Olsen, Kerry D. M.D.; Warren, Beth A. M.B.A.
Government, employers, communities, and individuals are all aware of the rising health care costs and the unsustainable current health care and reimbursement model. Mayo Clinic, as a leading health care institution, is committed not only to the care of the sick but also to the prevention of illness. One of the founders, Charles H. Mayo, M.D., said in 1932, “The object of all health education is to change the conduct of individual men, women, and children by teaching them to care for their bodies well.” The unfortunate reality is that we don’t care for our bodies well. Modifiable behaviors account for the majority of conditions that contribute to health care costs. Obesity and physical inactivity account for more than 25% of our nation’s health care costs, and the cost of smoking and problem drinking equals the cost of obesity (4,5). Overall, more than 75% of the health care costs of the United States is attributed to chronic conditions, which, in most cases, are preventable (1,6). It is easy to estimate that more than 50% of health care costs would be gone tomorrow if people didn’t smoke; maintained an ideal body weight; improved their nutrition; increased their aerobic capacity, strength, and flexibility; used alcohol moderately; developed social connections; and practiced common safety behaviors. All these lifestyle choices are possible without medications or medical procedures. Data show that the health of a population is measured by several factors: health care, social circumstances, genetics, environment, and individual behavior. The greatest of these factors is an individual’s behavior (40%), while genetics (30%), social circumstances (15%), environmental exposures (5%), and health care account for only 10% of the population’s health (3).
It is evident that we must focus on behavior to have any chance of changing the health of our work force, community, or nation. This article describes the implementation of a new model of care. Mayo Clinic is integrating health and health care at a level where the health and wellness professional is a valued member of the health care team. In addition, an onsite health and wellness facility is transitioned from a perceived workout center to a true integrated medical wellness center. This review will focus on lessons learned and the challenges of integrating these important areas of health — the health care world and the wellness world.
The Mayo Clinic staff in Rochester, MN, is the employer, the provider, the insurer, and the employee. Currently, there are 40,000 employees and an additional 46,000 dependents with total health care costs of more than $350,000,000 per year. As an employer, Mayo is committed to the health and well-being of its work force. Their health is essential in creating an unparalleled patient experience and in maintaining an efficient, productive work force. The leadership at Mayo Clinic recognizes the importance of healthy living in prevention and treatment of many chronic diseases. As a result, they have incorporated this language into the mission statement of the organization.
For many years, Mayo Clinic managed employee health and wellness through a suite of offerings including a health risk assessment, online telephonic coaching, 24-hour nurse care line, individualized Web-based health risk management, education programs, treatment tools, benefit incentive programs, healthy living newsletter, disease management programs, and comprehensive general and specialty health care. In addition, the Rochester campus had two small onsite fitness centers. In 2007, the worksite wellness offerings changed dramatically with the construction and opening of a new medical wellness center, the Dan Abraham Healthy Living Center (DAHLC).
Mayo Clinic’s vision for worksite wellness is to be the healthiest work force in America. To improve our employees’ health, we knew we must work on prevention and reduce adverse health risk factors. Our programs were designed with outcome-based measurements to promote continuous improvement that would lead to engagement and behavior change over time.
The Mayo Clinic Healthy Living Committee established the strategic direction for employee wellness on the Rochester campus. The committee is responsible for supporting healthy living in the Mayo Clinic work force, and it includes interested and passionate people in the areas of Preventative Medicine, Cardiology, Endocrinology, Psychiatry, Psychology, Employee and Community Health, Sports Medicine, Food Services, Benefits, Education, Research, and Communications. The team focused their activities around five strategic initiatives: assess the population for health, risks, preferences, and unmet needs; develop organizational policies that support a healthy living culture; maximize work force engagement and behavior change strategies; design and deliver appropriate, targeted healthy living interventions; and measure effectiveness of initiatives.
THE DAN ABRAHAM HEALTHY LIVING CENTER
The DAHLC was developed as the cornerstone for onsite health and wellness offerings at Mayo Clinic and serves as the main effecter arm for worksite wellness strategies. The vision for the center was robust and included a phased approach to meet the needs and interests of a variety of markets — employees, patients, and consumers. The goal of the first phase was to expand the limited onsite fitness offerings and include a broader focus on wellness areas, such as nutrition, stress, and sleep. The demand for onsite wellness services was well established through employee participation in Rochester, yet the space was limited. Objectives for phase II were to introduce the health and wellness professional into current models of care. They needed to become part of the health care team, both primary and specialty care models. Future phases include providing healthy living offerings to consumers and patients.
The current operation includes 95 team members, both allied health and physician staff, and 115,000 sq ft of studio, equipment, and programming space focused on serving a target population of employees and dependents. Key design and programming elements were to maximize staff engagement and achieve sustainable results. Our target audience was the nontraditional exerciser. Initial focus groups identified common barriers to participation, such as perceived lack of time, intimidation, child care availability, parking, and cost. Principal architectural elements included natural lighting, social space, activity aligned color palate, green space, accessibility, locker rooms with privacy, and the inclusion of specific areas, such as a women’s only space. The facility is open to any Mayo Clinic employee to use the cafe area, banking services, research programs, or a variety of meeting areas. Employees also can opt in for membership at a fee that is set at a level low enough to not discourage use but high enough to have some “skin in the game.” In addition, we wanted to encourage regular use, so we added an incentive program.
This is not just an exercise facility, although there are 160 cardiovascular machines, indoor track, and exercise and lap pools. The initial space and programming was designed to provide a full spectrum of offerings in five areas: aerobic conditioning, strength and flexibility, stress reduction, weight reduction, and optimal nutrition. Equally important to the facility design in achieving a successful revolution in preventive care was to create the right healthy living environment that was desired by the employees, offerings that focused on a variety of member needs and interests: a nonthreatening, welcoming atmosphere; exceptional service; and a motivating experience. Our hiring practices and on-boarding processes include all aspects of service delivery. Did we hit the mark? Membership is currently more than 16,000 people, with nearly 4,000 users per day. Every day, 850 people are served through individual and group classes and services. Are we reaching out to our target market? In 2007, 50% of membership reported being overweight, and 40% had never belonged to any health club; so clearly, this was the group we wanted to reach out to and engage in onsite programs.
Knowing that Mayo Clinic had invested significant resources to establish an outstanding onsite medical wellness facility, the logical next step was to integrate the areas of health and health care for the health of Mayo staff. The health risks of Mayo Clinic employees are similar to many organizations: sedentary lifestyle, stress, overweight, and high blood pressure. Additionally, the Mayo Clinic Healthy Living committee reviews the overall employee health cost data and develops programs with the highest potential benefit. When reviewing current health care and pharmacology costs, we determined a need to offer more programs focused on stress reduction, back injury prevention, and sleep.
The challenge was to go beyond the initial success of a busy employee wellness center and develop new models of care to address these health risks as a team. We met with primary and specialty care providers and introduced new solutions to address these patient needs. We talked about how to maximize the use of this onsite facility and team and how an integrated model would serve their patients more effectively and could help prevent and manage chronic and lifestyle-related health conditions.
From the time the new center opened in 2007, the DAHLC team members were told at staff meetings that they would be new members of the Mayo Clinic health care team. In many cases, they could do more than physicians or nurses to improve the health of people and prevent future disease. The first pilot program was initiated with a small group of primary care physicians who were encouraged to refer to the center those employee patients they felt would benefit from a lifestyle intervention: a wellness evaluation or consultation, treatment for stress reduction, weight reduction, or optimizing nutrition and exercise. At the conclusion of this pilot, the outcomes on employee and physician satisfaction were at a level that the program became an accepted model of care to address the common health risks of employees. Today, Mayo Clinic primary care providers can order services for their patients at DAHLC through the same ease and method they would use to order a chest X-ray.
Another distinguishing element with this phase of the vision was the front desk appearance. Mayo Clinic has devised a system for patients to easily identify check-in desks for clinical services. The member check-in area at the center became a new clinical designation point. There is no distinction from the member desk at the DAHLC to a similar clinical desk in Cardiology or Surgery.
THE ROLE OF THE ELECTRONIC MEDICAL RECORD
To effectively, efficiently, and safely communicate with our physicians and other health care providers, the wellness center team needed to have access to the electronic medical record (EMR). This process of establishing access was organizationally complex in terms of legal recuse, committee approvals, staff training, and chart documentation requirements and framework. The final result is that the DAHLC staff is appropriately using the EMR as part of a new model of expanded health care. Patients that are referred to the DAHLC staff are seen in an evaluation area that meets requirements for patient safety and quality. Individuals meet with a certified health and wellness coach, complete a series of wellness questionnaires, and walk away with a personalized plan of action. Some patients choose to meet their goals on their own; others engage in services at the center that match their interests and goals. Additionally, employees now can have point-of-care laboratory testing that measures glucose, total cholesterol, low-density lipoprotein, high-density lipoprotein, and triglycerides. All these results are entered into the Mayo Clinic employee’s EMR. Staff training protocols, business procedures and policies, and space requirements are now compatible with accreditation requirements, similar to any clinical area at Mayo Clinic.
USING INFORMATION SYSTEMS TO NUDGE BEHAVIOR
Mayo Clinic introduced a new innovative software tool, General Disease Management System, to try to improve rates of preventive services testing (2). This tool contains a rule-based application coded with national guidelines for age- and sex-specific preventive services and process and outcome measures for diabetes and coronary artery disease. This report can be generated in two ways: by the patient or the provider. Patients now can request a printout of their preventive services report at the DAHLC desk. In addition, providers can print their patient reports and check for any missing screenings or tests. Rules have been established according to body mass index (BMI). A BMI score higher than 30 generates an automatic wellness consultation at the DAHLC. A BMI of 25 to 30 triggers a recommendation for a wellness evaluation to DAHLC. In the near future, the identification of metabolic syndrome factors also will lead to an automatic referral to the DAHLC. The introduction of this electronic nudge has doubled the demand for the DAHLC wellness consultation services (Figure). The wellness consultations are delivered by a certified wellness coach. The coaching skill set is important in establishing an appropriate action plan, which may include ongoing wellness coaching or other wellness interventions.
Figure. General Dise...Image Tools
CLINICAL HEALTH SCREENINGS
To provide another venue for access to health providers and evaluations, we initiated clinical screening clinics. These are held on Tuesday evenings, 5:30 to 7:30 p.m., first come, first serve basis, at no cost to employees. The types of services offered include dermatologic assessment of a skin lesion, dental evaluations, and sports medicine examinations. Providers determine the necessary care of all patients, some resulting in follow-up appointments in their respective clinical areas. The clinical areas have been impressed with the types of cases presented during these sessions. Numerous benefits have been experienced through this new model of care, including detecting disease that might have otherwise gone untreated. Providers have appreciated the short focus appointments, and this drop-in model has freed up consultation appointments that can be offered to new patients versus to our employee patients. Patients appreciate the convenience of being able to receive these clinical services at their medical wellness center. The initial success of these clinics has led to an increase in our offerings of other focused screening clinics in the areas of biometric health screening, nicotine consultation, women’s health, Employee Assistance Program, and financial planning. This drop-in model has been effective with providing on-site immunizations as well.
Specialty areas also are demanding access to the health and wellness professional. We have established partnerships with colleagues in obstetrics and gynecology and developed a healthy pregnancy program. Other integrated programs include targeted programs for patients with fibromyalgia and cardiovascular rehabilitation and those seeking complementary and alternative treatment.
The incorporation of the DAHLC team into the health care team is a seamless integration of health into health care. This model should better meet the complete health needs of our employees and their dependents. Since the inception of the DAHLC facility and program, staff satisfaction surveys have shown a marked increase from 2006 to 2009. As to the response to the question “Does Mayo Clinic take a genuine interest in employees’ well-being,” the percentage of favorable response went from 66% to 81%.
Clinical providers have been pleased that the health and wellness team can spend more time reviewing and recommending lifestyle interventions and health behavior change. The DAHLC staff has noted more pride in their activities and recognition as to the important role they play in disease prevention and treatment. Mayo Clinic employees have voiced strong support for the many interactions and programs at the DAHLC.
Member use has shown that a quartile division of annual use correlates positively with increasing use and lower BMI, fewer comorbidities, and reduced health care costs.
Mayo Clinic is committed to providing an unparalleled patient experience as the most trusted partner in health care. We suggest that the integration of the health team with the health care team is an essential and necessary step in improving health and well-being and treating the whole person. Only time will show if this is indeed true. A variety of strategies including policies, programs, incentives, education, and penalties are all likely necessary to meet the individual needs of a diverse population. We believe that many of the programs and innovative approaches currently in use at the Mayo Clinic DAHLC may be applicable to other wellness centers in this country. Our hope is that many future programs will be developed, and people will benefit from the integration of the health and health care staff and facilities; disease management and disease prevention can and must be improved.
CONDENSED VERSION AND BOTTOM LINE
Health care systems have yet to discover the benefits of integrating the health and wellness professional into their multidisciplinary teams and improve patient care. Mayo Clinic is leading the way through the expanded role of the health and wellness professional, the introduction of new information strategies, and a commitment to patient health and well-being by integrating health and health care. The health and wellness professional will have a new role in innovative models of care that adds value to the total patient care experience.