Wellness

This standard reads:

The wellness organization has the ability to incorporate the use of participant incentive structures into its
wellness program(s) and it designs the incentive in a manner to collect data that will support evaluation of the
impact of the incentive. (3)

As the interpretive notes indicate, URAC fully expects the initiative for participant incentives to come from the employer/client, not from the wellness program.  Consistent with that notion, URAC requires the applicant for accreditation to have the capacity to respond to an employer/client request for the inclusion of incentives for wellness program participants in its wellness program.  However, URAC does place upon the wellness program the obligation, once asked by the employer/client to include an incentive, to design it in such a way as to support the collection of data and evaluation of those data to help assess the impact of the incentive.

Documentation for the desktop review level likely will be a policy and procedure which directs the program's staff to be responsive to employer requests for incentives, and to guide program staff in the development of interventions that lend themselves to data collection and evaluation.  The onsite review no doubt will involve an examination of documents demonstrating implementation of that P&P and an interview of senior clinicians involved with the incentive program(s).

This standard, which carries a weight of "4", reads:

The wellness organization includes additional interventions that focus on participants with disproportionate
risk factors. (4)

Borrowing from the world of disease management, URAC places a high value on stratification of the participants in the wellness program according to risk factors.   This standard requires an evaluation, along the spectrum of health risk factors, of the target population with an eye toward providing more intensive interventions for those at greatest risk. 

Documentation for purposes of the desktop review should include an official, approved document that describes the stratification process.  In addition, documentation should address how additional interventions for high-risk participants match the high-risk categories identified through this stratification process.  The onsite review will combine a closer examination of documents demonstrating the implementation of the stratification process, as well as an interview of senior clinicians associated with the stratification process to assure a full understanding of both the risk identification methodology and the administration of the interventions for high-risk participants.

This standard reads:

If the wellness organization implements new or innovative practices that are not evidence-based, it designs
the intervention to collect data that will support evaluation of the impact of the new or innovative practice. (L)

This is a leading indicator standard.  It reflects URAC's commitment to the use of data collection, measurement and evaluation to guide healthcare organizations as they navigate uncharted waters.  

While the current draft doesn't say what evidence would be required, one can extrapolate from other standards that an applicant would submit, for desktop review, something akin to a Quality Improvement Project Description Form, which outlines baseline measurements, clearly stated objectives, a complete description of the intervention, and a plan for remeasurement and evaluation of results.  The onsite review will involve an examination of the background data underlying that description form combined with the clinical and administrative leaders of the innovative intervention.

This standard has two mandatory subsections and a third subsection that is a "leading indicator":

The wellness organization selects and designs defined interventions that are: (---)
(a) Consistent with and supported by evidence-based practices; (M)
(b) Approved by a committee designated by the wellness organization to have authority over the clinical aspects of the wellness program; and (M)
(c) Within three years of initial accreditation, provides level of evidence supporting interventions to health benefits purchasers proactively and to consumers upon request. (L)

Subsection (a) echoes from earlier standards URAC's insistence on basing the fundamental components of a wellness program on evidence.  So, like the health risk assessment tool, the interventions must be evidence-based. Affirmative documentation demonstrating that the intervention was based on current clinical research will be an essential part of the submission to AccreditNet.  Additionally, however, URAC is almost sure to require that the program have a policy and procedure that requires the basing of the design of interventions on clinical evidence. 

Subsection (b) is written in a curious way, particularly when read together with the Interpretive Information.  The standard is unambiguous in requiring that the interventions be approved by a committee.  The interpretive guide, however, suggests that this could be something other than a standing committee, that is, the senior clinical officer could approve it in consultation with other providers, not necessarily a standing committee.   While I find it curious that the standard itself doesn't say that a committee is not required; on the contrary, it explicitly requires committee review.  That being said, applicants can take URAC at its word, at least for the initial version of the standard, and, if they choose, may submit evidence of approval by the senior clinical officer.  However, those that take the individual approval route rather than the committee approval route almost surely will require evidence that the senior clinician, in fact, did consult with others in the design and selection of interventions.  Absent such evidence, the applicant runs the risk of violating this mandatory subsection.

The leading indicator subsection (c) places a responsibility on the organization to provide the evidence it used in designing the intervention to the employer -- without the requirement of a request by the employer for that evidence.  Additionally, the program will have to provide such evidence to participants upon request.  Again, not only will there need to be documentation that this evidence was provided, but that the program has a policy and procedure requiring that it submit such documentation to employers and participants in a manner that complies with this subsection.

The onsite review for this standard is likely to be a combination of interviews with relevant personnel and documentation to be submitted onsite upon selection of employers from a list of employers.  Furthermore, the applicant would do well to maintain a log of participant requests for such evidence, from which the reviewer will select files to determine how responsive to those requests the program has been.

Subsec

This is a mandatory standard, which provides:

The wellness organization has adopted evidence-based behavioral change model(s) that promote healthy behavior for all participants.

There are, of course, a wide array of widely recognized decision-making and behavioral change models.  As a side note, I did my doctoral dissertation on one model mentioned by URAC in the "Interpretive Information" section, the Theory of Planned Behavior.  Certainly, if the program uses such a widely recognized model, the documentation required to demonstrate compliance with this standard is modest -- a clear articulation of the model and brief description of its elements will probably be sufficient.  However, if the behavioral change model is not widely recognized, URAC will allow an alternative model, but you can bet the documentation requirements will be steeper.  A safe bet is that an articulation of the research underlying the operating model will be required by the reviewer if it is a less-well-known model.

Onsite, the reviewer is likely to cover this standard primarily in the interview, in an effort to make sure that the designers of the interventions are familiar with the behavioral change model being applied and how it relates to the interventions in the Program.

This mandatory standard provides:

At least every two years, the wellness organization reviews and, if necessary, modifies the health risk assessment tool based on clinical updates and other research.

The underlying assumption of this standard is that, since the program's structure, including risk assessment and stratification methodologies, is evidence-based, that evidence conceivably could change over time, as new clinical research becomes available.  Therefore, URAC requires that the program remain current with that research by reviewing current literature and modifying the program to reflect current research. 

Documentation required for this standard likely will include evidence of review, by qualified people, of current research on the topic and the comparison of recent research to the health risk assessment tool currently used by the organization.  Onsite review may include an interview with the person or persons who conducted that review and, perhaps, committee meeting minutes if the review results are presented to a committee.

This mandatory standard provides:

The wellness organization applies the health risk assessment process on a specified and periodic basis.

This does not mean that the initial assessment needs to be repeated in full.  Indeed, URAC is clear that a pared-down version will be perfectly fine, so long as the program is monitoring risk factors with enough specificity to modify interventions for the participant where appropriate.

The application documentation should provide either a clear policy and procedure with specified intervals for reassessment or a clearly articulated method for collaborating with each employer on a regular and frequent reassessment.

The onsite review no doubt will include, in addition to the interview of relevant personnel, documentation of the periodicity of risk assessments across a sample, selected by the reviewer, of employers.

This 3-weighted standard reads:

The wellness organization has a process to apply inclusion criteria, based on the health risk assessment process, for the wellness program.

Because a Wellness Program is not likely to be asked by the employer to include the entire population of employees, this standard contemplates a selection of a subset of that population for participation.  The selection method, under this standard, needs to be a clearly-articulated approach, replete with "inclusion criteria" based on the health risk assessment method used in the Program.  "Inclusion criteria" is defined by URAC as "The factors, typically defined by the purchaser, that determine whether an individual is within the target population of the wellness program."

Whenever URAC uses the word "process", you can bet the documentation required will be a formal policy and procedure or other description of the Wellness Program.  Onsite evaluation is likely to be a combination of documentary review of the application of the criteria to select participants, as well as an interview with the staff members charged with applying the criteria to the data for participant selection.

This mandatory standard provides:

The wellness organization has a process to conduct an individualized assessment of each program participant. (M)

Thus, at the heart of the URAC accreditation is the ability of the organization to conduct individualized assessments of program participants.  In other words, the organization cannot merely focus its data collection at the population level, but must be able to provide information that is useful to the individual.  

A program description, combined with examples of individualized assessment reports, are likely to satisfy the documentation requirements for the purposes of the desktop review.  Onsite review activities regarding this standard are likely to be a combination of interviews with senior management and an examination of assessment reports of randomly selected participant assessment reports, drawn from a list of all program participants.

This standard speaks to the data analytic capacity of the organization:

The wellness organization has the ability to use additional and credible data sources in conjunction with the health risk assessment tool data to help stratify the target population. (4)

Thus, in this standard, URAC hopes to insure that URAC-accredited wellness programs be able to respond to a purchaser's request to include information in addition to screening results in its stratification of the target population.  

One can anticipate that the documentation required to demonstrate compliance with this standard will include a program description and two or three examples of the use of such information in population stratification.  The onsite review is likely to focus on an interview with those in the wellness organization who are most familiar with the data analytic capacity of the organization.