With more employers scaling back their workforces, fewer workers are around to keep businesses up and running. Stress levels are bound to rise, forcing employers to keep an eye out for overwhelmed and emotionally drained workers, especially those with chronic conditions.

Experts say if employers hope to hold on to the hard-won gains of their health management programs, then those same programs' services have to recognize stress and incorporate stress-management features.

"We have found that workers with chronic diseases are much more susceptible to complications if they don't manage their stress appropriately," says Anita Messal, chief operating officer at OptumHealth Care Solutions. "Our data shows that people with chronic diseases that have comorbidity behavioral conditions have 30% to 50% higher medical costs."

The HR consulting firm Mercer recently reported that two-thirds of all large employers and 85% of those with 20,000 or more employees offer a disease management program for one or more conditions. About 76% of employers offer a nurse advice line, up from 67% in 2007.

In its 2008 National Survey of Employer-Sponsored Health Plans, Mercer also found that DM programs typically target diabetes (63%) and heart disease/hypertension (59%). The survey is based on data from 2,873 employers that sponsor health plans.

DM programs primarily are offered through health plans, but 15% of employers contract with a specialty vendor to provide targeted programs. Among employers with 20,000 or more employees, 39% contract with a specialty vendor, up from 35% in 2007, Mercer reports.

Holistic help

Although it's up for debate as to whether stress can cause some chronic conditions, medical research shows that patients with chronic diseases who also suffer from depression tend to be less compliant with prescribed medications, explains Allan Khoury, chief medical officer at Pennsylvania-based Take Care Health Systems, a provider of worksite health and wellness centers.

Worse, employees with chronic conditions who are experiencing high stress levels may be even less compliant with treatment regimens, Khoury says.

As such, some disease management programs will have a behavioral health component to their services. For example, for a patient with diabetes, clinicians routinely will screen for depression and other anxiety-related symptoms. "That way, you are not only helping the employee, but also reducing costs," he adds.

Nurse-coaches in DM programs are trained to recognize the signs of stress and educate patients on diffusing stressful situations, says Ann Meyer, executive vice president of clinical programs at ActiveHealth Management, a New York-based firm specializing in health management services.

"We assist members with depression or other significant needs by offering support and coaching, and offering to connect members to other resources, such as making referrals to the employee assistance program," she says.

Some workers with chronic conditions may have seen their hours reduced, resulting in a smaller paycheck. They feel stress over paying their bills, and medication adherence may take a back seat.

Consequently, some employers are turning to valued-based insurance design in which employees with a chronic condition, or those who are fully engaged in a DM coaching program, receive a reduced copayment on their prescription drugs or free genetic drugs, explains Meyers.

A VBID program ensures that workers with chronic conditions are able to afford their medications. "It goes a long way to reducing stress because it offers financial support during these challenging times," she adds.

A stress-free zone

According to a recent survey by the Society for Human Resource Management, only 11% of employers offer stress-reduction programs in 2009, compared to 18% in 2005.

However, some employers are paying attention to stress-management opportunities by creating stress-free zones and rooms within their workplace where workers can relax, says LuAnn Heinen, vice president of the National Business Group of Health.

Companies are looking at stress as part of the environment, and fine-tuning programs to help employees manage stress. "For some employers, it maybe time to say, 'We need to add a few more perks to our health promotion programs or offer more flextime options to our workers to make their lives a little more easier,'" says Heinen.

Carl Mowery, managing director at SMART Business Advisory and Consulting, notes that some workers may be dealing with a spouse who has been laid off, taking an emotional toll that can affect workers' productivity.

Mowery urges employers to push stress-management options offered by their EAP vendor. In addition, employers need to educate managers to look for signs of stress among its workers and suggest that they use the EAP program.

HRAs and wellness programs

Wellness programs can help employees to better manage their stress. "Once you have identified someone with risks factors, whether it's clinical or behavioral, you can design your wellness programs to reflect the stressors that your workers are facing," explains Tracey Moorhead, president of DMAA, a Washington, D.C.-based trade association representing 200 health-improvement organizations.

Health-risk assessment programs are increasingly useful tools to identify where workers are in terms of their health status.

One of the target points on most HRAs is stress.

For example, on an HRA, "you can ask: How many hours do you typically sleep? How many meals in the day do you eat? Do you frequently feel overwhelmed?" Moorhead says.

Those are basic questions that can reveal some significant risk factors for stress and depression.

The HRA will allow employers to identify early on those individuals who may be at risk for complications of an existing chronic condition because of a self-reported increase in their stress level.

Within the context of population health management, HRAs can help employers to understand where on the continuum employees fall in terms of the health management services they might need, notes Moorhead.

Job stress can be defined as the harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources or needs of the worker. Job stress can lead to poor health and even injury.

Job conditions that may lead to stress:

Career concerns: Job insecurity and lack of opportunity for growth, advancement or promotion; rapid changes for which workers are unprepared.

Work roles: Conflicting or uncertain job expectations, too much responsibility and too many

Early warning signs:

• Headaches
• Sleep disturbance
• Difficulty in concentration
• Short temper
• Upset stomach
• Job dissatisfaction
• Low morale

Source: National Institute for Occupational Safety and Health.