Potential Synergies Between Workplace Wellness Programs and On-Site Clinics

Introduction

The United States faces an increasing burden from chronic medical conditions, especially type 2 diabetes mellitus (diabetes), which affects more than 30 million Americans and costs $327 billion a year. ¹ This concerning trend can be partially attributed to increased processed and sugar-sweetened food and beverage consumption. The consumption is driven, at least in part, by fast food and sugary drink companies spending approximately $5.4 billion in marketing annually, much of which is targeted toward younger children and adolescents. ² This growing epidemic of chronic conditions also affects US employers; for example, 17% of individuals aged 45–64 years have diabetes. ³ Given that the health care system has been largely ineffective in addressing increasing prevalence of diabetes and other chronic diseases, employers are increasingly focused on improving their employees' health, with potential goals to promote productivity, decrease absenteeism, or control health benefits costs. As an example, The Wonderful Company (TWC), a privately held $4.6-billion global consumer packaged goods company, implemented a comprehensive program, which is highlighted as a case study in this article.

One common approach adopted by US employers to address the burden of chronic conditions is to offer employees workplace wellness programs. A 2018 Kaiser Family Foundation survey found that among employers offering health benefits, 53% of employers with 3–199 employees have a wellness program as do 82% of employers with more than 200 employees. ⁴ The composition of these programs vary but may include disease or healthy lifestyle management components. Disease management often focuses on chronic conditions or illnesses (eg, through telephonic health coaching), whereas lifestyle management programs include activities to promote healthy habits that avoid disease (eg, smoking cessation). ⁴

A new trend emerged in recent years for employers to focus on primary care. For example, a recent high-profile formation of a joint venture between Amazon, JP Morgan, and Berkshire Hathaway (Haven) aims to improve access to primary care, as well as to simplify insurance coverage and increase prescription drug affordability. While Haven's approach is currently unclear, other employers have created on-site clinics that are staffed by primary care physicians or nurse practitioners and are associated with decreased hospital admissions and lower absenteeism. ⁵ As of 2018, about 10% of companies that offer health benefits and have more than 200 employees offer full primary care services through an on-site clinic. ⁴

Potential synergies between workplace wellness programs and on-site clinics are important to employers because they could improve the efficiency of both interventions and optimize employee health. However, questions remain regarding how primary care clinics and workplace wellness programs best work together toward these goals. Traditionally, primary care clinics focus more on medical treatment than health promotion, whereas workplace wellness programs emphasize the latter. When put together, each likely improves the effectiveness of the other. In this article, we review how these components are likely synergistic and how potential synergies between them can be realized. Further, we use TWC as an example and outline the importance of conducting future studies to confirm such effects.

Potential Synergies of Wellness Programs and On-Site Clinics

The Case of TWC

TWC has long been committed to improving well-being among consumers by producing healthy and nutritious products. That commitment recently expanded to include employees and their families by offering wellness programs and on-site clinics when the company identified such a dire need. A biometric screening among a sample of their Wonderful Pistachio & Almonds employees in 2015 revealed that 12% of their employees were diabetic and 49% were prediabetic. These figures represent a higher prevalence than adults across the United States (9.4% and 33.9%, respectively) and in California (9% and 46%, respectively). ^1,10

TWC decided to transform the health and wellness paradigm of Central California by integrating health promotion and primary care, modifying social norms, addressing social determinants of health, and supporting healthy lifestyles for employees, their families, and the community. The company spearheaded these efforts by first conducting employee focus groups to understand their needs and barriers to healthy living. Focus groups revealed a common attitude that getting diabetes was inevitable, and there was a lack of access to healthy food and high-quality health care despite having health insurance.

Based on feedback from focus groups, the company adopted several approaches to meeting its goals. First, TWC hired a team with diverse expertise to lead various wellness programs. Responding to employee feedback that they lacked access to fruits and vegetables, TWC not only began offering these in the company cafeteria but also discounted the healthiest options and sold produce at no profit. In particular, TWC hired culinary staff to design and make healthy cafeteria food. The company also provided healthy snacks, encouraged walking breaks, and held fitness classes led by a physical activity professional at a new on-site gym. To change the narrative that disease is inevitable, TWC implemented on-site marketing campaigns to educate employees about wellness and to encourage healthy behaviors.

Second, TWC started 2 on-site clinics and a mobile clinic designed to serve employees and their family members at the worksite and where they live, at no cost. TWC recruited bilingual and culturally sensitive medical providers—including physicians, nurse practitioners, physician assistants, physical therapists, behavioral therapists, nutritionists, and health coaches—who are inspired by the mission to take an innovative and holistic approach to primary care with a focus on disease prevention. Each patient is assigned a primary clinician and, depending on the patient's risk level and personal goals, the patient is guided by the clinician in a coordinated manner to see other clinic staff (ie, nutritionists, physical therapists, behavioral health counselors). Free labs and medications are provided on-site for patient convenience. To further increase access to care and establish meaningful relationships, clinic staff often interact with employees where they work instead of relying on patients to come to the clinic. For instance, they identify hot spots of obesity and poor diabetes control and visit those worksites to provide care for high-risk patients.

Furthermore, in order to implement a multifaceted program, TWC established a unified leadership team to oversee all program components, allowing for coordination so that clinic staff could leverage all resources to achieve results for individual patients and the employee population as a whole. Examples include nutritionists helping with the cafeteria menu, physical therapists going with patients to the gym, and physicians—employees' trusted regular primary care doctors—teaching on-site seminars about wellness topics (eg, stress management, sleep habits).

In addition, the company ensures that the efforts extend beyond the workplace and into the community. TWC is impacting the culture of health in its employees' communities by holding running events, building parks, paving roads, building affordable housing, and establishing local charter schools that make healthy foods from scratch and tailor the health curriculum to the students.

TWC's comprehensive efforts may be changing employee attitudes and health. For instance, after soda was removed from the worksite, an employee said during a recent focus group, “giving up soda was hard, but now it is the new norm.” Follow-up biometric screening results among Wonderful Pistachio & Almonds employees showed that the proportion of employees with prediabetic HbA1c levels decreased from 49% in 2015 to 33% in 2017 (a 33% reduction). TWC's comprehensive approach likely has contributed to such beneficial results both for individuals and company-wide, achieving TWC's goals to focus on disease prevention and a culture of health, although rigorous evaluations are warranted.

Conclusion

As exemplified in TWC's case, well-integrated wellness programs and on-site clinics may provide comprehensive and coordinated medical and health promotional interventions. These integrated interventions may generate synergies that facilitate the process of improving population health and building a workplace culture of health. TWC's success is likely attributed to such synergies, which future studies should be conducted to confirm.