Early Intervention in high risk individuals injured at work

1. Early Intervention in high risk individuals injured at work Concord Repatriation General Hospital Sydney

2. Concord Repatriation General Hospital 2,500 FTE employees (now has 4,500 FTE) Part of Sydney South West Area Health Service which has 17,500 FTE employees

3. Who are we? • We are not a consultant firm. • We are not academics or professional researchers • I am a F/T medical staff specialist. • Andrew McGarity is a F/T Rehabilitation Coordinator

4. Staff Health “One Stop Shop” Workers Compensation Occupational Health and Safety Medical management of workers (GP’s 80%) Compensation injuries Vaccinations Needle stick injuries and mucosal splashes Health monitoring e.g. noise, cytotoxic agents, etc Pre-employment assessments

5. Audit of 100 consecutive workers compensation patients through the unit showed the following case-mix: Soft tissue injuries to shoulder, upper limb, wrist and hand 36 Soft tissue injuries to back, lower back, knee, foot and ankle 37 Soft tissue neck injuries 2 Hernias 2 Fractures 2 Head injuries 2 Motor vehicle accidents 7 Assaults 6 Miscellaneous (bruising, needle stick) 6

6. NSW Health Self Insurer – Treasury Managed Fund Sub-contract to an insurer (EML)

7. Necessity is often the mother of invention • 2003-4 we had a huge number of open claims ~ 300 • We felt we were failing our injured workers because we were not meeting their needs despite good medical management and good case management. Something needed to change! • Spate of very difficult cases who went on to have chronic pain syndromes • There was no “road map” to tell us what to do! • The following is about 5 years to this presentation.

8. What we did first Change in Rehabilitation Policy to require worker to attend Staff Health for initial assessment (unless medically contraindicated). Database developed to track workers from notification to finalisation. Development of suitable duties lists for a majority of depts. Increased role of managers in the rehabilitation process. Meetings with managers of major depts. with monthly meetings to review claims and provide comparative data. Regular monthly meetings with the physiotherapists who regularly saw our patients. Despite these changes our results did not improve significantly

9. We decided that the first 4 weeks was the answer, – after that you start to lose control! • We did not need to do anything that is not normally done, only we needed to do it earlier (mainly for the high risk individuals). • We needed to find these high risk individuals in the first week. • We needed to see people face to face within 48 hours of the injury. • We needed expert help in the two areas that were most influential in a person’s recovery – the psychological area and the medical area (to assist the GP). • We needed to ensure that the GP was in control of the whole process through consultation and approval. • We also did not have the power to do it!. Where to go from here?

10. We decided to just use TOTAL COST OF THE CLAIM as the main indicator of success or not (time lost, treatments by all health professions, legals etc) • We needed an evidence-based intervention. • We needed to spend a significant amount of money upfront. • We needed to consult and convince stakeholders. • We needed the process to be “portable” so it was not just something that could only be done at Concord Hospital or by a particular medical specialty who had a particular expertise in MSK injuries • GP’s remained the main doctor involved and the main NTD. What else did we decide?

11. How to do it? • Literature search – confirmed our understanding about psychosocial issues as the best predictor of a person’s outcome following a W/C injury • OMPQ: 4 – 6 weeks NSW WorkCover • “Special sort of Psychologist” • Use the IMC Program that NSW WorkCover has in place. • Use WorkCover accredited rehab providers for all high risk people

12. Yellow Flags • Depression • Anxiety/ Fear avoidance behaviour • Stress • Poor pain coping strategies • Expectations of recovery • Perception of health change • Perceived psychological demands at work • Perceived confidence in management • Perceived high job demands

13. BUT before we could do the intervention we had to: We needed to change the current OMPQ (Orebro) 26 questionnaire which as designed to be done at 4 – 6 weeks to one that was one page and could be done soon after an injury and in around 10 minutes. We needed to trial the new form to see if it did what we wanted. We needed to categorise people into low, medium and high risk according to the new modified questionnaire We needed to involve and get agreement with all stakeholders.

14. Research • Pilot: 30 consecutive injured workers – asked if they would fill out the modified questionnaire and followed them through until they returned to work with a final certificate. Reviewed the costs and categorised the groups into high, medium and low. Took a year and a half. • Control Group: We then followed a cohort of 80 injured workers where they received “usual care” (no special intervention). In our institution, they still got seen within 48 hours of notification of the injury, put in a injury notification, received physiotherapy within a few days of the injury and often that occurred before we received a medical workers compensation certificate. • Trial Group: We then followed a cohort of 80 consecutive injured workers with soft tissue injuries and instituted the intervention program. • Took three years to complete the main part of the study

15. Örebro Musculoskeletal Pain Screening Questionnaire (Modified)(Linton & Hallden, 1998) Please tick the box that reflects you current age How many days of work have you missed because of this injury? How long have you had your current pain problem? Is your work heavy or monotonous? How would you rate the pain that you have had during the past week? How tense or anxious have you felt in the past week? How much have you been bothered by feeling depressed in the past week? In your view, how large is the risk that your current pain may become persistent? Physical activity makes my pain worse. An increase in pain is an indication that I should stop what I’m doing until the pain decreases. I should not do my normal work with my present pain. How long have you been employed at Concord Hospital In your estimation, what are the chances you will be working your normal duties in 3 months

16. Results of the Control Group

17. Intervention strategy • High Risk (>85) • Independent Rehabilitation Provider within 2 weeks • Independent psychological assessment and treatment within 2 weeks at Staff Health • Independent Medical Consultation within 2 – 4 weeks • Independent Physiotherapy Assessment after 6 weeks. • File review by Medical Director if not returned to work within 4 weeks. Medium risk (70 – 84) • Psychologist assessment and treatment within 2 weeks of injury plus “usual care”. • Independent Medical Consultation within 1 month • Low risk (<69) • “Usual care”

18. Results of the control and intervention arms

19. Key Findings • “Yellow flags” can predict the cost of a workers compensation claim within 48 hours and independently of what or where the injury is. • The provision of an early assessment and intervention process can reduce costs in high risk claims. • That there is a significant difference between the 20% in the “high risk” category and the other 80% who manage pretty well with “usual care”. • There is no further reason to separate low and medium risk patients.

20. But – what about the longer term – how much difference does it make?

21. Days lost per employee June 2009

22. SSWAHS Experience Premium Movement from 2007/08 to 2008/09

23. Number of claims in fund year

24. Cost/employee 2006/2007

25. Cost/employee 2007/2008

26. Cost/employee 2008/2009

27. Number of open claims

28. What do we do now? • All W/C injuries are screened at 48 hours • High risk clients are referred to an independent psychologist within 3 weeks and seen at Staff Health. • All high risk clients are seen by IMC within 4 weeks of the injury • Use IPC’s and independent professionals for all treatment areas including massage, chiropractors. • Accredited External Providers are used if people are not back on normal duties within 6 weeks or there are special reasons to use them upfront or injured workers request them.

29. Could you do this? • Yes but! • There are no short-term solutions and you need a longer-term plan • You need consistent staff and good leadership • If you are geographically diverse, you need to re-think how you do workers compensation • Consider centralising your most experienced W/C staff • Chose carefully your referral base • You need to think carefully about a psychologist • You need to have Executive/CEO support and advocacy • You need to consult with all stakeholders

30. Where to from here? • WorkCover NSW and SSWAHS are looking at funding a larger trial over two Area Health Services with one being a “Control” with no change in current practice but doing the early screening and one Area Health Service being an “Intervention” using similar approach.