Disability Management: What is it and why do we care?

1. Disability Management: What is it and why do we care? Gideon Letz, MD State Compensation Insurance Fund San Francisco, California Tel: 415 565-1677 e-mail: galetz@scif.com April, 2002

2. Take Home Message Communication and Teamwork are essential for successful rehabilitation and prevention of delayed recovery after disabling occupational injury or illness.

3. DIRECTION • Perspectives on the rehabilitation process • Transitional work as a key element in the treatment of work injury/illness • Common barriers to successful return to work • Practical suggestions to overcome these barriers with focus on tactics to improve communication

5. PERSPECTIVES • Worker • Health Care Provider • Employer • Claims Administrator • (Attorney)

6. According to a recent survey of Industrial Medicine Physicians Up to 80% of paid indemnity expense is unnecessary ... Stated Reasons Employer has a policy against light duty The treating doctor is not equipped to determine the right work restrictions Too little information about the physical demands of the job is provided to the physician Managed Comp Survey of Industrial Med Physicians April 1998

8. Direction • Common problems in the implementation of return to work prescriptions • A model program for triage and prevention of delayed recovery

9. Barriers to RTW - The Patient • Fear of re-injury or aggravation (pain avoidance) • Job satisfaction • Sense of entitlement (worker’s comp, personal injury) • “Illness behavior” • Motivation level • Financial issues

10. Sick Role Identity Loss of Identity Withdrawal Chronic Depression Helplessness Anger Blame Fear Acute Uncertainty The Pain Ladder (Weiser, 1997)

12. Barriers to Return to Work - The Doctor • Role as patient advocate vs “company doctor” • Treatment goals focused on feeling better rather than getting better • Failure to include transitional work in the treatment plan • Lack of information re physical demands of the job

13. Barriers to RTW - The Employer • Fear of liability for re-injury or aggravation • Failure to appreciate transitional work as therapy • Use of benefits system (WC, STD, LTD) to manage personnel problems • Lack of information re: the economic benefits of transitional work

14. Barriers to RTW - The Claims Adjuster • Focus on benefit delivery rather than rehabilitation • Poor communication with providers, employers and injured workers • Delays in treatment authorization • Caseloads too high given administrative complexity of WC system

15. WC Shift in Focus • Last Decade - Bill Audits and Utilization Review • Currently - Functional Recovery and Disability Management

16. Strategies for Improving Functional Recovery • Channeling patients to doctors with best outcomes • Financial Incentives for Employers (premium) and Doctors (fees) • Communication between injured workers, doctors, employers and claims administrators - with a focus on disability management

17. Disability Management: Where the perspectives merge • Injured Worker • Doctor/Therapist • Employer • Claims Administrator

18. Injured Worker Concerns • Pain • Fear/Anxiety • Lost Wages • Job Security • Return to Work

19. Physician Concerns • Diagnosis and Treatment • Authorization • Reimbursement • Administrative responsibilities • Return to Work

20. Employer Concerns • Liability • WC premium • Lost Productivity • Return to Work

21. Adjuster Concerns • Liability • Benefit Delivery • Reserving • Settlement • Return to Work

22. Delayed Recovery: the search for predictors • Early intervention facilitates successful recovery • Appropriate triage for non-routine care • “Holy Grail” for insurance industry - cost efficiency of managed care

24. ACES Accelerated Case/Claim Evaluation SystemWorkers’ Compensation Model • by • Industrial Health Strategies • Providence, Rhode Island

25. ACES model: Focus on Cumulative Trauma • Etiology often obscure • Treatment frustrating • High Risk for Delayed Recovery • Disproportionate Costs

26. ACES - 3 Steps: • Three Point Contact by Adjuster • Profiling with ACES software • Tasking and Triage

27. Three Point Contactby claims adjuster • Injured worker • Employer • Treating physician

28. Value of 3 point contact • Information gathering • Customer service (accessibility, education) • Identification of “red-flags”

29. ACES MODIFIERS • Injury Diagnosis,Duration • Modified Duty Availability • Physician, or Therapy Issues • Claims History • Attorney Presence • Employer/Employee Issues • Job Demands • Obesity, Smoking, Age

30. 90 / 10 THEORY 10% GOOD BAD 90% Purpose ofACESProfiling • Identify claims at high risk for “delayed recovery” • Refer for appropriate level of claims management and/or worksite assessment • Refer for Loss Control or Fraud Investigation when appropriate

31. CLAIMS MANAGEMENT DECISION-MAKING (Tasking) ACES Reports Level 1 • Worksite Assessment • Diagnostics/Therapy • Second Opinion/IME’s • Functional Capacity • Vocational Services • Fraud Investigation • Loss Control Activity Level 2 Level 3 • .

32. HOW DO WE GET PEOPLE BACK TO WORK? Worker’s Functional Ability Functional Job Demands A SIMPLE SOLUTION TO A COMPLEX PROBLEM

33. Worksite Assessment • Identify areas of stress related to diagnosis • Can be minimized through changes by Employer? • Can be minimized through changes by Employee ? • Identify appropriate modified duty

34. Case Example #1:47 year old high-tech manufacture plant worker • She had been off work 4 months with shoulder injury (rotator-cuff tendonitis) • Being treated by an orthopedic surgeon; • Employer apparently had no “modified duty.”

35. Case Example #2: 23 year old jewelry worker • On/off work due to wrist tendonitis • Then took extended leave during pregnancy and after birth of 3rd child • Was released for regular work by her treating physician • Employer was concerned about her attendance and believed absences were secondary to child-care issues

36. Communication is Key -What treating physicians need from the employer: • Detailed job descriptions for all positions • Prompt reporting and referral when an injury occurs • Opportunities for workplace visits • Cooperation with transitional dutyrecommendations

37. Communication is Key -What employers should expect from treating physicians: • Detailed description of work restrictions • Estimate of duration of work restrictions • Estimate of duration of temporary total disability (rare)

38. Patient Provider Employer Communication is the Key

39. Screening Tools for Delayed Return to Work • Watch the calendar • Grocery Store Test • Obstacle Question • Molehill Sign • (Christian J, 2000)

40. The Obstacle Question • Paperwork delays • Job placement delays • Can’t figure out how to…. • Patient is reluctant (Molehill Sign) • Patient is lost in medical system • Patient is focused on legal issues (Grocery Store Test)

41. Paperwork Delays • Waiting for authorization, referrals • Missing information, waiting for answer • Questions you can’t answer (diagnosis,functional capacity) • Job demands, availability of modified work not known • Employer dragging on modified work placement • Forms in “To Do” pile

42. Job Placement Delays • ER has “no light duty” policy • ER has policy but ignores it • ER uses modified work but this supervisor can’t find any • Doctor’s restrictions too rigid, hard to understand • Doctor’s work slip doesn’t get to ER promptly

43. Can’t Figure Out How To... • Perform key task at work • Get to work • Be comfortable at work • Be safe at work

44. Patient is Reluctant:Molehill Sign • Too many medical appointments • Afraid of re-injury (exertion, persistent hazard, pain) • Afraid of poor treatment at work • Afraid of jeopardizing benefits • Afraid of disciplinary action, being fired

45. The Real Issues Are Not Being Addressed: Grocery Store Test, Molehill Sign • Job conflict (personalities, performance, discipline) • Job dissatisfaction • Life dilemmas (aging, career choice) • Domestic disruption/obligation • Pending layoff/intentional fraud

46. References • Texts • The Comprehensive Guide to Work Injury Management. Isernhagen SJ, ed. Aspen Publishers, 1995. • Principles and Practices of Disability Management in Industry. Shrey DE & Lacerte M, eds. St. Lucre Press, 1995. • Risk and Disability Management in the Workplace. Randolph DC & Ranavaya MI, eds. Occupational Medicine, State of the Art Reviews. Vol 15:4, Oct-Dec 2000.

47. References • Articles • Abenhaim L, Rossignol M, Valat JP et al. The Role of activity in the therapeutic management of back pain. Report of the International Paris Task Force on Back Pain. Spine 25(4S):1-33. Feb, 2000. • Krause N, Dasinger L and Neuhauser F. Modified work and return to work: A review of the literature. J Occ Rehab 8(2):113-139, 1998. • Weiser SR. Psychosocial aspects of occupational musculoskeletal disorders. In, Nordin, Andersson & Pope (eds), Musculoskeletal Disorders in the Workplace: Principles and Practice. CV Mosby, 1997:51-61.

48. References • Articles • Campello M, Weiser S, vanDoorn JW, Nordin M. Approaches to improve the outcome of patients with delayed recovery. In, Nordin, Cedraschi & Vischer (eds), New Approaches to the Low Back Pain Patient. Baillere’s Clinical Rheumatology. Harcourt Brace, 1998:93-113 • Christian J. Reducing disability days: healing more than the injury. J Work Comp. 9:30-55, 2000. • Frank JW, Brooker A, DeMaio SE, et al. Disability resulting from occupational low back pain. Part II: What do we know about secondary prevention? A review of the scientific evidence on prevention after disability begins. Spine 21:2908-17, 1996.