  The culmination of this work over the two years of the project is a draft prototype guide called the “SBI Guide and Resource Manual for Workplace Practitioners” (available upon request) and an online compendium of SBI materials and resources called the “Workplace SBI Toolkit” http://www.ensuringsolutions.org/solutions/solutions_show.htm?doc_id=450551&cat_id=963.