1. A Strategic Measurement and Evaluation Framework to Support Worker Health COMMITTEE ON DHS OCCUPATIONAL HEALTH AND OPERATIONAL MEDICINE INFRASTRUCTURE June 10-11, 2013 Ron Z. Goetzel, Ph.D., Emory University and Truven Health Analytics

2. 2 Workplace Health Promotion/Health Protection Programs: What Should be Evaluated? Structure Process Outcomes

3. LOGIC MODEL: WORKSITE PROGRAMS STRUCTURE PROCESS OUTCOMES Modified Worksite Health Promotion (Assessment of Health Risk with Follow-Up) Logic Model adopted by the CDC Community Guide Task Force HEALTH PROMOTION/PROTECTION Employees

4. 4 44 EVALUATION MEASURES Worksite Health Promotion/Protection Programs Structure Leadership engagement Policies and Procedures Environmental Support Process Fidelity Dose delivered/ Dose received (participation, engagement, satisfaction) Outcomes Health Financial Productivity

5. 5 Program Structure Structure defines the program -- how does it work – the WHAT, HOW & WHEN? Individual components, e.g., HRA, feedback reports, mailings, internet services, high risk counseling, referral to community resources, incentives Environmental components, e.g., organizational policies, cafeteria/vending machine choices, time off for health promoting activities, senior management support, access to physical activity programs, walking paths, shower/change facilities, healthy company culture

6. 6 http://www.cdc.gov/niosh/docs/2010-140/

7. Environmental Assessment Tool 7 J Occup Environ Med. 2008 Feb;50(2):126-37.

8. Checklist of Health Promotion Environments at Worksites 8

9. Leading By Example Assessment 9 Am J Health Promot. 2010 Nov- Dec;25(2):138-46..

10. 10 HERO SCORECARD Sample Results  Category ABC Inc.’s Score Nation al Averag e Maximu m Points 1. Strategic Planning7511 2. Leadership Engagement 181633 3. Program Level Management 71122 4. Programs142856 5. Engagement Methods402967 6. Measurement and Evaluation 2511 TOTAL8894200 Based on ABC Inc.’s response and database average as of [May 1, 2009]. http://www.the-hero.org/scorecard_folder/scorecard.htm http://www.the-hero.org/scorecard_folder/scorecard.htm accessed 5/12/12.

11. CDC WORKSITE HEALTH SCORECARD http://www.cdc.gov/dhdsp/pubs/worksite_scorecard.htm

12. 12 PROGRAM PROCESS Program process evaluation defines how well the program is carried out: – Participation rates – Satisfaction with the program/process/people – Completion rates

13. GOAL: To summarize program implementation and to form hypotheses about how implementation may affect program outcomes To monitor progress during a program implementation and to inform potential adjustments to the program to improve program quality – Program Fidelity (quality) - how the program was implemented – Dose Delivered (completeness) – frequency and intensity of the program – Dose Received (satisfaction) - how participants react to the intervention – Program Reach (participation rate) –The proportion of eligible (employees) that participated in the various components of the programs? PROGRAM PROCESS COMPONENTS 13

14. EXAMPLE ASSESSMENT 14

15. Satisfaction 15

16. Performance Rating 16

17. Program Impacts 17

18. 18 PROGRAM OUTCOMES Program outcomes are evaluated by determining whether program objectives are achieved, at a given level of quality, and within a defined time framework – Health outcomes Behavior change Risk reduction – Medical care outcomes Health care utilization Health care costs – Productivity outcomes Absenteeism Disability Workers’ compensation/safety Presenteeism

19. RESEARCH DESIGN Pre-experimental Quasi- experimental True experimental Validity of results increases as you move down this list All are tools that can help understand the impact of the program 19

20. NON-EXPERIMENTAL DESIGN (PRE-EXPERIMENTAL) 20 Program start

21. GENERAL TREND OR PROGRAM EFFECT? 21 Program start

22. 22 PROBLEMS WITH A PRE-EXPERIMENTAL DESIGN: REGRESSION TO THE MEAN The most simple analysis may produce the wrong answers Before the Intervention Intervention Period Savings? Same people

23. 23 REGRESSION TO THE MEAN

24. 24 RESEARCH DESIGN: QUASI- EXPERIMENTAL Pretest posttest with comparison group 0 1 X 0 2Experimental Group -------------------------- 0 1 0 2Comparison Group 24

25. 25 ANNUAL GROWTH IN NET PAYMENTS Start of Program Annual growth in costs, Highmark, Inc. For matched-participants and non-participants over four years`

26. 26 RETURN ON INVESTMENT AND NET PRESENT VALUE Return on Investment (ROI) = Savings Program Cost = $1 break-even Net Present Value (NPV) = Savings – Program Cost = $0 break-even

27. 27 Cost-Benefit (ROI) Analysis Wellness Program Costs, Highmark, inflation-adjusted to 2005 dollars

28. 28 Evaluators must explicitly state the intervention pathway and metrics used to measure: – The “cause” or actual intervention – The “effect” – proximate and/or ultimate outcomes that result from the intervention Hypotheses that outcomes are “caused” by the HP program must be articulated and tested Assessing Causality HP Program Proximate Outcomes Ultimate Outcomes Effect Cause

29. CRITICAL STEPS TO SUCCESS Reduced Utilization Risk Reduction Behavior Change Improved Attitudes Increased Knowledge Participation Awareness Financial ROI 29

30. HEALTH RISKS – BIOMETRIC MEASURES -- ADJUSTED Results adjusted for age, sex, region * p<0.05 ** p<0.01

31. HEALTH RISKS – HEALTH BEHAVIORS -- ADJUSTED Results adjusted for age, sex, region * p<0.05 ** p<0.01

32. ADJUSTED MEDICAL AND DRUG COSTS VS. EXPECTED COSTS FROM COMPARISON GROUP Average Savings 2002-2008 = $565/employee/year Estimated ROI: $1.88 - $3.92 to $1.00

33. 33 Summary Evaluation of Health Promotion/Protection Programs is doable, but tricky Know your audience – the level of sophistication in conducting financial analyses varies significantly – well done studies are complex and expensive It’s easy to come up with the “wrong” answer if the proper research design is not used Ask for help – good evaluation studies require a team of individuals with diverse backgrounds and skill sets Tell the truth, the whole truth, even if it means saying the program didn’t work