San Francisco does not currently have an effective City-wide program to promote employee health. The Mayor's Shape Up at Work initiative is largely unfunded, and only 22 departments reported having implemented the Mayor's April 2006 directive to incorporate employee health promotion strategies into their mission statements. The City's decentralized approach to employee health promotion programs results in inconsistent information sharing and widely varying employee participation levels across departments.

The existing City-wide employee health promotion programs are managed across a patchwork of departments. The Department of Human Resources and Department of Public Health have shared some responsibility for coordinating Shape Up at Work. The Department of Human Resources currently oversees the Employee Assistance Program. The Health Service System oversees the City's health plans, which provide health and wellness programs to plan members, including health risk assessments, individualized wellness action plans, and follow up.

Additionally, City departments have implemented programs independently, without coordination or information sharing with other City departments or programs. The Health Service System has implemented City-wide health fairs for Health Service System members, and the Department of Public Works has implemented a department health fair independently of the Health Service System. The Police Department and Municipal Transportation Agency have both implemented department-specific physical health and fitness programs, and the Fire Department will begin to implement a program funded by the FEMA Assistance to Firefighters Grant.

Employee Health Promotion Programs in Other Local Governments

The Budget Analyst's Office recorded a number of best practices through a health promotion program survey of nine counties, listed in Table 3.1 below. Seven jurisdictions responded and provided data on employee health promotion programs and activities. The survey responses provided information about how other jurisdictions currently coordinate their employee health promotion programs. This section discusses several practices that could be successfully applied in San Francisco.

Table 3.1

Counties Surveyed for Employee Health and Safety Programs

All of the respondent counties reported central coordination of their employee health promotion programs. The centralized counties reported the following as the host departments: the Risk Management Department, Health Benefits Division in the Human Resources Department, and Public Health. In King County, Washington, an entirely separate centralized program was created. We profile three of these counties below.

King County, Washington's Health Reform Initiative

King County's Health Reform Initiative is a centralized health and safety promotion program organized under the elected County Executive's office. The program is a comprehensive, integrated effort to address gaps in the health care system and to control increasing utilization of health services by county employees. The goals of the program are focused on improving the health of county employees and their families, as well as reducing the rate of cost increase for health care. The centralized program manages an information sharing structure similar to San Francisco's Shape Up at Work through its Health Promotion Leadership Committee, which is composed of representatives from multiple county departments.

The primary differences between the Health Reform Initiative and Shape Up at Work are the dedicated staff and the funding of the Health Reform Initiative. The Health Reform Initiative maintains eight full-time positions, including a program manager, a benefits manager, two communications experts, two health educators, one web manager, and one statistician. The staff supports two primary program areas to promote employee health and safety, including publicizing the health risk assessment to King County employees and employee cost savings through its Healthy Incentives Program, which has resulted in over 86 percent of all eligible King County members completing the wellness assessment and subsequently developing an individual wellness action plan.

To provide King County employees with this continuum of support from program promotion to implementation, the Health Reform Initiative received a total budget of $4.1 million in FY 2006-2007: $1.5 million for the health risk assessment and individual action plan, $1.3 million for smoking cessation, $767,000 for staffing costs, $170,000 for a monthly newsletter, $60,000 for measurement and evaluation consulting, and $332,000 for the Healthy Workplace Funding Initiative, which provides funds to self-organized workgroups to purchase healthy goods and services.

King County's annual funding for the county's centralized Health Reform Initiative is significantly more than San Francisco's annual funding of employee health promotion programs, both in total funding and funding per full time position. As noted above, King County's FY 2006-2007 budget for the Health Reform Initiatives was $4.1 million. This compares to the Budget Analyst's estimate for the City departments' annual funding of health promotion programs for department employees of $814,577. King County's FY 2007-2008 budget is $4.0 billion and includes 13,360 full time positions, compared to San Francisco's FY 2007-2008 budget of $6.0 billion and 27,884 full time positions.

San Mateo County's Health Promotion Program

San Mateo County has operated a centralized employee health and safety promotion program for nearly thirty years. Organized under its Benefits Division in the Human Resources Department, the county centrally coordinates its health plans, work/life programs, retiree benefits, and other employee health and safety promotion programs such as the county's Employee Assistance Program, Workplace Violence Prevention, and onsite childcare. Work/life programs are intended to provide a comprehensive set of programs to "promote health and well-being of the family; increase the employee's capacity to resolve family issues; and ease the demands of balancing work and family responsibilities." Health and fitness programs with a focus on health promotion, physical fitness, and working well programs are also available to San Mateo County employees. According to County staff, in the aggregate, this centralization creates a widely-known and convenient hub for employees to access any employee health and safety promotion program currently offered.

Stanislaus County's Health Promotion Program

Stanislaus County centralized its employee health and safety promotion program, Workplace Wellness, fifteen years ago under the County Executive's Office. The county integrated wellness and mental health services with the county's Employee Assistance Program in an effort to provide coordinated services to all county employees and dependents. According to county staff, programs such as improvisation theater to reduce stress have cultivated a positive perception, helping the county integrate its health promotion programs and move employees beyond stigmas associated with employee behavioral health services. In recent years, the county has begun further developing the physical wellness side of employee health and safety programs, recognizing that its existing "outreach infrastructure" of newsletters, centralized location in the County Executive's Office, and reputation for providing comprehensive health services would facilitate the participation of county employees in a new set of programs.

The Stanislaus County Workplace Wellness program consists of two full time and two part time clinical staff and one administrative support staff. The Workplace Wellness program's FY 2007-2008 budget is $301,054. Stanislaus County's FY 2007-2008 budget is $946 million and includes 4,603 full-time positions.

Centralizing San Francisco's Employee Health Promotion Programs

The Health Service System, which became a separate department in 2005 after being housed in the Department of Human Resources, centrally administers health, dental, and vision benefits, as well as other non-pension benefits for the City employees. Duties include health plan rate negotiations, claims management, employee health outreach, and other initiatives focused on health promotion.

The Health Service System's Wellness Project

The Health Service System has been evaluating the feasibility of a "Wellness Project" through its contract with Mercer for consulting services. This project is being developed outside of the Mayor's Shape Up at Work initiative and other health promotion programs in the City. According to the August 2007 Health Service Board minutes, the Wellness Project would consist of:

• Health risk assessments
• Health coaching
• Fitness and disease management programs
• Behavioral health services provided through the Employee Assistance Program

According to a report provided by the consultant to the Health Service Board on September 13, 2007, the consultant is evaluating wellness programs provided by the City's existing health plans with the intention of evaluating gaps in existing programs and proposing program enhancements. The consultant expects to present the preliminary recommendations to the Health Service Board prior to March 2008.

Coordinating the Health Plan's Wellness Programs with the City's Health Promotion Programs

As noted in Section 1, health risk assessments, coaching, incentives, and individually designed physical activity and nutrition programs are typical components of health promotion programs. Because the Health Service System has begun working with the City's health plans to develop the health plans' existing health promotion programs, including data collection on health plan members' access to the plans' health promotion programs, the Health Service System is the logical home for a coordinated City health promotion program that incorporates health risk assessments, and other key components.

If the Health Service System were to coordinate a City-wide employee health promotion program, the Health Service System should also coordinate the two existing City-wide health promotion programs, Shape Up at Work and the Employee Assistance Program.

The Mayor's 2006 executive directive, establishing the Shape Up at Work Strategies, assigned the Health Service System responsibility for implementing Shape Up at Work, in conjunction with the Department of Human Resources and the Department of Public Health. If the Health Service System were to coordinate Shape Up at Work, the Health Service System would need to work more closely with the Department of Human Resources, the Department of Public Health, and other City departments than it currently does. Presently, the Health Service System is not a member of the Shape Up at Work Steering Committee and has not worked consistently with the Department of Human Resources and Department of Public Health in coordinating Shape Up at Work. Further, the Health Service System has moved forward with its Wellness Project with little discussion or involvement of other City departments.

The Health Service System's Role in Coordinating Shape Up at Work Initiative with the Health Plans' Risk Assessments

By reorganizing Shape Up at Work under the Health Service System, the City could combine health risk assessment services offered by the health plans with the healthy and active lifestyles promoted by Shape Up at Work. As discussed in Section 1, each City health plan already offers a health risk assessment and incentives to enrolled members. The City can use health risk assessment results to plan the City's health promotion programs. Health Service System's Dashboard Project, discussed below, is intended to consolidate and standardize data on the health plans' clinical performance and health plan members' access to wellness and disease management programs. To the extent that the Dashboard data will track aggregate health risk assessment results, the City can tailor the physical activity programs offered through Shape Up at Work to address the most prevalent risks that can be prevented through early intervention.

Integration of Shape Up at Work into the Health Service System would require a more detailed assessment by the Health Service System on how to implement Shape Up at Work effectively, including existing resources within the Health Service System to provide coordinating and analytical support, and availability of aggregate health risk assessment data for worksite health promotion program planning.

Prior to assuming coordinating responsibilities for Shape Up at Work, the Health Service System would need to meet with the Department of Public Health and Department of Human Resources staff who currently work with the Shape Up at Work initiative to identify what is included in coordinating Shape Up at Work and integrating Shape Up at Work into the Health Service System, and a reasonable timeframe for assuming coordinating responsibilities.

The Health Service System would need a plan to continue working effectively with the Shape Up at Work Steering Committee, maintaining channels of communication and ensuring effective outreach to departments' employees.

Members of the Shape Up at Work Steering Committee recommended a coordinator for the Shape Up at Work initiative to centrally manage recurring City-wide programs like the Walking Challenge and Active for Life. Prior to any request for a new position, the Health Service System needs to evaluate existing resources and the costs and benefits as well as the potential budgetary savings from the new position. The budget impact of the coordinator position could be offset with the identification of outside grant funding and community partnerships such as with the American Cancer Society for its Active for Life program.

Integrating the Employee Assistance Program into the Health Service System

Transferring the City's Employee Assistance Program from the Department of Human Resources to the Health Service System would facilitate integration of the Employee Assistance Program into a general employee health promotion program combining mental and physical health programs as well as better link the Employee Assistance Program to mental and behavioral health services provided by the health plans. The Employee Assistance Programs in San Mateo County and Stanislaus County are integrated into the array of employee health benefits in their respective counties. According to both counties' representatives, the Employee Assistance Program is perceived as integral to promoting the mental health of their employees as part of a supportive and comprehensive health promotion environment. Additionally, employee privacy protections under federal Health Insurance Portability and Accountability Act regulations are already in place with the City's health plans managed by the Health Service System and such privacy standards could be readily applied to the Employee Assistance Program.

According to the Department of Human Resources, the Department would not oppose transferring the Employee Assistance Program from the Department of Human Resources to the Health Service System. However, the Department of Human Resources noted that Employee Assistance Program services would need to be available to all City employees, not just members of the Health Service System.

Education and Outreach

Centralization of services under the Health Service System could facilitate outreach and communication, reducing redundancies and filling gaps in employee health promotion. Redundancies currently exist with outreach efforts for Shape Up at Work, the Employee Assistance Program, and the health fairs. All three programs are concerned with employee health and safety promotion, but are publicized through their own ad-hoc communication channels like emails, in person orientation sessions, flyers, and word-of-mouth. The Health Service System could use its existing outreach and communication tools to promote Shape Up at Work and the Employee Assistance Program resources but would need to actively maintain the department communication network of Shape Up at Work as used during the Walking Challenge.

Education and outreach to City employees is integral to the proposed organization of Shape Up at Work, the Employee Assistance Program, and the Department of Public Works' health fair. King County's learning model approach to the Health Reform Initiative involved three stages, based on the belief that employees would adopt positive change in their behavior over time, if given information to support their decisions. The stages included:

• Providing information aimed at increasing employee awareness of the impact of health on costs, productivity, and quality of life;
• Increasing personal commitment to improving and maintaining health; and
• Motivating actual behavior change.

While the breadth of programs offered through a reorganized Health Service System would be broader than those offered through King County's Health Reform Initiative, the education and outreach program was effective in developing countywide awareness and buy-in, which saw over eighty-five percent participation in its health risk assessment in the first year of the program

Maintaining Existing Department Programs

The Budget Analyst's recommendations to assign responsibility to the Health Service System for coordinating Shape Up at Work and managing the Employee Assistance Program are intended to bring these City-wide programs together and link these programs to the City health plans' wellness programs. Bringing these programs together under the Health Service System will be less effective if the current Shape Up at Work Steering Committee and department contacts are not well-maintained. Successful implementation of these recommendations will require an ongoing commitment by the Health Service System to maintain existing and develop new department Shape Up at Work contacts.

The Health Service System's role as the coordinating department for the City's employee health promotion programs would be to work with but not supplant existing City programs. For example, the Department of Public Works' health fair has been able to reach employees not reached by the Health Service System's health fair. The Municipal Transportation Agency is developing a program that mirrors much of the City-wide and Health Service System efforts, including developing individual health promotion plans based on health risk assessments and promoting worksite fitness and nutrition activities, but reaches department employees who may not otherwise participate in City-wide programs. By facilitating the exchange of information between City-wide and department-sponsored programs, City departments can better coordinate their programs with City-wide activities without losing the initiative and specific focus of department-sponsored programs.

Use of Data to Measure Program Performance

In order to evaluate and improve the impact of their programming, Health Service System management will need to develop consistent and integrated data measures into its management practices. Today's leading businesses and governments and nonprofits are mid-process in utilizing data to influence management decisions, including determining cost savings, return on investment, and trend analysis. King County is currently engaged in bringing in professional consultants to manage the development of data measures and analysis, which are described in detail below. King County's process to develop performance measures are outlined in the Attachment to Section 3.

Implementation of the Dashboard System

The Health Service System has not had systems to collect health plan utilization, medical claims, and other cost data. To the extent that employee health promotion programs are intended to reduce employee health risks and the associated medical claims costs, the absence of health plan data prevents the City from evaluating the impact of employee health promotion programs on health plan costs.

The Health Service System is in the process of developing an information system user interface (or "Dashboard") that would allow the four City health plans to electronically transfer utilization and health plan performance data to the Health Service System. The goals of the Dashboard include:

(a) Standardizing reports and data that the Health Service System receives from the four health plans;

(b) Improving financial and performance management of the health plans; and

(c) Measuring health plan members' access to and use of each health plan's health promotion or disease management program.

Once implemented, Dashboard would be able to track:

(a) The distribution of members among the four health plans;

(b) Claims data for the health plans, including the components of paid claims;

(c) Details of hospital and outpatient utilization; and

(d) The ratio of premiums collected to total claims.

According to the Health Service System, the first phase of Dashboard implementation was completed in December 2007. The second phase of Dashboard implementation, which includes measurement of members' use of the health plans' health promotion and disease management programs, will be completed at a later unspecified date.

Implementation of Dashboard should provide the Health Service System with utilization data that is currently lacking. The Health Service System will need to be able to collect and analyze this data to evaluate members' access and utilization of services, and trends in medical claims costs. Dashboard is a new system to the Health Service System, and the delivery and quality of data, as well as the Health Service System's use of the data, is still in development. Consequently, the Health Service System cannot yet show how the data will be collected and analyzed effectively.

The Employee Assistance Program's Database Software

The City also currently has database software that tracks Employee Assistance Program utilization, known as EAPISoft. EAPISoft is already folded into the Employee Assistance Program's current service operations, but would benefit from support from the Health Service Systems' existing analytical staff.

EAPISoft could provide a stronger analytical tool than is currently used. According to the EAPISoft website, EAPISoft has a spectrum of reports and outputs, integrated appointment scheduler, case management guides, comprehensive resources directory, and workplace and clinical outcomes evaluation capabilities, allowing EAPISoft to provide a customized management information system for the Employee Assistance Program to continue tracking and analyzing utilization trends for the City employees.

The Health Service System could use the EAPISoft database to develop workplace and clinical outcome measures. Well-developed outcome measures would allow the Health Service System to evaluate the Employee Assistance Program's existing and potential services and results. With this information, the Health Services System could then identify the Employee Assistance Programs services could be more effectively integrated into a City-wide employee health promotion program.

Program Accountability, Costs, and Savings

A growing number of studies and employer programs have found that employee health promotion programs can contribute to reductions in risky behavior and corresponding health problems, potentially reducing health care and other costs. Whether a coordinated employee health promotion program in San Francisco would ultimately lead to budgetary savings, either through reduced health plan premium costs or reduced absenteeism, is unknown. To ensure the best possible outcomes, including minimizing program costs and maximizing benefits, the proposed employee health promotion program needs to build on existing resources, contain new or increased program costs, and develop strong measures and systems of accountability.

Key components of the proposed central employee health promotion program under the Health Service System include:

• Providing the program at a low cost. Cost components of the program would include program coordination, data collection and tracking, communication and outreach, and direct services. Some of these cost components already exist. The Health Service System has already begun to implement increased data collection capability through the Dashboard project and would assume the Employee Assistance Program's EAPISoft system. The Health Service System also has marketing, communication, and outreach capacity through its existing program to keep health plan members informed of their benefits, including the annual health fairs. The Health Service System would need to carefully evaluate the need for staff positions to provide coordination and analytical support to the health promotion program and present sufficient justification for any position requests.
  
  
• Developing systems to measure productivity, especially decreases in sick leave, disability leave and workers' compensation leave that can be attributed to improved employee health status. The Fire Department could be tested as a pilot, under the Department's wellness and fitness program funded by the recently-awarded FEMA Assistance to Firefighters Grant.
  
  
• Developing performance measures and tracking performance. Performance measures can include participation and outcome. Performance measurement should incorporate some of the practices already developed in King County, Washington, including identifying baseline data, developing the evaluation approach, identifying data needs and collection capacity, and developing specific first, second, and subsequent year measures for participation and outcomes.
  
  
• Achieving high levels of participation. The Health Service System would have to continue to work effectively with the Shape Up at Work Steering Committee and City departments to support worksite physical activity, nutrition, and other health promotion programs, and increase and track worksite participation.
  
  
• Informing members of their health plan benefits. The Health Service System has begun this process through the annual health fairs. The Health Service System should work with the Department of Human Resources and other City departments to provide ongoing information about health plans' programs through existing employee orientation and training programs.
  
  
• Keeping policy makers informed. The Health Service System would need to produce an annual report and report at least annually to the Board of Supervisors on the health promotion program's participation and outcomes.