Posts from — June 2009

A program is required to offer appropriate interpretation of cholesterol evaluation results, including a caution that a single measurement neither excludes nor establishes a diagnosis of their blood cholesterol.

Follow national ground rules:

Total Cholesterol
Desirable cholesterol   < 200 mg/dl
Borderline cholesterol   200 - 239 mg/dl
High cholesterol   > 240 mg/dl

HDL
Desirable HDL    > 35 mg/dl
Low HDL    < 35 mg/dl

Refer blood lipid screening participants to healthcare as follows:

Total Cholesterol
< 200 mg/dl    Recheck blood lipid in five years, if history of coronary heart disease or if two or more CHD risk factors are detected refers to risk reduction program or health professionals, as appropriate.
200 - 239 mg/dl    If history of CHD or if two or more other risk factors are detected, refer to healthcare or risk reduction service within two months; if no reported history of CVD or less than two other risk factors, reassess cholesterol status within 1-2 years.
> 240mg/dl    Refer to health care within two months.

HDL
> 35 mg/dl   If fewer than 2 risk factors and borderline total cholesterol, refer to risk reduction service, as appropriate. Reassess HDL in 1-2 years.

Give the following:
• The relationship of blood cholesterol, high Blood Pressure (BP), and other risk factors.
   o Risk factors include: high Blood Pressure (BP) 140/90 or higher or on hypertension medication; current cigarette smoking; family history of premature CHD; diabetes mellitus; age - male > 45 years, female > 55 years or premature menopause without estrogen replacement therapy.
   o Negative risk factor: high HDL 60 mg/dl or greater (subtract one risk factor).
   o Risk factors such as family history, smoking, high fat or other unhealthy diet, and lack of exercise lead to the development of cardiovascular disease (CVD).
• Definitions and causes of high blood lipids and HDL, desirable levels, the meaning and limitations of a single measurement, the cause of variability, and the need for multiple measurements prior to diagnosis.
• Wide range of treatment options, including diet (e.g., effect of controlling fat intake less than 30 percent of total calories from fat, less 10 percent saturated fats), less than 300 mg. of cholesterol per day, well-balanced diet, weight maintenance or reduction, exercise, and medication.
• Importance of following prescribed treatment and professional advice.

Appropriate medical or allied health professional trained in measurement of Blood Pressure (BP), referral protocols, and delivering educational messages to colleague delivering Blood Pressure (BP) programs. These programs are needed to follow national instructions.

• National guidelines for Blood Pressure protocols:
   o Calibration of Blood Pressure quantifying equipment
   be done at least annually.
   o Two or more measurements of attendant’s Blood Pressure ought to be taken.
   o Referral of participants with high Blood Pressure (BP) readings to personal physician for further evaluation.

• Systolic/Diastolic Follow-Up:
   o Normal:   <130 / <85
      Action: Recheck in 2 years
   o High Normal:   130-139 / 85-90
      Action: Recheck in 1 year

• Hypertension:
   o Stage 1 (Mild):   140-159 / 90-99
      Action: Confirm within 2 Months.
   o Stage 2 (Moderate):   160-179 / 100-109
      Action: Refer to source of care within 1 month.
   o Stage 3 (Severe):   180-209 / 110-119
      Action: Refer to source of care within 1 week.
   o Stage 4 (Very Severe):   >210 / >120
      Action: Refer to source of care immediately.

• Appropriate educational messages:
   o Normal:   <130 systolic and <85 diastolic
      Action: No referral. If on treatment, then inform colleague that Blood Pressure is under good control today and must continue seeing and following treatment program.
   o High Normal:   130-139 systolic and/or 85-89 diastolic
      Action: Recommend that attendant have Blood Pressure rechecked within 1 year unless under treatment. Advise attendant that the readings are in a high normal range that needs rechecking. In the interim, suggest that one of the most effective means to lower Blood Pressure is to bring weight into normal range and to exercise.
   o High:   >140 systolic and/or >90 diastolic
      Action: Refer to physician for further assessment within 2 months unless the level is within urgent, emergency, or isolated systolic hypertension levels. If already on treatment, advise attendant of readings and need to get Blood Pressure to a objective of 140/90 or less.
   o Isolated Systolic Hypertension:   140-159 systolic and < 90 diastolic in a participant 65 years of age or older.
      Action: Advise attendant to inform physician of readings at next visit and consider advice regarding weight loss and exercise if appropriate.
   o Urgent:   180-209 systolic and/or 110-119 diastolic
      Action: Recommend obtaining health care evaluation within 1 week.
   o Emergency:   >210 systolic and/or >120 diastolic
      Action: Get immediate health care attention.

• Provides the following:
   o Written results, referral standard procedures, and an explanation of Blood Pressure levels given to each participant with individualized counseling, including advice about the interval of time recommended when the participant ought to be checked again.
   o Utilizes the recommendations in The Fifth Report Of The Joint National Committee on Detection, Assessment and Treatment of High Blood Pressure, March 1994.
   o Written and audiovisual materials that are informative, simple to be aware of, and useful while containing scientifically accurate information.
   o Relationship of high Blood Pressure (BP) and other risk factors, such as family history, smoking, high fat and unhealthy diet, lack of exercise, in the development of cardiovascular disease, including stroke, kidney disease, heart attack, and other diseases.
   o Definition and causes of elevated Blood Pressure (BP).
   o Importance of following prescribed treatment.

Health risk evaluation programs must be carried out on a one-on-one basis by trained medical professionals. Health risk measures must include the following:

• Blood Pressure measurements - at least two Blood Pressure measurements taken during the assessment episode, using a mercury sphygmomanometers or regularly calibrated aneroids.
• Blood Pressure (BP) treatment status - determine whether the attendant is under a doctor’s care, on any medication, on a prescribed diet, or any other type of treatment for hypertension.
• Blood cholesterol measurement - total cholesterol and HDL-cholesterol taken either using a properly tested and maintained table top blood analyzer providing immediate feedback to the client, or sending blood to a laboratory providing feedback using a method that is as effective as immediate feedback.
• Cholesterol treatment status - evaluate whether the client is under a doctor’s care, on any medication, on a prescribed diet, or any other type of treatment for elevated cholesterol.
• Obesity - utilize an accepted method for estimating obesity. By way of example evaluate participants height and weight and use the 1959 Metropolitan Life Height/Weight charts or use Body Mass Index.
   o Identify people 20% or more above their ideal weight.
• Smoking status - assess whether the attendant currently smokes cigarettes, whether the client has quit or never smoked, and the number of cigarettes smoked/day.
• Exercise habits - assessment questions may be limited to frequency and duration exercise. Do participants exercise in a moderately vigorous fashion at least three times per week for 30 minutes or more.
• Diabetes - whether the client has diabetes, and whether or not it is currently under control. A blood glucose may be also done via finger stick and desk top analyzer. Several manufactures make available cassettes which include cholesterol and glucose measurements.
• Cerebrovascular disease or occlusive PVD - evaluate if the client has had a stroke or other kind of blood vessel disease.
• Family history of cardiovascular disease - evaluate whether any of the participants’ parents or siblings had a heart attack or sudden death due to heart disease before age 55.
• Coronary heart disease - ascertain if the client has had a heart attack or other type of coronary heart disease.
• Stress - colleague’s assessment of stress in work and/or personal life. A series of well-tested and validated questions assessing levels of stress are available from the Worker Health Program.
• Participant release form (see forms) - A release form is necessitated in which the participant authorizes the program to draw blood for testing to send information to the participant’s medical provider if medical risks are identified, and to get information from the provider about diagnosis and prescribed treatment.
• Participant interest survey - if an assessment of interest has not been collected previously, the evaluation activity must assess levels of interest in programs such as: weight control, smoking cessation, fitness or exercise, stress management, diet, self-care, cholesterol control.
• Health education messages - the screener must review with the attendant his/her identified health risks and what they mean to the attendant’s central health, and give the attendant a written record of the Blood Pressure, total cholesterol, and any other physiological measures taken.
• Referral of participants for treatment - participants with elevated risks must be referred to appropriate sources of diagnosis and possible treatment following nationally or locally recognized guidelines for such referral.

Demographic information should include location of the evaluation, worksite, client’s name, address, social security number, work and home phone number, sex, race, birthdate, relevant job information (e.g., hourly or salaried), department number, and work shift.

Program directors or providers must have a background in wellness programming and a professional health-related degree or certification. They must have expertise in content areas, planning, promotion, administration, evaluation, and ability to grow a program and tailor the program to the worksite.

Program providers should have a quality assurance program for evaluating the performance of service personnel, to assess satisfaction of participants, and for personnel training and continuing education.

An overall policy statement ought to be available from directors and program vendors discussing the following problems: assurance of confidentiality of health data, referral to medical care for at-risk participants, follow-up with referred participants and those at-risk, program evaluation on process and outcomes, company of the worksite for promotion of wellness and changes in corporate culture. A clear contract or letter of agreement for services ought to be provided.

Stay away from being the “best” or doing the “most.” Encouraging staff members to be the best or doing the most promotes excessive behavior, discourages others, and creates elitism. The best designed incentive programs are ones which are based on achieving goals and objectives that are attainable by most people. Recognition, acknowledgment by top management, or special privileges are examples of great intangible incentives and rewards.

Incentive ideas:

• Free or Low-Cost:
   o Certificates
   o Movie passes
   o Recognition in employee newsletter
   o Mugs
   o Water bottles
   o Commendation from management
   o T-shirts
   o Hats

• Moderate Cost:
   o Entertainment tickets
   o Sweatshirts
   o Waist packs
   o Subscriptions to health magazines
   o Health and fitness books
   o Videos

• High Cost:
   o Week-end getaways
   o Dinner for two
   o Clocks
   o Watches

• Others:
   o Cash
   o Gift certificates

Utilizing posters, newsletter articles, and brochures are great means of promoting the program. Other promotional methods to consider are e-mail and announcements at employee meetings. Ask Employee Wellness Program Committee participants to recruit participants.

Once the program is kicked off you may want to provide an incentive for any employee who recruits another employee to any of the program offerings.

When selecting a program from a vendor you must ask the following questions:

• How many worksites have done the program?
• What types of employee population was the program provided?
• What educational materials are used?
• Will the program meet the needs of workers?
• What are the techniques used to help alter behaviors?
• Does the program help employees move through stages of readiness to make health behavior changes?
• How do you market the program to workers?
• What follow-up do you provide?
• How do you make referrals for medical or other supportive services employees may need?
• How do you know the program works?
• How do you measure participant satisfaction?

When staffing your wellness program you need to consider whether to hire a wellness employee or contract with wellness professionals from outside your organization.

Small and medium size worksites do not usually have a wellness professional on employee. If your workplace is in this category, you will need to contract with providers outside your employer.

Large organizations have several options. They can hire a employee solely for the wellness program, they can contract with outside wellness providers, or they can use a combination of internal employee and outside providers.

When selecting a provider some key questions in the areas of employee, program structure, process, and performance need to be addressed. Each of these key questions is discussed in the following sections.

Staff

Health professionals become wellness professionals when they are trained in the full range of wellness activities. Wellness professionals are generalists who come from a wide variety of backgrounds and schooling. They may be nurses, dietitians, health educators, counselors, exercise physiologists, or have other backgrounds. But in addition to their primary training, they know something about all wellness topics, including smoking, stress, exercise, and nutrition. They also know how to engage and support people in making and sustaining health improvements and have good people skills.

Generally, wellness professionals at worksites fall into three broad categories, wellness screeners, wellness counselors, and wellness instructors.

• Wellness screeners introduce staff members to the program, take health measurements, gather health-related information, offer initial counseling, and help staff members define for themselves what they need and want in a wellness program.
• Wellness counselors work with staff members after the screening to help them create and carry out a plan to decrease their risks and better their health.
• Wellness instructors instruct classes and minigroups on different health issues.

A wellness program in a small employer can be staffed by a single employee person who fills all three roles. Larger worksites will use different staff members to fill these roles.

When choosing employee or choosing among vendors, ask the following questions:

• Do prospective staff members have a range of health backgrounds that will provide appropriate expertise in the subject matters to be addressed?
• Have prospective workers functioned well as wellness screeners, wellness counselors, and/or wellness instructors?
• Will this employee include employees from the racial and ethnic backgrounds found in your employee population?
• Is each employee member comfortable with the range of backgrounds found in your employee population, and able to communicate effectively with the various social and educational levels of your workers?
• Do workers have a warm, but professional, counseling style when interacting with workers?

An yearly plan for the major wellness programs and activities is a useful management tool. This is an great Corporate Health Promotion Program Committee task. Often an exercise and wellness theme per month is offered to workers.

Some corporations choose to follow a National Health Observances calendar which offers advantages. The materials developed by these various national health corporations are very credible. The materials are usually high quality and available free or at a nominal cost.

The corporation benefits from additional publicity that occurs in various media throughout the neighborhood related to the national observance. For planning ideas you may want to utilize the HOPE Publications Wellness Resource Planning Guide available for no cost at this Web site.

A Health Risk Appraisal (HRA) is occasionally used in conjunction with a health assessment. An HRA is a computerized assessment tool which looks at an individual’s family history, health status, and lifestyle. An HRA seeks to identify precursors associated with premature death or serious illness and quantifies the probable impact for each individual.

An HRA instrument is derived from an understanding of the course of a disease. Based on this understanding, useful prediction instruments can be constructed to evaluate the health risks of an individual. Individuals with a higher number of health risks tend to have more weighty health problems over time.

Drawing attention to their health risks can help clients decrease risk factors which lead to the onset of unnecessary disease and subsequent premature death. The questionnaire covers lifestyle habits (such as smoking, Safety Belt use, and exercise) and physical measures (such as cholesterol, Blood Pressure (BP) levels, height, and weight).

For accuracy, it is crucial to get direct measures of Blood Pressure (BP), cholesterol and HDL-cholesterol. The HRA also provides recommendations and indicates what risks are potentially modifiable. Types of measures to assess health risks are discussed under Screening Programs.

The impact of a health risk appraisal is much greater when it is given in-person, with immediate feedback to the client. This also provides an opportunity to invite the client’s participation in continuing health counseling and to gain their written consent to do pro-active outreach to them.

A health age can be computed based on the individual answers to the questionnaire and physiologic factors. The health age may indicate the individual to be younger or older than their chronological age.

HRA programs are one the most prolific types of wellness activities utilized by employers. Continuing research on HRAs is examining the efficacy of this tool. One of the big benefits of this tool is that it can provide an aggregate group report of a corporation and can be utilized as an assessment tool.

Detailed information is available from the Society of Prospective Medicine (www.spm.org/desc.html) who publishes a handbook on HRAs.