key: cord-0057261-3rms3wyr authors: Burrell, Gregory; Nundy, Shantanu title: A Return-to-Work Program for Covid-19 for a Multistate Essential Business date: 2021-03-09 journal: NEJM Catal Innov Care Deliv DOI: 10.1056/cat.20.0642 sha: 82b8eea893da69b3b11f18f94368723afc003f81 doc_id: 57261 cord_uid: 3rms3wyr Essential businesses need to protect both their workers and their customers during the Covid-19 pandemic. A manufacturer with a significant on-site service and installation component created a comprehensive program for work site safety, symptom monitoring, quarantine, contact tracing, and return-to-work verification that showed high employee engagement and satisfaction, and an almost 3-to-1 return on investment. » The pandemic is changing daily, and unexpected issues should be expected. Weekly and sometimes twice weekly quality improvement meetings are needed to surface and address issues as they arise. At the outset of the Covid-19 pandemic, essential industries -organizations whose products and services are deemed critical to public health, safety, and national security -employed approximately 90 million people.1 Roughly 50 million of these workers perform jobs that require them to physically show up at a job site to perform their function.1 Employers of essential workers were forced to keep their businesses open and protect the safety and health of their employees quickly while navigating a highly uncertain and rapidly evolving environment. Common challenges included: • complying with continuous changes to regulations and requirements for businesses including across state lines, • communicating to employees with the most up-to-date health and safety information, and • implementing new and costly health and safety measures while facing major financial constraints related to the pandemic. Exacerbating these challenges was a lack of timely access to Covid-19 testing. Accolade partnered with a global manufacturing company to design and implement a comprehensive, evidence-based "return-to-work" program. The company produces, installs, and services HVAC and other equipment for commercial buildings. The organization's goals were to: • protect the health and safety of a population of over 35,000 U.S.-based essential workers in multiple states, • provide essential workers with the assurance needed to feel safe and work productively in their environment, and • demonstrate at least a budget-neutral return on investment from implementing a comprehensive return-to-work program. Our team created a comprehensive and evidence-based strategy, synthesizing U.S. Centers for Disease Control and Prevention (CDC) guidelines with a whole-person, integrated approach. The first step is for employees to enroll through the program's app and/or online portal. The foundational pillars include (see Figure 1 ): • Communication. Regular communications across mobile, Web, and phone engage employees with the latest guidance on staying healthy and complying with healthy-workplace procedures, such as wearing personal protective equipment (PPE), social distancing, and reminding them to complete a regular online self-assessment of their symptoms and exposures. Through the portal and the app, employees receive timely communications about prevention and safe procedures. • Employee Triage. Employees with any questions or concerns about Covid-19 receive access to a nurse line for clinical guidance and triage. Employees with symptoms or exposure are directed to a telemedicine service. Employees requiring testing receive navigation support to local testing options including up-to-date information about costs, scheduling, testing procedures, and wait times. • Covid-19 Condition Management. Employees with Covid-19 receive ongoing telephonebased nurse support for self-quarantining, symptom monitoring, and follow-up care. Nurses also support employees to meet return-to-work requirements as soon as the employee meets local requirements for self-quarantining. • Contact Tracing. For employees who are presumed or confirmed positive, the clinical team conducts contact tracing for any work-related close contacts, defined as being within 6 feet of the positive patient for a cumulative time of 15 minutes or more in a given day. The infectious period is defined as 48 hours prior to symptom onset or prior to positive test if asymptomatic. • Return-to-Work Verification. Regular symptom self-assessment for employees via a mobile app also provides information to daily dashboards for human resources leaders, allowing them to ensure that the workplace is as safe as possible. To have a successful implementation, it was crucial to have internal buy-in from key management stakeholders that the program was mission critical to the business. The issue was framed to the executive team as one of employer commitment and business continuity, to which they agreed. The employer has a diverse population of workers composed of plant and distribution center employees who make up about 25% of the population, and service and installation employees who make up approximately 67% of the employee base, with the remainder being corporate teams. To ensure processes were optimized for each population, the program was piloted in multiple, staggered stages before fully launching the program to the entire population of 35,300 employees. To support the launch, the key stakeholders met twice weekly to identify and solve for known communication challenges with each population segment. We selected pilot groups that would both be representative of the overall population and be open to learning and iterating on the program. Employee communications were built and refined into several versions to support each target audience. Site champions (often local HR managers) were called into the leadership sessions to obtain alignment on rollout plan and success measures. Of particular concern were fears from employees that this program would unnecessarily prevent them from working and being paid or conversely require them to work when they weren't healthy…. Presenting the rules as originating from a separate clinical team and based on clear guidelines helped to alleviate some, but not all, of these fears." As pilot groups rolled out, the key stakeholders continued to meet twice weekly to review dashboards that presented data on key performance indicators such as program adoption, check-in compliance, and clinical utilization. Teams continued to refine the offering, including building in some custom processes such as supporting nontechnical employees with a paper-based process. " Periodic sessions were hosted by the internal HR executives along with local leaders to collect feedback, gain trust, and provide clarity on process. When investigations or escalations arose, the key stakeholders continued to address and test different models to support the urgent need for answers and resolutions. For example, as some employees were not allowed to use phones on the factory floor throughout the day, in certain circumstances contact tracing was turned over to plant leaders so they could contact employees more quickly for quarantine. There were several challenges to overcome. The first was employee buy-in and adherence. Although use of the routine check-ins was mandated, it was unclear what compliance would be. Of particular concern were fears from employees that this program would unnecessarily prevent them from working and being paid or conversely require them to work when they weren't healthy. (Workers could use standard sick leave or paid time off for Covid-19-connected absences, or could apply for medical leave, but the employer did not change its leave policy for the pandemic.) Presenting the rules as originating from a separate clinical team and based on clear guidelines helped to alleviate some, but not all, of these fears. At times, the advice of the medical leadership within the employer or from outside physicians differed from the guidance provided by our medical team. One common example is when the recommendations of the treating physician differed from our return-to-work protocols -either the treating physician decided the member could return to work when our protocols did not clear them or vice versa. Typically, our clinical directors work directly with the treating physicians and patients to discuss the case, understand the rationale, and come to an agreement. In addition, national, state, and local guidelines have frequently changed throughout the course of this pandemic. They are often complex and meant to be interpreted by senior medical leaders and clinicians, not necessarily HR leaders. From June 18, 2020, through November 18, 2020, the program successfully enrolled 28,300 employees, which is 80% of the total applicable population. Enrollment reached 78% within the first month of launch. Amongst employees who work in the field (plant or service operations), enrollment was 95%. Adherence to regular check-in protocol (defined as completing a check-in at least 3 days a week) was 70%. The check-ins were especially important for service workers, who would often have to furnish proof of a successful check-in at the client job site. Not having a completed check-in would mean discipline at work and potentially lost wages. The daily rate of failure of the regular check-in was approximately 2% a day, with a large spike on Mondays. This equated to over 500 members a day. For these, our team of nurses and health assistants supported over 500 interactions a day (messaging and phone) to provide clinical guidance and direction (see Figure 2 ). From June 18 to November 18, 2020, 35% of all enrolled employees received at least one nurse triage for Covid-19. Three percent of this group were referred for telemedicine or a physician visit, and of those referred 99% received testing. The median time from first call to test was 3 days. During the study period, 537 employees were diagnosed with Covid-19. This number correlates to a daily incidence of illness of 99.6 per million. Nationally, the incidence has been 70.3-459.8 daily cases per million during the same period.2 The total program fees to the employer were $6 per employee per month, and with a phased deployment the total savings were $376,826. Thus, the estimated return on investment for the study period is 2.8:1." Contact tracing was completed for 90% of presumed or confirmed cases, and 85% of all workrelated close contacts were successfully reached within 24 hours. Nationally, this number varies widely across different localities in the United States.3 Employee satisfaction was measured by surveying employees following an interaction with our nurses or health assistants. Satisfaction was measured on a 4-item scale (Very Satisfied, Somewhat Satisfied, Not as Satisfied as I Would Like, Not Satisfied at All). Ninety-two percent of employees reported being "Very Satisfied" or "Somewhat Satisfied" with their care. There were two sources of savings: improved worker productivity and lower administrative costs. The first is a reduction in missed days of work. In the absence of the program, we assumed that any potentially exposed or infected employees would miss work for 14 days (per CDC guidelines during the program period). By being able to clear employees to return to work sooner, either immediately because a test was not warranted (Figure 3 , Case 1) or per the CDC guidelines with a negative test for an exposed individual earlier than 14 days ( Figure 3 , Case 2), we were able to improve worker productivity. This resulted in 3,873 saved days of work. With a productivity cost of $15/hour for 8 hours per day, this conservatively equates to an estimated $464,760 savings over the 3 initial observed months of the program. " A second source of savings was from reduced costs on the internal HR team. Each case was estimated to take one hour to resolve (including time coordinating testing, treatment, and return to work). With 3,092 scenarios requiring testing and coordination, the program saved 3,092 hours of administrative time at a conservative cost of $40/hour, or $123,680 in total. The total savings from the program in the first 3 months were therefore $588,440. Not included in this estimate is any downstream savings from prevented infections, which is harder to estimate. The total program fees to the employer were $6 per employee per month, and with a phased deployment the total savings were $376,826. Thus, the estimated return on investment for the study period is 2.8:1. During this pandemic, a large burden of health responsibility has fallen upon employers, especially those that employ essential workers who cannot perform their jobs remotely. As we have worked with employers, here are a few of our learnings so far: • A comprehensive approach is needed, as the amount of assistance offered by various local and state public health agencies varies widely by region and overall is less than desired. • Executive leaders should openly endorse and encourage the efforts of a clinical team to promote safety in the workplace. An endorsement by senior leadership of a strict clinical protocol sends the message that adherence to protocols is in the best interest of the employee, and not meant to be punitive or reduce pay. • Earning the trust of the employee is extremely important, as essential workers may not always trust their employers to act in the best interest of their health. Having a dedicated clinical team to act as an independent advisor to the employee will help significantly as they search for testing and treatment options. • Achieving a medical consensus can be difficult. Guidelines frequently shift as new information emerges; expert opinion as well as routine discussions between our team and the employer's medical advisors was needed. Organizations can begin by developing an internal business case for a comprehensive approach to managing Covid-19. This requires not only the legal perspective, but also a health, operations, and HR perspective. Organizations should identify a single external partner to manage the entire process or invest in a dedicated team to coordinate and manage multiple partners. In either case, involvement of clinical experts as well as the company's own senior leadership will be essential to building trust and getting buy-in across the organization. Essential Work: Employment and Outlook in Occupations that Protect and Provide Coronavirus Pandemic Data Explorer. Our World in Data Contact Tracing Is Failing in Many States: Here's Why. New York Times. The New York Times Company The authors would like to acknowledge the tremendous efforts of Sally Jessup, Kristen Bruzek, Phong Nguyen, Kevin Keller, and many others in helping on this project.Disclosures: Gregory Burrell and Shantanu Nundy have received salary compensation and stock compensation from Accolade, Inc.