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Health Promotion Plan – Part 2

The most common screening performed in wellness programs is heart health assessment.

The screening can include a written heart health test, blood pressure (BP) measurement, cholesterol/HDL-cholesterol test, glucose (blood sugar), weight, educational materials specific to diet, nutrition, exercise, cholesterol, use of tobacco, and weight.

The health professional conducting the screening then provides a consultation and helps set objectives with the participant.

The backbone of wellness programming at the worksite is medical testing. It is the first major activity a business ought to do when first beginning a wellness program.

Medical screening is often used coupled with the administration of a Health Risk (Assessment|Appraisal} .

The most effective way to screen is to utilize a health specialist trained in wellness screening techniques and counseling to privately and individually assess participants.

This wellness expert takes a brief health history and measures blood pressure (BP) and cholesterol. With computerized cholesterol desktop analyzers, results are acquired in about four minutes.

Immediate feedback, consultation, and educational materials are provided. for those identified at-risk, follow-up appointments could be scheduled at this time. the whole process takes about twenty minutes per individual.

The screening also provides an immediate opportunity to register participants in various health betterment programs based on their interests and identified health risks.

Medical screening may be done on an annual basis and used to monitoring health risks within the worksite.

A health screening program needs to provide multiple opportunities for participation. the service should be provided for all the various shifts of a corporation. the screening program should be conducted in highly visible areas so the process may be observed.

Reluctant employees often like to be able to see what the program is about before they participate. When wellness screeners aren’t busy, they should perform outreach going to areas where employees gather and try to recruit employees.

When well-planned and promoted, biometric screening can attract participation rates of 60% to 100%. These high participation rates have a positive impact on management producing support for further programming.

Goals are broad-based statements about what the program is expected to do. the goal of the wellness program is to enhance the health of the individual and the organization. Goals like mission statements provide direction in a program.   

Goals are specific and provide a means of measurement of the program to determine effectiveness. There are two kinds of goals, process and outcome.    

Process objectives state the activities that need to occur to achieve a desired outcome.

Examples of process objectives are –

В• Number of participants screened

В• Number of participants in and completing health improvement programs

В• Satisfaction of program participants

В• Number of participants who were medically referred and saw their doctor

В• Number of promotional activities

В• Number of participants seen in follow-up

Example of outcome objectives are –

В• Number of participants who improved fitness level

В• Number of participants who lowered cholesterol level

В• Number of participants who lost weight, body fat

В• Number of participants who quit use of tobacco

В• Number of participants with high blood pressure (BP) who decreased their blood pressure (BP)

В• Number of participants whose initial level of alcohol consumption put them at-risk who are no longer at-risk

В• Number of participants with risk factors who saw their doctor and are being treated for high blood pressure (BP) or cholesterol years later

Wellness committees are important in that they create a sense of ownership in the program, and facilitate various tasks involved in wellness programming at the workplace.

The committee should be composed of a cross-section of workers representing various occupations, levels, and subgroups with the organization.

A common mistake is filling the committee with the most health/fitness-conscious individuals  in the business. Don’t rely solely on volunteers to fill a committee. Be certain that your committee members have enough power in the business to run an effective wellness program.

The wellness committee is made up of employees from the workplace. It oversees the wellness program and helps carry it out.

The committee ought to meet about once a month to review the previous month’s activities and plan future ones. When the program is just beginning, the committee may meet weekly until things get going.

Committee members don’t carry out medical procedures, counsel patrons, or handle confidential medical information. Wellness specialists perform these tasks.

In general, the committee’s duties fall into three areas –  planning, promoting, and helping to run programs.

Planning the programs can include –

В• Finding space for activities

В• Planning and organizing worksite-wide events such as contests

В• Analyzing reports prepared by the program staff and making recommendations

Promoting the program can include –

В• Recruiting staff members to participate in screening and health betterment programs

В• Encouraging staff members to participate in follow-up counseling

В• Organizing promotional strategies using newsletters, signs, bulletin boards, computers, and other media available within the workplace

Helping to run the program can include –

В• Setting up equipment for various activities

В• Assisting to conduct worksite-wide activities

В• Monitoring all activities and investigating  the performance of the expert staff

В• Acting as wellness mentors to fellow employees

The size of the wellness committee will be dependent on the size of the organization. Select members by asking day management to nominate or appoint staff members.

Make an announcement through flyers, memos, and meetings to recruit potential members. Explain the purpose of the committee, duties and responsibilities, and the time commitment.

Recognize your wellness committee volunteers. Allow them to participate in programs at a decreased cost. Hold appreciation breakfasts/lunches/dinners.

Print names of committee members on business communications about the wellness program.

Purchase special T-shirts, caps, and buttons for them. Write letters to supervisors saying that you appreciate the member’s service. Create awards certificates for members.

The following may be used as a guide for committee size –    

В• Less than 300 employees   2 to 4

В• 300 to 1,000 employees   4 to 6

В• 1,000 workers or more   6 to 12

Effective wellness programs recognize the importance of building a supportive cultural environment. the workplace culture includes shared values/heartfelt beliefs about what’s important. It includes social standards of expected and accepted behavior called “cultural norms.”

It includes colleague support from family, friends, and colleagues. This support can help one adopt healthful lifestyles. Tools are available to audit a company.

The long-term success of any wellness program is dependent on the corporate culture.

Some healthful culture signs in a corporation are –

В• Employees communicate openly

В• Leaders support diversity and opinion

В• Employees have fun

В• Policies support wellness

В• Workers are encouraged to grow

В• Employees work together as a team

• Employees’ skills and talents are matched to their jobs.

В• Flexible work schedules are available

В• Businesss consider employees as their most valuable asset

Effective wellness programs try to develop healthful workplace climates. A healthful workplace climate is one which encourages teamwork, cooperation, and empowerment of the individual.

People  have a sense of community, a shared vision, and a positive outlook. Policies promote and support wellness efforts within the workplace.

В• Effective programs identify ways that company policies and organizational traditions encourage wellness.

В• Effective programs work at the group and organizational level to build support for healthful lifestyle options.

В• Effective programs set clear target objectives and objectives for the health improvement of the worksite.

An initial health screening can include a recent survey of employees’ interests as part of the assessment. Successful wellness programs are designed to meet the needs and interests of the staff members.

The information you need to get from a recent survey depends on the scope of your program. A sample survey may be obtained in the HOPE Publications Web site.

When you plan to adapt this sample survey or develop your own survey, keep the following hints in mind –

В• Ask mainly closed-choice questions, namely when you will be sending the survey to a large number of employees. Closed-choice questions provide specific choices and are easy to tabulate. You might want to use a computer for data entry and analysis.

В• Invite comments, suggestions and recommendations, or ask open-ended questions after the survey. Open-ended items are more difficult to summarize.

В• Include a brief explanatory cover letter with the survey with the signature of the company president. Make certain to include a statement about confidentiality and anonymity.

В• Ask a group of representative workers to review the survey before it is distributed. Find out if the questions will be understood by workers and will not be objected to.

В• Include demographic information at the beginning or end of the survey. Consider various ways that you could analyze the responses by demographic characteristics (gender, age, shift, site, department, etc.).

When considering who should get the survey, a simple rule is when you have under 500 staff members, everybody should receive one. the public relations advantage of everybody receiving a recent survey may be significant.

Over 500 staff members, a sample of the work population will suffice. A sample saves on costs and time. You could want to consider consulting with a statistician to determine an appropriate sample size for your worksite.

Needs surveys are confidential and anonymous; they don’t request information that may identify a individuals.

Getting support from management is crucial to the success of the program.

One way to do this is to survey managers (see forms) and conduct interviews with decision-makers in the organization. You can use the surveys here or make up your own.

If you decide to do your own, keep the survey short. It should not take more than ten minutes to complete.

The interview process can also serve to educating management. Give concise fact sheets on the benefits of wellness programs for management.

When surveys and interviews are completed, tally the surveys and write brief summaries of the interviews. Provide these reports to management.

Once completed present a brief executive summary to management. Highlight several intriguing findings that can be used immediately to make decisions about the program.

Utilize charts and graphs to make your points. Prepare a detailed report for wellness committee members itemizing each response. Provide a short article about the survey in the company newsletter.

The higher the response the more accurate and reliable the results. A minimum response of 40 percent to 50 percent is acceptable.

Robust wellness programs involve all employees, deal with all major health risks, offers options, and target both the employees and the worksite environment; provide periodic analysis of its results.     

Extensive wellness programs emphasize follow-up and offers support for the worker as long as he/she is employed. Studies have shown this approach to be highly successful. Key components are planning, implementation, and investigation.   

Planning robust wellness programs involve performing a needs and interest assessment, appointing a wellness committee, selecting  wellness providers, establishing goals/objectives for the wellness program, advertising/promoting the program, and establishing procedures to ensure confidentiality.   

Implementation of robust wellness programs consist of five major tasks –    

1   Health testing and referral

2   Follow-up and counseling employees

3   Follow-up with doctors

4   Health improvement programs

5   Organizing worksite-wide activities.

Examination involves monitoring wellness programs to find out when it’s working and to help you refine it. Measuring success shows what you have achieved, helps justify costs, and provides information for management to support continued programming.   

Comprehensive wellness programs involve all employees, deal with all major health risks, offers choices, and target both the employees and the worksite environment; provide periodic examination of its results.     

Comprehensive wellness programs emphasize follow-up and offers support for the employee since he/she is employed. Studies have shown this approach to be highly successful. Key components are planning, implementation, and investigation

Planning extensive wellness programs involve performing a needs and interest assessment, appointing a wellness committee, picking  wellness providers, setting goals/objectives for the wellness program, marketing and advertising/promoting the program, and establishing procedures to ensure confidentiality

Implementation of extensive wellness programs consist of five major tasks –

В• Medical testing and health risk (assessment|appraisal}

В• Follow-up and counseling employees

В• Follow-up with doctors

В• Health improvement and disease prevention programs

В• Organizing worksite-wide wellness program activities.

Analysis involves monitoring wellness programs to find out when it’s working and to help you refine it.

Measuring success shows what you have achieved, helps justify costs, and provides information for management to support continued programming.

Initially introduced by Halbert Dunn in the 1950′s, wellness became a popular buzzword during the late 1970′s and received considerable academic attention in the 1980′s.     

Wellness programs for employees became more widespread during the following decade, and credible evidence for their economic viability began to be published.     

There have now been over 100 published studies on this topic and a number of systematic reviews.

Health risks increase costs.  Medical and health insurance costs escalate with both age and number of risks present.8,10   the number of risks is also strongly related to sick leave absenteeism, Employee’s Compensation costs, short-term disability, and reduced productivity (“presenteeism”).

Early worker wellness programs were relatively basic and typically produced a return on investment (ROI) of less than one dollar for every dollar spent operating the program (ROI = <1 – 1).8

Such programs could  be characterized as “fun-oriented”.  Participation is entirely voluntary, and there’s no particular focus on the reduction of particularly identified high risks.  

Interventions and activities are not customized, and there is no emphasis on the management of healthcare costs.  These programs are normally site-based only, lack choices to address all of the major behaviorally-related health risks, and lack multimodal presentation.  

Minimal or no incentives are provided to workers for participation, and services to spouses and family members aren’t available.  Most such programs lack meaningful analysis.  

More conventional programs are “activity-oriented” and have shown an ROI of between 1 – 2.5 and 1 – 3.5.8 These programs might have a greater emphasis on health and risk reduction, although the efforts are relatively wide and not personalized.  

They might have some generalized emphasis on healthcare cost management, although not necessarily aimed at specific high risks.  Most are site-based and voluntary, with spouses included only rarely.  

Modest incentives may  be utilized to encourage participation.  Formal evaluation may  be weak.

The newest and most economically viable programs are “results-oriented” and exemplify the health and productivity management model.  These programs consistently produce return rates of 1 – 4 or greater within a 12-24 month period.8  

Such programs are strongly focused on the reduction of especially identified high risks and the management of healthcare costs.  They are generally voluntary, but use strong financial and other incentives to promote participation.  

They are multi-component in nature (address all major risks), and have both onsite and virtual modalities of operation.  The interventions are highly targeted and individualized, and offered to spouses in addition to employees.

For companies, the cost of providing health insurance for their workers is of excellent importance.  Those costs have been increasing at annual rates between 6 percent and 14 percent.

Chapman’s 2007 systematic review7 stated an average reduction in health care costs of 26.5 percent as a result of staff member wellness programs.  His review covered 60 of the most scientifically precise studies, with an average of 3.77 years of study.

Absenteeism due to illness is another cost driver.  Chapman’s review7 reports an average reduction in sick time of 25.3 percent.   Cost for Employee’s Compensation was decreased by 40.7 percent, and disability costs by 24.2 percent.

There’s also an emerging literature on the costs of presenteeism (reduced productivity).11,13  In one study, every risk lowered through a wellness program yielded a 9% reduction in presenteeism (and a 2% reduction in absenteeism).11

Some companies have achieved a zero% increase in healthcare costs across at least brief periods of time.10  Doing so requires 90-95% participation of the worker population in focused wellness programs, with 75%-85% of the staff members falling into the low risk category.10     

Although comprehensive efforts to lower the risk status of those in moderate or high risk categories must be made, the needs of currently healthful workers must be addressed as well to avoid increases in risk-status.   

Given the size of the federal workforce, meaningful cost savings in the government’s contribution to health insurance premiums for employees could be achieved if a majority of that population were participating in active wellness programs.     

Similarly, improvements in absenteeism, employee’s compensation, disability, presenteeism, and turnover then of extensive employee wellness programs would yield substantial fiscal benefits for the government.   

References   

1   Aldana, Steven G.  (2001)   Financial Impact of Wellness Programs –   A Robust Review of the Literature.   Am J Wellness 15(5) – 296-320.

2   Chapman, Larry.  (1998)   the Role of Incentives in Wellness.  The Art of Wellness  2(3) – 1-8.

3   Chapman, Larry.   (2003)   Biometric Screening in Wellness –   is it Really as Important as We Think?  the Art of Wellness  7(2) – 1-12.

4   Chapman, Larry.  (2005)   Meta-Investigation of Corporate Wellness Economic Return Studies –  2005 Update.  The Art of Wellness, July/August, 1-15.

5   Chapman, Larry.   (2006)   Worker Participation in Corporate Wellness and Wellness Programs –   How Important are Incentives, and Which Ones work Best?   North Carolina Medical Journal   67(6) –   431-432.

6   Chapman, Larry, Lesch, Nancy, and Passas Baun, Mary Beth.   (2007)   the Role of Wellness Coaching in Corporate Wellness.   the Art of Wellness, July/August, 1-12.

7   Chapman, Larry.  (2007)   Proof Positive –   an Analysis of the cost-Effectiveness of Corporate Wellness.  Northwest Health Management Publishing, Seattle, WA.

8   Chapman, Larry.  (2007)   an In-Depth Look at the Economic Evidence for Rewarding Health Behavior Change.   Workshop presentation at the World Research Group “Rewarding Healthful Behaviors for Health Plans and Employers” Conference, Orlando, FL, January 23-24.

9   Edington, Dee.   (2001)   Emerging Research –   A View from One Research Center.  American Journal of Wellness 15(5) –  341-349.

10   Edington, Dee W.  (2007)   Health Management as a Serious Company Strategy.  Presentation at the World Research Group “Rewarding Healthy Behaviors for Health Plans and Corporations” Conference, Orlando, FL, January 23-24.

11   Pelletier, Barbara, Boles, Myde, and Lunch, Wendy.  (2004)  Changes in Health Risks and Be certain to work Productivity.   Journal of Occupational and Environmental Medicine, 46(7) –  746-754.

12   Pelletier, Kenneth R.  (2005)   A Review and Analysis of the Clinical and Cost-Effectiveness Studies of extensive Health and Disease Management (DM)Programs at the Worksite –  Update VI 2000-2004.  JOEM 47(10)1051-1058.

13   DeVol, Ross, Bedroussian, Armen, et. al.  (2007)  an Unhealthful America –   the Economic Burden of Chronic Disease.  Report released by the Milken Institute.   www.milkeninstitute.org.

14   Partnership for Prevention.  (2008) Investing in Health –   Proven Wellness Practices for Workplaces.   http – //www.prevent.org/images/stories/2008/investinginhealth_finalfinal.pdf.

Corporate America is increasingly investing in staff member wellness because it is good company.  In order to meet productivity demands, companies must rely on a healthful, productive workforce to succeed in the highly competitive global marketplace.  

Over a hundred studies in both corporate and governmental settings have documented the economic advantages of staff member wellness programs, including lowered absenteeism, lowered injuries and workman’s compensation costs, lowered healthcare costs, lowered staff member turnover, in addition to increased productivity, greater staff member satisfaction, and improved morale.1-10  

The more recent literature reflects improvements in wellness programming along with greater return on investment.  In general, the more focused and intensive the program, the greater benefit realized.  

To enhance their effectiveness federal government employee wellness programs could  be able to incorporate some features described.  Staff Member wellness programs shown to have positive returns on investment often include the following features –    

1   Health and productivity management model

Programs characterized by this model focus attention on identification and reduction of specific risks or behaviors like tobacco use, lack of exercise, excess weight, unhealthy diet, high cholesterol, high blood pressure, stress, depression, and so on.     

High-risk workers are especially targeted for intervention, although the most successful programs also direct efforts towards healthy workers in order to maintain their low-risk status.  This model emphasizes outcomes as opposed to simply offering wellness activities for their own sake.     

2   Health risk (assessment|appraisal}

Use of a computerized health risk (assessment|appraisal}  instrument with individualized feedback and recommendations is nearly universal in successful programs.  Staff Members take the questionnaire each year in many cases.     

The HRA serves to increase awareness, provide direction, and motivate individuals to improve specific behaviors.  In some cases, the customized report is directly linked to appropriate resources related to identified risks.     

Research indicates that the use of an HRA is effective if it’s followed by some kind of educational or therapeutic intervention for identified risks.  It often serves as the entry point into wellness programs.   

3   Biometric analysis

A lot of wellness programs combine the results of the health risk (assessment|appraisal} with measurement of each employee’s biometrics, including weight and Body Mass Index , blood pressure, cholesterol, fasting glucose, and assorted other metrics.     

Combining the results of the HRA with biological measures causes a more precise risk profile.   Computerized health risk (assessment|appraisal}s often incorporate biometric data in their risk analysis.   

4   Wellness Program Incentives

Employees are frequently given monetary or other significant rewards for completing an HRA, participation in a program or class, specific accomplishments such as stopping smoking, losing weight, or exercising, and for maintaining healthy status and/or behaviors.     

In many cases the monetary incentives are associated with reductions in medical insurance premiums.  Some programs use disincentives in addition to incentives, like charging workers who smoke higher rates for their medical insurance contribution.   

5   High wellness program participation rates

Successful programs use incentives to drive participation rates up.  They also market their programs robustly, and may use contest or challenge strategies to heighten enthusiasm and encourage participation.   

6   Wellness coaching

Workers with identified risks or desire to improve their health habits may  be periodically coached via telephone by trained health coaches.     

Coaching helps workers set and achieve realistic lifestyle-related goals including those addressing stress, work life balance, use of tobacco, weight, physical activity, and various behavior modifications.     

Three or more sessions are generally offered.  In some intensive programs, the coaching extends to actual disease management (DM) intervention for employees with identified high-risk illnesses.    

7   Multiple formats

Programs may offer wellness content in online, paper, and seminar formats to provide stimulating variety and alternatives to accommodate the needs of all employees.     

In addition to onsite physical activity and healthy consuming events, on-line programs, e-mail reminders and notices, printed newsletters and materials, and workplace courses and workshops are common dissemination strategies.   

8   Upper management support

Enthusiastic and frequent endorsement by  senior level management is critical to achieving high rates of participation.  When senior executives are wellness role models themselves the effects of endorsement are enhanced.   

9   Frequent contact

Successful programs have frequent contact of some sort with every employee.  This might  be through advertising efforts (e.g., posters, e-mail notices, reminders, or messages, etc.), bulletin boards, newsletters, staff meeting presentations, discussion in new employee orientation, supervisory sessions, etc.      

The key is to enhance staff member awareness of wellness opportunities and reinforce the corporate emphasis on wellness through frequent and multiple “touches”.   

10   Open enrollment

To encourage high participation rates staff members must have easy access to the wellness programs and activities.  Open and uncomplicated enrollment processes achieve this.     

Some corporations automatically enroll all staff members and then allow those who do not wish to participate to “opt-out”.  This practice has been shown to improve enrollment rates in some settings.   

11   Family involvement

Many programs encourage spouses and other family members to participate in the corporation wellness activities and to adopt a healthful lifestyle along with the designated staff member.  It’s far easier for the staff member to have a healthful lifestyle if his/her family does so as well.   

12   Use of tobacco cessation

Because tobacco use and other tobacco use is the number one threat to health it’s critical to offer staff members effective and convenient assistance with quitting.     

Access to smoking cessation pharmaceuticals is often part of such programs.  In-house programs provide the most convenient access to these services, although on-line or telephone-based programs might  be available as well.     

13   Exercise

Regular exercise is a core component of every wellness program.  Employees must be strongly encouraged to engage in regular exercise.     

Most programs provide either periodic or continuous on-site opportunities, and some locations have on-site fitness centers, swimming pools, walking trails, etc.  Discounted or compensated memberships to community exercise facilities is a common alternative to on-site facilities.   

14   Weight management

Because obesity is a major threat to health it’s imperative that programs offer effective assistance with weight control.  Comprehensive encouragement from  executive management to shed excess weight is important.     

Online programs, worksite programs, or discounted access to weight control programs in the community may all be available.  Long-term follow-up is vital for maintenance of weight loss.   

15   Stress management

Workplace stress is perhaps the most common complaint among staff members and a major contributor to absenteeism, presenteeism (reduced productivity), and low morale.     
   
Almost all successful wellness programs offer assistance with personal and workplace stress.  Some programs refer employees to outside resources for additional serious conditions like depression and anxiety disorders, but most offer internet based or frequent on-site general stress reduction programs.     
   
Some companies endeavor to structure the work environment to minimize stress, both physically and operationally.   

16   Biometric testings/immunizations

Workers are actively encouraged to complete recommended medical screenings for blood pressure, cholesterol, Body Mass Index (BMI), colorectal and breast cancer, and others.     

Annual influenza immunizations are also encouraged.  Some sites provide these services at the worksite.  Incentives are often awarded for completion of these screenings/immunizations.    

17   On-Site health care

Actual provision of on-site primary care medical services is a growing trend.  The quickly escalating costs of medical care insurance for employees has stimulated this trend.     

Some companies have found that it is less costly to provide primary care services themselves than to fund those services through medical insurance.     

On-Site care also lowers the amount of time workers would otherwise spend away from the worksite getting such services.    

References   

1   Aldana, Steven G.  (2001)   Financial Impact of Wellness Programs –   A Comprehensive Review of the Literature.   Am J Wellness 15(5) – 296-320.

2   Chapman, Larry.  (1998)   the Role of Incentives in Wellness.  The Art of Wellness  2(3) – 1-8.

3   Chapman, Larry.   (2003)   Biometric Screening in Wellness –   is it Really as Important as We Think?  the Art of Wellness  7(2) – 1-12.

4   Chapman, Larry.  (2005)   Meta-Analysis of Corporate Wellness Economic Return Studies –  2005 Update.  The Art of Wellness, July/August, 1-15.

5   Chapman, Larry.   (2006)   Worker Participation in Corporate Wellness and Wellness Programs –   How Important are Incentives, and Which Ones work Best?   North Carolina Medical Journal   67(6) –   431-432.

6   Chapman, Larry, Lesch, Nancy, and Passas Baun, Mary Beth.   (2007)   the Role of Wellness Coaching in Corporate Wellness.   the Art of Wellness, July/August, 1-12.

7   Chapman, Larry.  (2007)   Proof Positive –   an Analysis of the cost-Effectiveness of Corporate Wellness.  Northwest Health Management Publishing, Seattle, WA.

8   Chapman, Larry.  (2007)   an In-Depth Look at the Economic Evidence for Rewarding Health Behavior Change.   Workshop presentation at the World Research Group “Rewarding Healthy Behaviors for Health Plans and Corporations” Conference, Orlando, FL, January 23-24.

9   Edington, Dee.   (2001)   Emerging Research –   A View from One Research Center.  American Journal of Wellness 15(5) –  341-349.

10   Edington, Dee W.  (2007)   Health Management as a Serious Business Strategy.  Presentation at the World Research Group “Rewarding Healthful Behaviors for Health Plans and Corporations” Conference, Orlando, FL, January 23-24.

11   Pelletier, Barbara, Boles, Myde, and Lunch, Wendy.  (2004)  Changes in Health Risks and Make certain to work Productivity.   Journal of Occupational and Environmental Medicine, 46(7) –  746-754.

12   Pelletier, Kenneth R.  (2005)   A Review and Analysis of the Clinical and Cost-Effectiveness Studies of extensive Health and Disease ManagementPrograms at the Worksite –  Update VI 2000-2004.  JOEM 47(10)1051-1058.

13   DeVol, Ross, Bedroussian, Armen, et. al.  (2007)  an Unhealthy America –   the Economic Burden of Chronic Illness.  Report released by the Milken Institute.   www.milkeninstitute.org.

14   Partnership for Prevention.  (2008) Investing in Health –   Proven Wellness Practices for Workplaces.   http – //www.prevent.org/images/stories/2008/investinginhealth_finalfinal.pdf.

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