BSI: A Great Wellness Opportunity for EAPs
By Richard L. Brown, Maria Lund, and Stanford W. Granberry
Recent research has called into question the effectiveness and return on investment (ROI) of conventional workplace wellness programs. A new alternative – behavioral screening and intervention (BSI) – offers a great opportunity for EAPs to address this shortcoming.
The previous article in this two-part series (Brown, 2015a) described this shortfall and presented BSI as a viable option in which health coaches: 1) verbally screen employees for important behavioral risks and disorders; 2) conduct additional assessment to discern the severity of risks or disorders; 3) administer motivational interviewing to promote healthier behaviors; and 4) deliver collaborative care for depressive disorders. Part one also summarized research on the effectiveness of BSI and its ROI.
This article compares BSI and health risk appraisal (HRA) programs, discusses implications of BSI for EAPs, and suggests how EAPs could deliver BSI.
BSI versus Health Risk Appraisals
Behavioral screening and intervention (BSI) is superior to HRAs and can in fact supplant them. There are two main reasons:
* Coaches who promote confidentiality, establish rapport and pursue non-verbal cues are likelier to elicit more accurate responses from employees than computerized surveys. For example, during screening, when coaches encounter responses of “not really” or changes in eye contact or tone, they can explore further. Conversely, HRAs would likely elicit negative responses.
(A brief description of coaches is in order. As explained in part one, coaches may or may not have a background in mental health or employee assistance. They meet one-on-one with employees annually, assure them of confidentiality, and ask roughly one dozen screening questions on various behavioral risks and disorders. Additional information on coaches is presented in part one.)
* Health risk appraisals (HRAs) can help modify behaviors only when they engage at-risk respondents in coaching (Soler, 2009). However, with BSI, coaches build trust and rapport through screening, assessment and motivational interviewing. In this way employees are more likely to choose ongoing coaching.
Implications for EAPs
Behavioral health screening and intervention (BSI) complements EAPs, whose primary mission is to respond to psychosocial and other crises as identified through self-referrals or referrals from supervisors or family members. Serving an average of only 6% of employees per year (Taranowski, 2013), EAPs do not see the majority of employees whose behavioral risk or disorders incur costs for employers. But through population-wide employee screening, BSI could identify and assist most employees with behavioral risks and disorders.
As of 2010, 62% of EAPs routinely incorporated BSI for alcohol and drugs (also known as screening, brief intervention and referral to treatment, or SBIRT) into intake sessions. Also, 23% did so by employer request (Taranowski, 2013). However, few have embraced the complete SBIRT model, which includes population-wide screening and systematic identification of employees who would benefit from BI or RT.
Offering employers BSI would also serve EAPs and their mission. Stigma is an important barrier to employee utilization of EAP services. Through BSI, an annual behavioral health check-up can become as routine as a regular medical examination, and services can be framed as preventive rather than remedial. Thus, employees who have positive experiences with EAPs through BSI may be quicker to seek EAP services in the future.
Moreover, behavioral health services are increasingly being integrated into general health care settings. (The implementation of mental health parity is another related issue.) As a result, another consideration for EAPs is that their corporate clients will likely reconsider their strategies for treating mental health and substance abuse. It’s true that EAPs whose services are redundant and that only serve small numbers of employees may be at risk for losing contracts. However, while BSI is recommended in primary care settings, few providers in fact are delivering BSI in an evidence-based manner. By offering BSI and its well-documented return on investment, EAPs can position themselves as unique purveyors of valuable, population-based behavioral health services.
Selecting BSI Service Providers
Just who should deliver BSI is an important decision facing interested EAPs. Comprehensive BSI addresses a wide range of behavioral issues, which few professionals are typically trained to address. The Wisconsin Initiative to Promote Healthy Lifestyles (WIPHL) has trained and supported dozens of coaches who are delivering BSI in general health care settings. In fact, it has trained and supervised a total of 44 coaches during the first five years of WIPHL’s existence. The qualifications of the coaches broke out as follows:
* Nine were master’s-level counselors or social workers;
* Thirty-three held bachelor’s degrees with a variety of majors; and
* Two were high school graduates with special language or cross-cultural skills.
WIPHL trainers found it easiest to train the bachelor’s-level coaches in a motivational interviewing approach to BSI, as many master’s-level trainees had set patterns of working with clients that were difficult to break. The trainers found that the master’s-level coaches often strayed from addressing targeted behavioral risks. High turnover was another drawback for coaches with master’s degrees, since they preferred positions where they could apply broader counseling skills.
Analyses of outcomes for randomly selected patients who received brief interventions found that the bachelor’s-level coaches elicited greater reductions in binge drinking than those with master’s degrees (Brown, 2015b). Thus, EAPs planning to offer BSI are advised to consider hiring bachelor’s-level coaches, who would likely be more effective and less costly than staff with master’s degrees.
Coach Training and Supervision
Because motivational interviewing (MI) is a central skill set for BSI, recommendations on BSI training and supervision are drawn in part from literature on MI training (Bohman, 2013; Miller, 2001; Moore, 2012; Moyers, 2008). The leadership of WIPHL and its spin-off, Wellsys, has honed these recommendations based on its experience in training and supporting more than 50 BSI coaches since 2007.
Initial training of one to two weeks is suggested, depending on the trainee’s prior experience. Training should convey information on the prevalence, impacts and clinical management of behavioral issues. It should also cover how to administer screening and assessment tools, interpret responses, and offer feedback to employees.
The major focus of training should be on the development of competency in motivational interviewing and working with employees to develop behavior change plans and refine them over time in relation to employees’ goals. The training should involve multiple learning strategies, including:
* Introspective exercises;
* Feedback; and
This should occur initially among fellow trainees and later with simulated employees, as an intermediate step toward actual delivery of services.
Coaches should begin service delivery as soon as possible after the training to maintain and reinforce new skills. For several months thereafter, coaches should participate in weekly conference calls in which they celebrate clinical successes, report on barriers to effectiveness, and learn to overcome those obstacles. Trainers and coaches should also review taped sessions of coach-employee sessions – recorded, of course, with the employee’s consent.
Continuing trainee development is important, because learning MI is much like learning to play a musical instrument, where ongoing practice, feedback and coaching are essential. To promote excellence and retention, EAPs should offer incentives for reaching higher levels of competency.
Tracking and Reporting
To maximize the value of BSI for employers, EAPs offering BSI must be prepared to record, analyze and report behavioral data across employee populations. Reports should include information on the prevalence of various risks and disorders among employees, the service delivery for various risks and disorders, and behavioral outcomes for employees and employee subgroups. Relevant subgroups include those based on age, gender, race, ethnicity, location, department and coach. However, reporting on small subgroups should be avoided to protect individual confidentiality.
These reports will help EAPs optimize BSI delivery and enable employers to gauge the effectiveness of BSI and maximize health and wellness plans for their employees. EAPs could proceed even further and have a third-party vendor merge BSI data with info on employee health care costs, workplace attendance, and disciplinary issues – and analyze for employers whether BSI is associated with favorable outcomes. Data and reporting needs could be accomplished through a spreadsheet, database program, or customized BSI software.
With ample scientific evidence that backs its effectiveness and ROI, it’s clear that BSI should become a leading wellness service, which EAPs are in an excellent position to offer to customers. It’s true that, to succeed at BSI, EAPs will need to ensure exceptional delivery of services and document results. Moreover, high-quality training and support on data collection and reporting will be essential for coaches.
Several additional learning resources on BSI are available. To learn more, send me an email: firstname.lastname@example.org.
Richard L. Brown, MD, MPH, is a professor of family medicine and director of the Wisconsin Initiative to Promote Healthy Lifestyles at the University of Wisconsin School of Medicine and Public Health.
Maria Lund, MA, is president and CEO of First Sun EAP in Columbia, S.C.
Stan Granberry, PhD, is the executive director of the National Behavioral Consortium in Baton Rouge, La.
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