An Examination of An Examination of Clinical Outcomes Clinical Outcomes

from EAP and from EAP and Work/Life Product Work/Life Product

IntegrationIntegrationMelissa Back Tamburo, PhD, Melissa Back Tamburo, PhD,

LCSW-CLCSW-C

Chesapeake Chapter, EAPAChesapeake Chapter, EAPA

September 1, 2011September 1, 2011

EAP BackgroundEAP Background““Worksite based programs Worksite based programs

designed to assist: a) designed to assist: a) work organizations in work organizations in addressing productivity addressing productivity issues, and b) employee issues, and b) employee clients in identifying and clients in identifying and resolving personal resolving personal concerns including, but concerns including, but not limited to, health, not limited to, health, marital, family, financial, marital, family, financial, alcohol, drug, legal, alcohol, drug, legal, emotional, stress or other emotional, stress or other personal issues that may personal issues that may affect job performance” affect job performance” (EAPA, 2011)(EAPA, 2011)

Work/Life BackgroundWork/Life Background

W/L programs are “actions W/L programs are “actions taken by employers and taken by employers and employees to help the employees to help the workforce effectively handle workforce effectively handle the growing pressure and the growing pressure and responsibilities of both work responsibilities of both work and personal lives, to live and personal lives, to live and work up to their full and work up to their full potential, and to achieve potential, and to achieve both life balance and both life balance and increased productivity” increased productivity” (Boston College Center on (Boston College Center on Work and Family, 1999)Work and Family, 1999)

Integration BackgroundIntegration Background

Customers of EAP and W/L services Customers of EAP and W/L services are driving program integrationare driving program integration

Cost advantages to integrationCost advantages to integration (Peck, 2001; (Peck, 2001; Roberts, 2000; Stein, 2002; Swihart & Thompson, Roberts, 2000; Stein, 2002; Swihart & Thompson, 2002; Turner & Davis, 2000; Willaman, 2001)2002; Turner & Davis, 2000; Willaman, 2001)

““One Stop Shopping” for employees reduces One Stop Shopping” for employees reduces confusion about where to go for helpconfusion about where to go for help (Stein, (Stein, 2002; Turner & Davis, 2000; Willaman, 2001)2002; Turner & Davis, 2000; Willaman, 2001)

Professional associations (EAPA, Professional associations (EAPA, EASNA & AWLP) have studied EASNA & AWLP) have studied integration in three part study integration in three part study (Herlihy, (Herlihy, Attridge & McCormick, 2003; Herlihy, Attridge & Turner, Attridge & McCormick, 2003; Herlihy, Attridge & Turner, 2002)2002)

Purpose of StudyPurpose of Study

To introduce clinical outcomes in the To introduce clinical outcomes in the discussion of impact of integration of discussion of impact of integration of EAP and Work/Life (W/L) servicesEAP and Work/Life (W/L) services

To examine whether there are To examine whether there are differences between program models differences between program models in treatment effectivenessin treatment effectiveness

Political Economy TheoryPolitical Economy Theory

Examination of Examination of interrelation between interrelation between organization and an organization and an economy system economy system (Wamsley & Zald, 1973)(Wamsley & Zald, 1973)

Model to examine Model to examine various pressures various pressures (market fluctuations, (market fluctuations, labor shortages, labor shortages, competition) competition) influence on decision influence on decision makingmaking

Analysis of LiteratureAnalysis of Literature

PolicyPolicy

Case StudiesCase Studies

SurveysSurveys

Trade LiteratureTrade Literature

Design & Data SourcesDesign & Data Sources Secondary data analysis using Secondary data analysis using

information from EAP Case Closing information from EAP Case Closing Forms from a large Behavioral Health Forms from a large Behavioral Health Company’s (BHC) regional office Company’s (BHC) regional office between April, 2002 and June, 2003between April, 2002 and June, 2003

(N=5,792)(N=5,792)

Quasi-experimental 2 group designQuasi-experimental 2 group design

Proxy pretest design Proxy pretest design (Trochim, 2000)(Trochim, 2000)

Stand Alone Model

W/L Client W/L Intake

W/L Program

W/L Data

EAP Client EAP Intake

EAP Program

EAP Data

Partnership Model

W/L Client

EAP Client

EAP Intake

W/L Case

W/L Case with Clinical Features

EAP Case

W/L Data

EAP Data

SampleSampleN=5,792N=5,792

High tech company (N=3,976) High tech company (N=3,976) Stand Alone EAPStand Alone EAP

Communication conglomeration Communication conglomeration (N=1816)(N=1816) Partnership ModelPartnership Model EAP & W/LEAP & W/L

MeasuresMeasuresIndependent VariablesIndependent Variables

Independent Variable: Independent Variable: Program ModelProgram Model

Stand AloneStand Alone: up to 8 sessions of face-to-: up to 8 sessions of face-to-face EAP counseling, CISM, member and face EAP counseling, CISM, member and management trainingmanagement training

PartnershipPartnership: mean number of sessions of : mean number of sessions of EAP counseling (between 2 operating EAP counseling (between 2 operating units), CISM, member and management units), CISM, member and management training; training; partnership with W/L vendor partnership with W/L vendor (dependent care issues, academic (dependent care issues, academic concerns, life management consultation concerns, life management consultation and materials and financial consultation)and materials and financial consultation)

MeasuresMeasuresDependent VariablesDependent Variables

Level of functioning scale (LOF)Level of functioning scale (LOF) Single-item questions measuring Single-item questions measuring

Overall functioningOverall functioning

5-point Likert type scale with categories of5-point Likert type scale with categories of ExcellentExcellent Above averageAbove average GoodGood Below averageBelow average PoorPoor

Proxy pretest measureProxy pretest measure Post treatment measurePost treatment measure

MeasuresMeasures Dependent Variables Dependent Variables

Global Assessment of Functioning Scale Global Assessment of Functioning Scale (GAF)(GAF)

One of the most widely used measures of One of the most widely used measures of impairment and functioning in clinical and impairment and functioning in clinical and research settings research settings (Basco, Krebaou & Rush, 1997)(Basco, Krebaou & Rush, 1997)

Single scoring scale for evaluating Single scoring scale for evaluating psychological, social & occupational psychological, social & occupational functioning with rating on 0 to 100 point scalefunctioning with rating on 0 to 100 point scale

Excellent inter-rater reliabilities Excellent inter-rater reliabilities (Startup, Jackson & (Startup, Jackson & Bendix, 2002)Bendix, 2002)

Excellent reliability (ICC >.74) Excellent reliability (ICC >.74) (Hilsenroth et. al, 2000)(Hilsenroth et. al, 2000)

MeasuresMeasuresCovariatesCovariates

Pre-test scoresPre-test scores

Number of visitsNumber of visits

Data AnalysisData Analysis

Examine characteristic differences in sampleExamine characteristic differences in sample

Examine differences in proportions for Examine differences in proportions for penetration, traditional W/L presenting penetration, traditional W/L presenting problemsproblems

ANCOVA for Overall LOF & GAF (separate)ANCOVA for Overall LOF & GAF (separate) DV = posttest scoreDV = posttest score IV = IV = program modelprogram model CVs = pretest score & number of visitsCVs = pretest score & number of visits

Data AnalysisData AnalysisSpecific Presenting ProblemsSpecific Presenting Problems

Select cases with problemSelect cases with problem Alcohol/drugAlcohol/drug Mental healthMental health RelationshipRelationship Traditional W/LTraditional W/L

ANCOVA for Overall LOF & GAF (separate)ANCOVA for Overall LOF & GAF (separate) DV = posttest scoreDV = posttest score IV = IV = program modelprogram model CVs = pretest score & number of visitsCVs = pretest score & number of visits

Results!Results!

Differences in SampleDifferences in SampleRaceRace

Race/EthnicityRace/Ethnicity Stand AloneStand Alone

N %N %PartnershipPartnership

N %N %

CaucasianCaucasian 3308 3308 84.684.6

1232 1232 69.369.3

African African AmericanAmerican

286 286 7.37.3

366 366 20.620.6

HispanicHispanic 141 141 3.63.6

120 120 6.86.8

Asian/Pacific Asian/Pacific IslanderIslander

88 88 2.32.3

28 28 1.61.6

Native Native American/AlaskAmerican/Alaskanan

4 .1 4 .1

6 .36 .3

OtherOther 82 82 2.1 2.1

25 25 1.41.4

Missing DataMissing Data 67 67 1.7 1.7

39 39 2.12.1

Differences in SampleDifferences in SampleReferral TypeReferral Type

Test of proportions Test of proportions statistically statistically significantsignificant(z=420.00, (z=420.00, p<.01) with p<.01) with Partnership Partnership model having model having larger larger proportion of proportion of Mandatory Mandatory referralsreferrals

ModelModel NN %%

StandStand

AloneAlone13/13/

3,9763,976 .3%.3%

PartnPartner-er-

shipship

43/43/

1,8161,816 2.4%2.4%

Research Question 1Research Question 1Do utilization rates increase Do utilization rates increase with program integration?with program integration?

Test of proportions Test of proportions statistically statistically significant significant (z=24.04, p<.01), (z=24.04, p<.01), with the with the PartnershipPartnership model having model having larger proportion larger proportion of employees of employees using the using the programprogram

Model N %

Stand Alone

3,976/214,757

1.85%

Partnership

1816/52,447

3.46%

Research Question 2Research Question 2

Is there a Is there a significant significant difference difference between program between program models for the models for the number of cases number of cases presenting with presenting with traditional W/L traditional W/L issues?issues?

YES,YES, but opposite of but opposite of hypothesishypothesis

Partnership Model = Partnership Model = 12%12%

Stand Alone Model = Stand Alone Model = 10%10%

Test of proportions significant Test of proportions significant (z=2.177, p<.05)(z=2.177, p<.05)

Research Question 3Research Question 3Do scores forDo scores for Overall Level of Overall Level of

FunctioningFunctioning differ between program differ between program models?models?

Stand Alone Overall Stand Alone Overall LOF scores slightly LOF scores slightly higher higher than than Partnership scores Partnership scores after adjusting for after adjusting for pretest scores & pretest scores & number of visits number of visits

(F=90.414, p<.01)(F=90.414, p<.01)

Model Adj. Mea

n

SD

Stand Alone

2.83 1.13

Partnership

2.55 1.26

Research Question 4Research Question 4DoDo Global Assessment of Global Assessment of

FunctioningFunctioning scores differ between scores differ between program models?program models? 2550 cases with 2550 cases with

complete GSF pre & complete GSF pre & post scorespost scores

NO significant NO significant differencedifference between between program models program models on GAF scores on GAF scores after adjusting for after adjusting for pretest scores & pretest scores & number of visitsnumber of visits

F=3.397, p=.065F=3.397, p=.065

Model Adj. Mea

n

SD

Stand Alone

69.36

11.15

Partnership

68.62

10.53

Research QuestionsResearch Questions

Are there significant differences in Are there significant differences in outcomes between program models outcomes between program models for those clients presenting with:for those clients presenting with:

5.5. alcohol/drug involvementalcohol/drug involvement??

6.6. relationship issuesrelationship issues??

7.7. mental health issuesmental health issues??

8.8. traditional W/L issuestraditional W/L issues??

RQ5-8: Specific Presenting RQ5-8: Specific Presenting ProblemsProblems

See Handout See Handout Presenting Presenting ProblemProblem

LOF ScaleLOF Scale GAFGAF

Alcohol/DrugAlcohol/Drug Not significantNot significant Not significantNot significant

RelationshipRelationship SignificantSignificant

SA slightly SA slightly higher scoreshigher scores

Not significantNot significant

Mental HealthMental Health SignificantSignificant

SA slightly SA slightly higher scoreshigher scores

Not significantNot significant

Traditional W/LTraditional W/L SignificantSignificant

SA slightly SA slightly higher scoreshigher scores

Not significantNot significant

DiscussionDiscussion

Statistical versus Practical differencesStatistical versus Practical differences Non-significant findingsNon-significant findings

GAFGAF Alcohol/drug presenting problemAlcohol/drug presenting problem

Sample size and resultsSample size and results Increased size, smaller effects found Increased size, smaller effects found

significantsignificant Increased power, decreased false Increased power, decreased false

retention of null (Type II error)retention of null (Type II error)

DiscussionDiscussion

Sample differencesSample differences RaceRace Mandatory referralsMandatory referrals UtilizationUtilization

Call flowCall flow Role of intake assessmentRole of intake assessment

DiscussionDiscussion

Increased marketing efforts of Increased marketing efforts of Partnership modelPartnership model

EAP role as gatekeeperEAP role as gatekeeper ““turf issues”turf issues”

Implications for TheoryImplications for Theory

Need organizational analysis to fully Need organizational analysis to fully apply political economy theoryapply political economy theory Proprietary/confidential informationProprietary/confidential information Role of union in support of researchRole of union in support of research

ROIROI

Cycle of innovationCycle of innovation

Implications for PracticeImplications for Practice

Supports literature that integration Supports literature that integration increases accessibility and visibility increases accessibility and visibility of EAPof EAP

Supports proposal that EAP maintain Supports proposal that EAP maintain lead role due to training and clinical lead role due to training and clinical credentials of staff credentials of staff (King, 2002)(King, 2002)

Implications for PolicyImplications for Policy Continued struggle for identity for EAPContinued struggle for identity for EAP

Domain expertise in clinical assessmentDomain expertise in clinical assessment

Findings mixed on specific focus for Findings mixed on specific focus for EAP & W/LEAP & W/L

Clinical differences not practically significant in all Clinical differences not practically significant in all areas except alcohol/drugareas except alcohol/drug

More Traditional Work/Life cases in Partnership modelMore Traditional Work/Life cases in Partnership model

EAP clinical skills create distinction EAP clinical skills create distinction between other potential collaboratorsbetween other potential collaborators

Future ResearchFuture Research

Data with demographic informationData with demographic information Include W/L dataInclude W/L data Measures Measures Organizational analysisOrganizational analysis Include more levels of integration & Include more levels of integration &

integration partnersintegration partners Explore relationships between race Explore relationships between race

and accessand access Explore assessment processExplore assessment process

LimitationsLimitations

Use of administrative dataUse of administrative data

Lack of organizational informationLack of organizational information

Outcome measures limitationsOutcome measures limitations

StrengthsStrengths

Fills gap in literature, adding clinical Fills gap in literature, adding clinical outcomes to impact of EAP and W/L outcomes to impact of EAP and W/L integrationintegration

Data from leading provider of EAP Data from leading provider of EAP services in the countryservices in the country

Technical support and access to Technical support and access to industry experts from BHCindustry experts from BHC

ConclusionsConclusions Partnership Model had higher penetration Partnership Model had higher penetration

ratesrates

Outcomes did not substantially improve Outcomes did not substantially improve with access to increased resources; the with access to increased resources; the SA model had slightly better outcomes SA model had slightly better outcomes than Partnership modelthan Partnership model

EAP retain clinical lead roleEAP retain clinical lead role

Vast research trajectoryVast research trajectory

6 years later…..6 years later…..

Data integration & benefits to Data integration & benefits to programmingprogramming

Apples & Oranges, make fruit salad!Apples & Oranges, make fruit salad!

Wellness…new player, new door to Wellness…new player, new door to enterenter

Domain expertise holds trueDomain expertise holds true

ResourcesResources

Boston College Center for Work & Boston College Center for Work & FamilyFamily http://www.bc.edu/centers/cwf.html

Global Assessment of Functioning Global Assessment of Functioning ScaleScale http://en.wikipedia.org/wiki/http://en.wikipedia.org/wiki/

Global_Assessment_of_FunctioningGlobal_Assessment_of_Functioning

Question & Question & AnswerAnswer