Evaluation of Telephonic Alcohol Screening and Brief Intervention (SBI) inan Employee Assistance Program (EAP)

Gregory Greenwood, PhD, MPH1; Eric Goplerud, PhD2; Tracy L. McPherson, PhD2;Eugene Baker, PhD1; Francisca Azocar, PhD1

1OptumHealth Behavioral Solutions; 2Center for Integrated Behavioral Health Policy, Department of Health Policy, George Washington University Medical Center

Abstract

Background: Substantial empirical support exists for alcohol screening and brief intervention (SBI) in medical, but not non-medical settings. Workplace settings remain underutilized for delivering evidenced-based health services. A public-private partnership attempted to fill this gap by translating the World Health Organization (WHO) alcohol SBI protocol for delivery in telephonic EAP. Methods: A pretest-posttest, one-group, pre-experimental design is used to examine the feasibility and preliminary impact of an alcohol SBI pilot program implemented by EAP clinical consultants in three call centers serving members of a large health plan. The SBI intervention is adapted based on the World Health Organization (WHO, Babor et al., 2001, 2004) alcohol SBI protocol. The intervention includes systematic routine alcohol screening using the AUDIT during clinical intake, brief counseling using motivational interviewing (MI) for at-risk drinking, alcohol education, referral to face-to-face counseling or other treatment as appropriate. Results: From August 2008 through February 2009, EAP completed 367 full AUDIT screens using a new online tool. Of these, 231 (63%) were females, and 136 (37%) were males. Screening results were: 287 (78%) Risk Zone I (no or low-risk drinking), 41 (11%) Risk Zone II (hazardous drinking), 9 (3%) Risk Zone III (harmful drinking), and 30 (8%) Risk Zone IV (abuse or dependence drinking). All together, 30 (10%) were referred to substance use behavioral health services, and 247 (81%) to follow up EAP. Comparing alcohol identification rates pre- and post-SBI launch, we found 80 (22%) screened positive for alcohol misuse 6-months post-SBI launch compared to 31 (4.5%) who screened positive for misuse 6 months pre-SBI (p<.001). Conclusions: Integrating telephonic alcohol SBI into existing EAP services resulted in improved rates of identification of risky alcohol use and delivery of EAP telephonic brief interventions, We believe it requires the unique, strategic collaboration of private and public stakeholders in order to effectively translate and integrate evidence-based protocols into large national managed behavioral health organizations, as well as the commitment and partnership of key stakeholders such as health plans and employers. Future advances in evaluating and improving EAP telephonic alcohol SBI protocols include assessing the impact on member health and productivity at follow-up including changes in risky drinking (alcohol consumption) and productivity at 30, 60, and 90 days. Sponsor: OptumHealth Behavioral Solutions.

Introduction

It is estimated that the health care costs associated with alcohol problems amount to almost $36 billion annually and, as almost 80% of the 16.3 million adults who drink in risky or hazardous ways are employed either full- or part-time, these costs extend to employers (NIAAA, DHHS 2000). Risky drinkers cause 60% of alcohol-related absenteeism, tardiness and poor work quality; and utilize roughly twice the health care resources of healthy employees (Witbeck et al., 2000). Analysis of more than 360 controlled trials on treating alcohol use disorders found that SBI was the single, most effective treatment method of more than 40 methods studied (Miller & Wilbourne, 2002). Return on investment for alcohol SBI typically exceeds 2:1, consistent with the savings associated with diabetes or depression disease management programs (French & Fleming, 2002). Whereas substantial empirical support exists for SBI in medical settings, there is very little in workplace settings. This collaborative public-private partnership aims to fill this gap by translating medical research into behavioral healthcare practice settings that can potentially reach tens of thousands of workers each year, and potentially save employers and health plans millions of dollars.

Research Objectives:

Objective 1: Describe alcohol SBI results from the multi-site pilot study.

Objective 2: Measure and compare alcohol identification rates 6-months pre-alcohol SBI launch vs. 6-months post-SBI.

Design and Methods

A quasi-experimental design is used to examine the feasibility and preliminary impact of an alcohol SBI pilot program implemented by EAP clinical consultants in three telephonic call centers serving members of a large health plan. The SBI intervention is adapted based on the World Health Organization (WHO, Babor et al., 2001, 2004) alcohol SBI protocol. The intervention includes systematic routine alcohol screening using the AUDIT during clinical intake, brief counseling using motivational interviewing (MI) for at-risk drinking, alcohol education, referral to face-to-face counseling or other treatment as appropriate.

Design: Quasi-experimental design.

Target Population: EAP members from a single health plan served by three EAP call centers.

SBI Training: Modified the WHO alcohol screening and brief intervention (SBI) protocol (WHO, Babor et al., 2001 & 2004).

Measures:

AUDIT-C and AUDIT (Babor et al, 1989; Babor et al, 2001).

EAP Administrative Data: Positive alcohol screen.

SBI Intervention:

Alcohol screening is integrated into telephonic clinical intake conducted by EAP clinical consultant.Figure 1 presents an overview of the EAP SBI workflow.AUDIT score classifies member into one of four risk categories:

Risk Zone I – no or low-risk drinkingRisk Zone II – hazardous drinkingRisk Zone III – harmful drinkingRisk Zone IV – abuse or dependence drinking

Table 1 presents components of the brief intervention. The BI approach was modified using the WHO FRAMES approach. The components include:

Feedback Responsibility Advise Assess Assist Menu (Options) Empathy Strengths

Analysis

First, we ran descriptive statistics on primary outcomes including the number of positive alcohol screens, and the number (and type) of referrals. Second, chi-square analyses were run to examine whether the telephonic SBI program could be associated with increased identification rates of alcohol misuse.

Findings

EAP completed 367 full AUDIT screens from August 2008 through February 2009.Table 2 presents monthly results. Overall:

287 (78%) scored in Risk Zone I – no or low-risk drinking41 (11%) scored in Risk Zone II – hazardous drinking9 (3%) scored in Risk Zone III – harmful drinking30 (8%) scored in Risk Zone IV – alcohol abuse or dependence drinking

Using EAP administrative data, there were 681 members from the health plan who used EAP services 6 months prior to alcohol SBI launch (“pre-SBI group”). We compared alcohol identification rates between (1) pre-SBI period and (2) post-SBI period. 80/367 (22%) screened positive in the post-SBI period compared to 31/681 (4.5%) in the pre-SBI period, which was statistically significant (chi-square=73.25, df 1, p<.001).

Conclusions

A telephonic alcohol SBI protocol modified for EAP delivery is feasible and highly acceptable.Slightly more than 1 out of 5 screened positive for hazardous or more severe alcohol use, and brief telephonic interventions were delivered to promote abstinence or reductions in substance use.Telephonic EAP alcohol SBI is associated with improved rates of alcohol identification compared to usual care.

Ongoing Activities

OptumHealth and GWU are completing final analyses of this pilot project to include a full set of screening and EAP/MH behavioral health claims data to assess effects. Results from this pilot will be used to improve quality of services across the book of business within OptumHealth.OptumHealth and GWU will continue to work collaboratively to advance the science of alcohol SBI in non-medical settings, as well as to improve MBHO services.Future advances in evaluating and improving EAP telephonic alcohol SBI protocols include assessing the impact on member health and productivity at follow-up including changes in risky drinking (alcohol consumption) and productivity at 30, 60, and 90 days.

More information about OptumHealth Behavioral Solutions: http://www.inside.optumhealth.com/Home/ Contacting Author Information: Gregory Greenwood, PhD, MPH; Gregory_L_Greenwood@uhc.com; 415-265-7858

Figure 1. Overview of EAP SBI Workflow

Table 1. Brief Intervention Components: FRAAMES

Table 2. Monthly Number of Completed Screens, Risk Levels, and Referrals

XXXXStrengthsS

XXXXEmpathyE

XXXXMenu (Options)M

XXAssistA

XXAssessA

XXXXAdviseA

XXXXResponsibilityR

XXXXFeedbackF

Referral

(Risk 4:

Abuse or Dependence)

Advice + Brief

Counseling

(Risk 3:

Harmful)

Simple

Advice

(Risk 2: Hazardous)

Alcohol Education

(Risk 1:

Low Risk)

XXXXStrengthsS

XXXXEmpathyE

XXXXMenu (Options)M

XXAssistA

XXAssessA

XXXXAdviseA

XXXXResponsibilityR

XXXXFeedbackF

Referral

(Risk 4:

Abuse or Dependence)

Advice + Brief

Counseling

(Risk 3:

Harmful)

Simple

Advice

(Risk 2: Hazardous)

Alcohol Education

(Risk 1:

Low Risk)

Large Health Plan EAP AssessmentAlcohol

ScreeningAUDIT

HazardousUse

DependenceSymptoms

Harmful Use

Risk Score & BI Level

Deliver Brief Intervention

Risk 1No or Low Risk

Alcohol Education

Risk 2Hazardous Drinking

Simple Advice

Risk 3Harmful Drinking

Brief Counseling

Risk 4Abuse/Dependence

Drinking

Referral

21331328356

29222431395

2473030941287367Total

22130222277

385211444614

435611048653

46882458722

48662456681

EAP

Refer

MH/SA

Refer

Risk 4Risk 3Risk 2Risk 1ScreensMonth

21331328356

29222431395

2473030941287367Total

22130222277

385211444614

435611048653

46882458722

48662456681

EAP

Refer

MH/SA

Refer

Risk 4Risk 3Risk 2Risk 1ScreensMonth