May 07, 2020
This series of frequently asked questions (FAQs) describes how to redesign your employee assistance program (EAP) to make it more effective in supporting the mental health and general life challenges of your employees and their families.
Redesigning the EAP
An EAP is a voluntary, work-based program that offers free and confidential assessments, short-term counseling, referrals and follow-up services to employees who have personal and/or work-related problems. EAPs address a broad and complex body of issues affecting mental health and emotional well-being, such as alcohol and other substance use, stress, grief, family problems and psychological disorders.1
The Business Group’s Quick Survey Findings: Employee Assistance Programs covers many of the topics included in this FAQ.
While the Business Group does not promote or endorse any specific vendors, many employers use EAP services offered by their health plan carriers. Others choose to partner with other vendors to provide EAP services, including, but not limited to, the following:
- ACI Specialty Benefits
- AXA ICAS
- Health Advocate
- Morneau Shepell
- Mutual of Omaha
- New Directions
- Optum/Optum International
- Sand Creek
- Value Options
- Workplace Options
EAP visits per employee typically range from 1 to 6, with large employers reporting an average of 3.6 visits per participant in 2018.2 Employers interested in expanding their EAPs to more adequately recognize the importance of mental health and parity should consider increasing the number of sessions allowed annually for employees. Many leading employers have begun to increase the number of visits they cover in the EAP, given that most employees will not utilize the full set of free visits, and many mental health conditions require more than a handful of visits with a mental health professional.
However, the majority of employer survey respondents do not plan to increase the number of visits allowed per year in 2020 or 2021, with the caveat that employers with global EAP offerings may vary the number of visits allowed to address local needs and preferences.
Respondents to a 2019 Business Group Quick Survey reported average EAP utilization rates of 7.5%, with 26% as the highest reported rate. Many employers report low engagement rates as a top challenge related to their EAP. Utilization may improve in the future as employees are able to communicate with EAPs beyond just the telephone and email and use other methods, such as video chat, apps/texting or on-site EAP services. Integrating the promotion of the EAP into other health and well-being benefits and tools may also help increase utilization. Given the impact of the global pandemic in 2020 and beyond, there is some presumption that EAP utilization rates will increase, but this has not yet been borne out, with the exception of increased utilization for pregnant employees.
A number of employers have rebranded their EAP to change employee perception, remove possible stigma and align the program with the organization’s mission and goals. Examples of rebranded names include “Work Life Solutions,” and “Your Life Matters.” As a part of this rebranding, employers are promoting the full scope of EAP benefits, from core services like mental health counseling, to the often less well-known services such as financial, legal, child and elder care assistance. One Business Group member, for example, is marketing its EAP by communicating the positive reasons employees might use it, such as for career development. Marketing the full scope of EAP services also enables employers to integrate its promotion into other health and well-being communications or tools (i.e., well-being platforms) so that the EAP stays top of mind for employees and their families.
Other employers have taken the stance that they shouldn’t shy away from the fact that the EAP is intended to be a support for mental health, and they have branded it accordingly.
EAP vendors are increasingly offering online booking through websites and apps. Some also provide digital questionnaires that triage care or offer recommendations; provide live video coaching or counseling; include on-demand, self-guided exercises; and offer app-based messaging with providers. Such digital capabilities may increase access to care and improve the employee experience with the EAP.
According to the Business Group on Health and Fidelity Investments Employer-Sponsored Health & Well-being Survey, 35% of employers offer on-site EAP in 2020, with an additional 14% considering doing so in 2021. Bringing the EAP on-site may improve utilization by increasing convenience, particularly for those locations that have employees with longer commuting times, and employee familiarity with and confidence in its services. On-site services may also allow employers to align the EAP with their organizational culture by hiring EAP counselors for fit and educating them on company policies, practices and norms, along with available benefits and programs. On that note, an on-site EAP may enable greater coordination and/or referrals to other available services. Companies with an on-site EAP report good utilization. Potential drawbacks to bringing the EAP on-site include cost, scalability and the potential perception of inequity among those without access.
Employers should have expectations from the beginning, including the EAP’s role in supporting employees across the continuum of mental health and holistic well-being needs, as well as how the EAP will integrate with other vendors.
Additional strategies to strengthen the relationship between an employer and EAP provider include:
- Agreeing on EAP reporting metrics and frequency, establishing key performance measures such as wait time for counseling, utilization rate and percent of cases resolved.
- Discussing how the EAP will be communicated across the population, identifying possible barriers to use and partnering on solutions.
- Inviting employee feedback and incorporating this into regular performance reviews with the EAP provider.
- Including the EAP in vendor summits and ensuring that counselors are aware of and able to refer across the employer ecosystem in addition to making community referrals.
- Inviting the EAP to provide recommendations on how to improve reach and impact.
- Clarifying “critical incident” definition and related policies; where does COVID-19 fit?
Many EAP providers conduct peer and manager trainings on a variety of topics. Although research shows that manager training can have a positive impact (e.g., training was associated with improved confidence in communicating with employees about mental illness, none of the studies were specific to training conducted by an EAP. Employers interested in peer and manager trainings should ask their EAPs if they offer them and if they have outcomes data associated with both kinds of training.
The intake, counseling and referral services provided by an EAP may be necessary but not sufficient to meet the full range of mental health needs within your population. Ideally, your EAP will provide a welcoming front door on a range of issues, including effective assessment and referral to specialized resources that can address many common problems:
- Financial concerns;
- Legal concerns;
- Alcohol and substance use;
- Family and relationship problems;
- Interpersonal conflict with a manager or colleague;
- Eating and sleep disorders; and
- Anxiety, depression and other mental health disorders.
Common additional services employers offer in conjunction with their EAP include:
- Curating a network of specialty mental health providers and facilities;
- On-site counseling;
- Telebehavioral health care (virtual visits); and
- Apps for cognitive behavioral therapy, happiness, sleep, behavior change, etc.
There may be some overlap between the services an EAP offers and other mental health vendors covered under the medical benefit. Employers considering consolidating their EAP and mental health offerings under the medical benefit should pay attention to which service is currently seeing more demand, whether access is currently easier in either path, the employee experience for each channel, costs of consolidating or expanding services, and the ability of each to address particular patient needs (e.g., diversity of providers, language(s) beyond English, pediatric or other specialized skills.) Some apparent redundancy may be warranted to offer employees choice and ensure capacity at times of peak need.
There are several things an EAP should be able to do to support employees or their families experiencing substance use disorder (aka addiction):
- Curate networks of providers for inpatient and outpatient services that provide evidence-based treatments, including all three major forms of medication-assisted therapy.
- Navigate people with substance use disorder, or often their families, to appropriate therapy.
- Provide crisis support for plan members experiencing a crisis when they need quick access to intensive treatment for serious substance use episodes.
- Maintain support for employees who are under “first offense forgiveness” policies. These policies, put in place by many employers, state that employees with substance use disorders who experience condition-related job performance issues will not be terminated upon a first offense, but are instead diverted to the EAP. For these employees, their continued employment is contingent upon getting professional help for their condition; this help can be directed and monitored by the EAP.
From the legal/compliance perspective, a significant advantage of EAPs is their status as “excepted benefits” under HIPAA. Excepted benefits generally are not subject to a number of requirements, such as the Affordable Care Act’s rules on annual/lifetime dollar limits and preventive services.
Therefore, when evaluating EAP vendors or designs, employers should keep in mind whether the EAP can maintain excepted benefit status. Relevant questions include:
- Exactly what types of benefits are included in the EAP?
- If the EAP offers mental/behavioral health counseling sessions, how many sessions are available?
- Does the EAP include telehealth benefits? If so, how extensive are those benefits?
- What other health-type benefits are available through the EAP?
- Is the vendor representing the EAP as an excepted benefit? Is the vendor willing to cover penalties or remedies if the U.S. Department of Labor determines that it is not an excepted benefit?
In most cases, EAPs also are subject to legal requirements, such as ERISA, HIPAA and possibly COBRA. We recommend that employers examine how their EAPs can be designed to ensure compliance.
- In what languages is your Web portal available? Do you have acculturated online materials? If so, where?
- Please outline your global technological capabilities outside of your website (apps, instant messaging/chat, video counseling, AI, etc.). How do you use these to help people access services in a confidential manner when and where they need to?
- What data privacy and transfer issues/laws are relevant in our company locations?
- What are your minimum requirements for both counselors and intake staff? If this varies by country, please detail those differences.
- How many affiliate providers do you have in each of our locations (by city and country if possible)?
- In which countries do you have your own staff versus in which countries do you have affiliates/subcontractors?
- What is your training process for new and existing employees and affiliates? How do you ensure global consistency in your training for network affiliates?
- Do you have continuing education requirements for your employees and affiliates? If so, what does this involve?
- Please provide a listing of your global affiliates.
- In which of our countries do you not offer face-to-face capabilities? How will you meet employee needs in those locations? Please explain your system for referring employees to community providers once EAP services are exhausted. What do you do in countries where there are no appropriate community providers or where they are prohibitively expensive?
Data collection, reporting and measurement
- How do you evaluate the effect of EAP on organizational performance (productivity, disability, engagement, absenteeism, retention, etc.)? Can you quantify this?
- How can we benchmark the success of our program versus other companies in your book of business?
- How often will market-level, regional and global reports be available and in what timeframe? For example, how soon after a quarter closes will we receive a quarterly report?
- Can you provide examples of market-level, regional and global reports?
- How do you count utilization, and what types of utilization statistics do you include in your typical reports?
- What services do you offer for critical incidents and crises (e.g., natural disaster, employee death, workplace accident, etc.)? Are there additional costs for these services? Who provides the services, and where are they located?
- Do you currently provide on-site therapists for other large employers? If so, in which countries? What is the average utilization rate by region for your book of business?
- Do you recommend providing on-site services in certain locations and why?
- What is the cost differential for providing EAP services on-site?
- How many global clients are you currently serving and in which countries?
- Please describe the laws and regulations that affect your EAP offerings in the countries in which we have operations (e.g., where are you most limited? Where do you need to take very different approaches)?
- Can you give specific examples of regional/country/cultural differences in service delivery that are applicable in our top 5 or 10 locations?
- Please walk me through exactly what would happen from the time a potential client called the EAP in our top 2 or 3 locations to the time they finished receiving services. Who would answer the phone and in what language? What type of mental health treatment would they receive (if applicable)? How would their progress be monitored?
- What types of cross-cultural training can you provide for both local hires and expatriates in order to help them work together successfully?
- Please give a few recent examples of how employers have tailored your EAP to meet their specific needs.
- What emerging issues do you see in global EAPs that we should be aware of?
- What are you doing to address barriers such as access and stigma in particular countries?
- Are calls answered in a regional call center or locally in each country? Is there a toll-free number available in all of our locations?
- Please outline your wellness/well-being capabilities globally. Specifically outline which services are available in our top 2-3 locations and how exactly those services are provided.
- How do you provide services for expatriates and their families (e.g., preparation for trip, while on assignment and preparation for returning home)? Are these proactive or reactive services?
A “global EAP” means different things to different people. Typically, employers either implement a single global EAP supplier or utilize a variety of regional or local vendors around the world. Even when they contract with one global vendor, that may be with a vendor that has operations or contracts with providers around the world or it may be with a domestic, U.S.-based provider or health plan that then establishes a contract with a global provider. EAP vendors that operate in most countries around the world include AXA ICAS, ComPsych, Morneau Shepell, Optum International and Workplace Options.
EAPs can be an essential offering in countries where there is little access to mental health and work/life services, but providing EAP services around the world comes with challenges. These can include higher costs, a limited number of providers, a lack of licensure/standards, varying regulatory and privacy issues, limited familiarity among employees and cultural issues that may impact acceptance of the program. Employers often say they have difficulty getting consistent data due to the many different providers involved across countries, making it difficult to implement and assess streamlined services across the globe. The lack of availability of digital solutions and telephone access in some local languages across countries remains a challenge as well. Global employers also have to contend with acquired rights directives and works councils in many countries, as well as getting local staff on board to pay for the program if it is not going to be funded centrally.
Even with all the challenges listed above, EAP has the potential to have a significantly positive impact on the global workforce if well-implemented and consistently promoted over time. Employers who have well-utilized EAP programs say that the following best practices have led to their success:
- Involve local leadership and staff early to get buy-in. This may be in the form of an EAP committee, ambassadors/champions or informal feedback, but it’s important that the local site leaders feel as if they have a voice in the decision. Partnering with local leaders may also assist in combating any unknown biases or stigmas that exist in that culture.
- Adhere to local legal and labor requirements. You may need to engage with legal counsel and local labor and employee relations when implementing the EAP locally. Depending on contracts, you may need to notify, inform or consult with unions or works councils before communicating and implementing. If you are implementing the program across several European countries, this could trigger requirements with the European Works Council in addition to country and local work councils.
- Adjust your communications to fit local culture and content. Your communications should be flexible and culturally adaptable in order for them to be successfully received by the intended audience.
- Familiarize employees with the program and make sure it is easy to access. In many countries, an EAP is a new concept that may be viewed with suspicion. Helping employees to understand what an EAP is and does, putting a face to the EAP provider’s name and ensuring that it is easy to use may help encourage employees to take advantage of the program.
- Work with your vendor to make digital solutions available in the local language and culturally adapted. This is true for other services as well. All programs should be viewed as local and be personalized to the needs of a specific location or business. Needs can be identified through focus groups, employee surveys or informal conversations; regardless, it is crucial that an EAP provider understand these needs and provide services, as well as employ locally based counselors who understand the culture (when possible), accordingly.
- 1 | OPM. Frequently asked questions: Work life. https://www.opm.gov/faqs/QA.aspx?fid=4313c618-a96e-4c8e-b078-1f76912a10d9&pid=2c2b1e5b-6ff1-4940-b478-34039a1e1174. Accessed May 7, 2020.
- 2 | Business Group on Health. Quick Survey Findings: Employee Assistance Programs. May 2019. https://www.businessgrouphealth.org/resources/quick-survey-findings-employee-assistance-programs. Accessed May 7, 2020.