Are You Getting Enough Sleep?

Sleep-deprived workers pose a danger to themselves and others.

Insufficient sleep and sleep disorders have a major impact on health, wellness and the ability to perform daily activities such as concentrating and remembering things. Primary care providers (including occupational medicine practitioners on the front lines) can advise patients on lifestyle changes to improve sleep; patients with more serious sleep problems should see a specialist, according to findings from a newly released study from the Centers for Disease Control and Prevention (CDC).

Health care providers are encouraged to advise patients who need to improve their sleep quality to 1) keep a regular sleep schedule; 2) avoid stimulating activities (e.g., vigorous exercise within two hours of bedtime; 3) avoid caffeine, nicotine and alcohol in the evening; 4) avoid going to bed on a full or empty stomach; and 5) sleep in a dark, quiet, well-ventilated space with a comfortable temperature.

The CDC study reportedly is the first investigation of the relationship between reported short sleep duration and sleep-related difficulties in performing daily activities in a broad, non-clinical population (10,896 adult respondents).

The National Sleep Foundation suggests that adults need seven to nine hours of sleep a night. In the CDC analysis, adults who reported usually getting less than seven hours of sleep on weekdays or workdays were more likely to have difficulties with daily activities than adults who reported getting seven to nine hours of sleep.

Women were more likely to report four out of six sleep-related difficulties than men, regardless of sleep duration. One factor that might contribute to these differences is that men and women may differ in the way they recognize sleepiness and its effect on their ability to perform daily functions.

Refer to Effect of Short Sleep Duration on Daily Activities: United States, 2005-2008; AG Wheaton, et al.; March 4, 2011/60(08);239-242.

Case Manager Board Certification Carrying More Weight

Occupational health practitioners who appreciate the value of positive working relationships with external case managers may be interested to know that the Commission for Case Manager Certification (CCMC™) is doing what it can to streamline the path to board certification.

CCMC strongly encourages case managers to enhance their skills and credibility by obtaining board certification as health care delivery systems strive for improved service delivery and patient outcomes. CCMC is a non-profit, volunteer organization overseeing the case manager certification process for applicants including registered nurses, social workers, and other professionals in workers’ compensation and vocational rehabilitation.

New models of care such as the patient-centered medical home emphasize care coordination and other core case management principles. A foundational emphasis on team-based care in advanced primary care models has also expanded the role of case managers, CCMC reports. The concept of team-based care is aligned with the commission's philosophy that all parties in the system benefit when patients reach their optimal level of wellness, self-management and function.

In a press release issued yesterday, the organization announced two new related services:

• Candidates who take the exam to obtain a CCM® credential now receive immediate pass/fail feedback via an Instant Preliminary Scoring system rather than having to wait six weeks for test results. 

• A Pre-Approved Continuing Education (PACE) program for CCM-certified organizations simplifies the process to gain approval for workshops, webinars and continuing education coursework. PACE is an online system that reduces duplicate approvals for repeated courses and simplifies data entry and fee structures.

 “These new initiatives demonstrate our commitment to our core values – promoting, advancing and advocating for quality case management,” said Patrice V. Sminkey, R.N., the commission’s chief staff executive. “Health care reform is changing the landscape for board-certified case managers, and the commission will continue to explore ways to be the go-to resource for the professional case management community.”

Employers Need Help Defining Value of Health Interventions

Occupational health professionals are strategically positioned to help employers make informed choices about their investments in workforce health.

According to a study released this week, employers face challenges when gathering the information they need to fully assess the impact of ill health and health-related interventions in working populations. The study, Synergies at Work: Realizing the Full Value of Health Investments, provides a framework for evaluation. Eight employer case studies are used to illustrate the concepts.

To appreciate the big picture, employers must incorporate evidence beyond medical claim data, such as intervention results and incidence and duration rates associated with workplace absence and disability, the study’s authors said.

The findings shed light on opportunities for occupational health professionals as they prepare to assist employers with value-oriented analysis through the rigorous application of key performance indicators relevant to both internal operations and the end user. 

An NAOHP benchmarking committee is engaged in the process of defining key metrics and plans to pilot-test them at selected locations starting this spring. Preliminary results will be presented at RYAN Associates’ 25^th annual National Conference, Oct. 17-19 in Atlanta.  

Synergies at Work is a collaborative effort of A. Mark Fendrick, M.D., co-director of the University of Michigan Center for Value-Based Insurance Design (V-BID Center), Thomas Parry, Ph.D., president, and Kimberly Jinnett, Ph.D., research director, both of the Integrated Benefits Institute (IBI), San Francisco. The study was supported by the National Pharmaceutical Council, a health policy research organization funded by pharmaceutical companies.

“Employers can contribute greatly to the transformation of the health system by focusing on value and not simply on financing and who pays,” said Dr. Fendrick. “It is imperative that we move beyond the current paradigm of exclusively measuring medical offsets and include measurement of the effects in increased productivity that accompanies improvements in health.”

Employers generally undervalue the impact of improved health outcomes to businesses and their employees, the authors said. According to IBI’s research-based modeling tool, the Full Cost Estimator, for a 10,000-life sample employer in the health care services sector, for example, medical care costs amount to less than 30 percent of all health-related costs for workers. The remaining 70 percent is associated with wage-replacement payments and lost productivity from absence or reduced job performance from ill health. 

“Including a measure of the economic benefits of good health that reflects the true costs of ill health and the full savings from health improvement would immediately allow decision-makers and payers to make better choices as to how much to invest in health care, prevention and wellness, as well as how to determine the specific services in which to invest,” Dr. Parry said.

Budget Ax Hovers Over Occ Med Residency Programs

Occupational medicine physicians are voicing their concern about a federal budget plan to cut the Education and Research Centers (ERCs) Program within the National Institute for Occupational Safety and Health (NIOSH), which would have a direct impact on OM residency programs.

The centers were established to support academic institutions, promote research, and develop occupational health and safety training programs. It is estimated that NIOSH funds more than 80 percent of occupational medicine residencies; about 70 percent of residents are trained at an ERC. If the centers are eliminated, other valuable continuing education programs in occupational health for community-based practitioners also would be affected. 

In a letter to senators, Natalie P. Hartenbaum, M.D., M.P.H., president of the American College of Occupational and Environmental Medicine Board of Directors, said the White House's FY 2012 budget "proposes to jeopardize funding for occupational medicine training programs at a time when:

1. there is a recognized shortage of physicians training in occupational medicine; 
2. a core strategy of the Patient Protection and Affordable Care Act (PPACA) is prevention; and 
3. workplace health promotion and disease prevention programs are part of PPACA’s National Prevention Strategy."

Meanwhile, in a plea for support being circulated by the New England College of Occupational and Environmental Medicine, the proposed measure is described as “the equivalent of suddenly ending Medicare funding for hospital-based residencies like internal medicine and surgery.”  

NECOEM has prepared a sample letter for occupational health and safety professionals to send to their elected representatives. To obtain a copy, post your request here or write to kohara@naohp.com.

An Entreaty to Demonstrate the Business Case

An American Industrial Hygiene Association (AIHA) white paper containing recommendations on a proposed federal Injury and Illness Prevention Program contains some valuable insights on establishing the business case for occupational health and safety interventions.

OSHA Director David Michaels says the prevention program is the Occupational Safety and Health Administration’s top regulatory priority. In its FY 2011 budget request, the Department of Labor has designated $583 million for OSHA, including $2.4 million for prevention program development.

The AIHA’s recommendations to OSHA are taken in part from its Value Strategy Manual. The manual features findings from a 2008 study of how Fortune 500 companies determine the value of contributions by occupational health and safety professionals, and it presents a solid framework for worker protection.

The AIHA Value Strategy promotes a comprehensive process in which occupational hygienists align risk management with business objectives – similar to what occupational health programs need to do to demonstrate the value of their interventions to client companies and other stakeholders.

The process incorporates the following steps:

1. Identify business objectives and hazards.
2. Evaluate and prioritize value opportunities.
3. Assess risk reduction.
4. Select approach to establish the value proposition.
5. Identify changes and assess impacts.
6. Document and present the value proposition.

In the third critical step, industrial hygienists identify actual or predicted risk reduction(s) associated with the implementation of a program, activity or intervention. The process includes pre- and post-intervention baseline risk assessment.

In a subsequent step, data (cost, performance, quality) are analyzed to determine whether the value proposition is best made using a qualitative or quantitative approach, or a combination of both.

According to the white paper: 

“Ample anecdotal and case study data demonstrate that a systematic approach to OHS management is cost-effective. Many AIHA members and other OHS professionals have demonstrated this in their companies and practice. A large benefit is commonly observed in lower workers’ compensation costs, which in some cases can be significant. Improved productivity and quality are also associated with implementation of these programs.”

Both the white paper and the Value Strategy report reference a number of related studies that are worth checking out. In addition, resources for conducting the risk assessment are contained in an AIHA publication, A Strategy for Assessing and Managing Occupational Exposures, 3rd Edition, and in the American National Standard Institute/American Industrial Hygiene Association Z10-2005, Occupational Health and Safety Management System.

As the AIHA notes: “Imagine what could happen when 12,000 IH experts begin applying this strategy to demonstrate the powerful impact the profession can have on business! We often talk about wanting our profession to be a household name. Now we have the strategy to make that happen. These results are a beginning, not an end.”

Occupational health professionals can learn from this challenge. They must strive to re-affirm their own value proposition in order to best serve clients and patients and have an influential voice in the development of OSHA’s proposed Injury and Illness Prevention Program.

Urgent Care-Occupational Medicine Mixup: What Do You Think?

Robert L Broghammer M.D., M.B.A., M.P.H., of Allen Occupational Health, a hospital-affiliated program in Waterloo, IA, writes us to express dismay about RYAN Associates' plans for an April seminar on Integrating Urgent Care and Occupational Health Services:

"I realize this is a ‘trend’ currently, especially with Concentra, but I must vehemently disagree that the two are complementary let alone easily integrated. While it is true that much of what we do has an ‘urgent’ basis (i.e. lacerations, traumas, chemical exposures, etc.), Occupational Medicine is a distinct and separate discipline with its own ACGME-approved post-graduate medical training programs and separate board certification process.  

"As you know, occupational medicine training focuses on toxicology, epidemiology, statistical analysis, orthopedics, surveillance screening, impairment and disability, wellness, and a host of other specific areas dedicated to the care of workers and their companies. Urgent care is nothing more than a descriptor for a clinic that will see you ASAP for a perceived medical problem. There is no specific knowledge base, even rudimentary, for urgent care providers who may provide services for injured workers covered by the worker’s compensation system or for the myriad of other occupational specific issues that need to be addressed and taken care of.

"Urgent care providers may have extremely diverse backgrounds and there is no formal standardization of training to practice in an urgent care setting – one simply needs a license and a pulse. Family practitioners, internists, pediatricians, physician’s assistants, nurse practitioners, general surgeons, and obstetricians are just a few of the disciplines that I know of personally that have/do practice in urgent care settings.  Likewise, occupational medicine providers, such as myself, have very little or no training in the variety of medical problems that may present to an urgent care center which have no relationship to work. Imagine an infant presenting with a fever versus a normally healthy worker. The differential diagnosis for the two is vastly different. For instance, the worker may have metal fume fever but it is highly unlikely the infant does.

"The integration of the two separate and distinct services will only serve to confuse the clients and dilute the value of providing specific occupational medicine services. The trend, in my opinion, is nothing more than attempting to squeeze a couple extra bucks out of clinics by short-sighted administrators.  Not one of my colleagues who I trained with and who are board certified in Occupational and Environmental Medicine would consider working in such a clinic long-term."

RYAN Associates' President and CEO Frank Leone responds:

"I don't think anyone is saying that it is a wise idea for a clinician to do both occupational medicine and urgent care. Yet they are not that different. The larger issue is economic; blended clinics offer a vast array of economies of scale (staffing, operations, shared equipment and diagnostic tools, sales and marketing, etc.) which not only makes them advisable in the economic climate, but often essential."

Donna Lee Gardner, a senior principal and consultant with RYAN Associates, adds:

"In my opinion, the economy has driven the need for a Total Health Management focus for employers and their employees.

"We are not saying the occupational medicine model should be one with urgent care. We are saying that episodic care in a customer friendly environment that is available to employers and their employees helps reduce emergency department visits, decreases the overall cost of care and provides one-stop shopping.

"The American College of Occupational and Environmental Medicine has long defined the role of occupational medicine as improving the safety and work environment for employers and their employees. What more expeditious way but to improve the health of the workforce AND provide appropriate access to care for all health concerns? Having the occupational medicine provider there can then provide meaningful return to work for all workers for work-related and non-work-related illness and injury."

What do you think? Please comment here or send email to Kohara@noahp.com.