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
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