Workplace Disability Management

Workplace Disability Management Steven R. Pruett, Ph.D, CRC SERNRA Conference May 16, 2005

Private Sector Rehabilitation • Rehabilitation Counselors have been employed in the private sector performing rehabilitation services for various insurance related settings since the 1970’s. • Workers’ Compensation • Managed Care

Private Insurance Rehabilitation Economic Rationale • For Vocational Rehabilitation services • Return of the claimant to gainful employment thereby reducing payment of lost wages. • For medical case management • Facilitate the treatment and recovery of the claimant for a quick and safe return to work. • Reducing costs by curtailing unnecessary or unrelated medical treatment and reducing compensation for lost wages.

Disability Management • The rising cost of health care and disability at the work place in conjunction with a competitive business economy provided the impetus for cost containment strategies with large companies in the United States.

Definitions of Disability Management “Disability management is a workplace prevention and remediation strategy that seeks to prevent disability from occurring or, lacking that, to intervene early following the onset of disability, using coordinated, cost-conscious, and quality rehabilitation service that reflects and organizational commitment to continued employment for those experiencing functional work limitations.” (Akabas, Gates & Galvin, 1992, p. 2)

“Disability Management means using services, people and materials to (a) minimize the impact and cost of disability to employers and employees; and (b) encourage return to work for employees with disabilities.” (Schwartz, Watson, Galvin & Lipoff, 1989, p.1)

“A proactive and systematic workplace strategy to enhance organizational health and to promote employee’s wellness by providing preventive and remedial services to minimize the economic and human costs of disability.” (Lui, 2000, p.5)

The first disability management programs appeared in late 1970’s and early 1980’s • Burlington Industries • AT&T • 3M Corporation • Sears • Goals: Humanitarian & Economic

Evolution of Disability Management • During the 80’s and 90’s a growing number of employers were implementing DM programs in the workplace (Breslin & Olsheski, 1996; Habeck, Leahy, Hunt, Chan, & Welch, 1991; Shrey, 1995) • DM programs began hiring many different rehab professions • Rehabilitation counselors • Occupational health nurses • Other occupational health professionals

Scope of Practice in Disability Management • Commission on Disability Management Specialist Certification (CDMSC) • 1991 Essential work role & function categories • Case management & human disabilities • job placement & vocational assessment • rehabilitation services & care • disability legislation & forensic rehabilitation • Habeck’s (1996) two-level concept of disability managers (DM & dm)

Scope of Practice • DM (Level I) • System, administrative oriented • Practice & knowledge domains are predominately managerial and fiscal. • dm (level II) • Service oriented • In addition to those cited in the 1991study practice & knowledge domains include: disability management concepts, principles of insurance, benefit plans, ergonomics, managed care concepts, and business practices and operations. Currier, Chan, Berven, Habeck & Taylor (2001)

Scope of Practice • Chan et al. (2001) • sole focus on practice & knowledge domains of level II disability managers • Practice domains • Managerial/Consultative • Vocational Counseling, Assessment, and Job Placement/Job Development • Disability Case Management • Early Return-to-Work Intervention

Scope of Practice • Chan et al. (2001) continued • major knowledge domains • case management techniques • psychosocial intervention skills • vocational aspects of disability • managed care • managed disability • human resources

Scope of Practice • New study (2003) by CDMSC • 12 experts in the field of DM • 3 day exploratory fact-finding meeting on current status of DM • Educators, employers, practitioners & adminstrators • consensus based model • Current practice based on 3 primary domains • Disability case management • Disability prevention & workplace intervention • Program development, management & evaluation

Scope of Practice (A sample CDMSC finding)

DM Core Competencies • Case management within DM is an essential element for dealing with a workplace disability (Akabas et al., 1992). • In general, rehab nurses and occupational health nurses have adequate medical knowledge & skills, but may lack understanding of the interaction between disability and work. • VR counselors & rehab psychologists generally have an adequate understanding of disability and work, but are likely to have limited knowledge specific to medical problems (Rosenthal & Olsheski, 1999)

DM Core competencies • Case management • Haw (1996) found that only 4% of nursing programs provide coursework in case management • Chan, McMahom, Shaw, Taylor, & Wood (1997) found only 20% of master’s level RC programs had one or more course in case management. • CORE requires some case management courses, but rehab case management is related, but is not equivalent to disability case management.

DM Core competencies • Habeck et al. (1994) found some evidence for a natural fit between the background & skills of RCs and DM work practice. • Employers found RC had necessary but insufficient knowledge & skills to work effectively with DM programs and employers • RCs in DM expressed frustration with inadequate pre-service training to meet work demands

DM Core competencies • Shrey (1992) noted traditional RC paradigms overemphasize characteristics of injured worker while ignoring significance of the environmental factors. • Traditional rehab programs have focused too much on reactive, provider-based clinical models. • RCs in DM must be able to develop active partnerships with employers to enhance employment of injured workers while advocating for interventions in the workplace. • RCs must be able to conduct ergonomic and disability prevention programs, including workplace safety programs & EAPs

DM Core competencies • Very few academic programs provide a comprehensive DM curricula. • Only a few CORE accredited master’s degree programs offer an emphasis in DM • Generally CORE programs train students to provide counseling and support to individuals with disabilities using private non-profit and public VR systems as models. • Concepts necessary to DM have not been emphasized in these models.

DM Core competencies • CDMSC requirements are changing due to changes in the profession of DM • Emphases on prevention has made job analysis, reasonable accommodation and ergonomics into the mainstream of practice. • Early intervention has brought greater focus on medical management and requires knowledge of high quality medical care with an occupational perspective. • Additional changes will most likely be in work organization and management structure (Caulkins, Lui, & Wood, 2000)

Emerging Practices in DM • Changing Demographics • Hursch (2003) projects: • Number of older workers will increase substantially over next couple of decades. 18.4 million workers over 55 in 2000 will reach 31.9 million by 2015 (US GAO, 2001). • Proportion of older workers will increase from 13% to 20% by 2020 (Purcell, 2000). Fewer younger workers entering workforce to replace positions vacated by retired workers. • In 2000 30% of the older population was in the work force. By 2015 this will increase to 37%. (Purcell, 2000)

Emerging practices in DM • Changing Demographics • Older workers are needing health insurance and additional finances to support desired lifestyles. • Holistic approaches needed for work and life planning. • Older workers are heterogeneous • differing in health, financial and career needs • Longer healing times may be needed, but many older workers are loyal, skilled and careful workers, who have fewer work-related injuries. They are also less likely to have family problems. (Douglas, 2000)

Emerging practices in DM • Changing Demographics • Recent census data indicate African Americans, Hispanic Americans and Asian Americans comprise approximately 33% of the US population. • By 2010 it is estimated that European Americans will be a distinct numerical minority. • Workplace will be even more diverse requiring greater cultural sensitivity.

Emerging practices in DM • Outcome orientation • Accountability and accuracy driven by business competition and rising disability costs. • Many companies lack tools for effective outcome measurement. • Employer Measures of Productivity, Absence and Quality (EMPAQ) (in development by WBGH) • Industry-wide, consensus-based standardized “health related lost-time measure” • Comparative & predicative analyses • Establishment of meaningful goals, measurement criteria, and evaluation of outcomes that cover the overall benefits of DM.

Emerging practices in DM • Prevention • DMs work closely with occupational health teams: ergonomics, risk management, EAPs • Optimization of communication across corporate “silos” • understanding of differences in expertise • Job Analysis, job accommodation, job modification & ergonomics • Assistive Technology • EAPs

Emerging practices in DM • Response: how to avoid employee absences. • Too frequently a referral for VR does not occur until MMI is reached and claimant cannot RTW • Catastrophic injuries  immediate referral • injury that has potential to limit RTW should result in a expedited referral. • In-house monitoring of claims can promote this type of referral.

Emerging practices in DM • Transitional Work Programs (TWP) • involve a combination of purposeful and productive job duties, tasks, functions & therapeutic activities for a worker with functional restrictions.

Emerging practices in DM (TWP) • DM coordinator’s involvement • initiates early contact with injured worker to explain program, discuss type of work, review benefits, answer questions • Analyze available job duties & physical demands consistent with worker’s residual abilities • Arrange for an objective worker functional eval • Reviews TWP program with medical staff or primary physician & worker, including transitional work assignments, clinical supervision, time frames, safety precautions, and expectations for RTW.

Emerging practices in DM (TWP) • DM coordinator’s involvement • Collaborates with treating MD in discussing with worker how the TWP involves safe work activities and minimizes potential for reinjury • Discusses modified work duties with work supervisor • Monitors worker’s progress with clinical supervisor during the structured period of transitional work & keeps medical staff informed of progress or changes • Arranges realistic accommodations/assistive aides or modified work if needed. • Updates stakeholders on the worker’s progress.

Emerging practices in DM (TWP) • Post TWP planning • DM case management monitors worker’s performance, productivity & adjustment following a successful RTW. • If needs are not attended to poor productivity, increased absences or job loss can result. • Medical/disability management programs in the 1990’s returned many workers to work, but 60% of those that RTW had one or more injury related absences that often resulted in job loss. (Butler, Johnson, & Baldwin, 1995)

Emerging practices in DM • Facilitating Adjustment and Coping • Psychosocial interventions • Reduction of stigma for psychiatric disabilities • Integration of psychosocial interventions requires policies & procedures that define relationship between VR and and mental health • EAPs have traditionally not been involved in the RTW process and may be unfamiliar with vocational objectives, operations & services in the DM program.

Emerging practices in DM • Integrated Disability Management (IDM) • Combining all disability related programs • Worker’s comp, group health, short & long-term disability • Motivated by pursuit of efficiency at all levels this is an attempt to reduce duplication of services to reduce benefit costs. • 24/7 model: Regardless of etiology or time of occurrence of the health problem, health care and RTW services are provided in a consistent and coordinated manner.

Emerging practices in DM • IDM • Definitions, interpretations, & applications are not universal across employers. • Elements that are consistently rated as the most effective in controlling disability costs: • Common case management • Aggressive RTW policies or practices • Responsible, internal, and active management of disability issues; and identifiable, simple and coordinated points for intake & claims reporting (Watson Wyatt Worldwide and WBGH, 1999/2000)

Emerging practices in DM • Absence Management (AM) • Many employers have moved beyond integration-of-benefits to overall productivity. • Combining programs that involve work interruptions: • Medical, Worker’s comp, disability • Unauthorized time off, sick pay, FMLA • Still a 24/7 model like IDM.

Emerging practices in DM • AM implementation • Formulate a leave of absence policy delineating length of absence by category (e.g., severe health, pregnancy, adoption, death in family, military) • Create a same-job protection policy for work-related and non-work-related disabilities • Generate specifications on how an employee’s salary will be replaced while he or she is on leave. • Ascertain how long an employee on leave will be treated as an active employee. • Explain what happens if an employee discontinues health insurance or other benefits while on leave.

Emerging practices in DM • AM implementation • Specify when COBRA will be offered to employees on leave. • Explain whether an employee’s work will be reassigned while s/he is on leave • Adopt a leave policy, consistent with workers’ comp law which encourages employees to RTW • Make revisions to employee handbook that include general information about employee rights and responsibilities under FMLA/WC and similar laws and leave policies. Ritter (2000)

Emerging practices in DM • Presenteeism • Shift in focus from absence of employees, to present, but lacking productivity due to chronic illness, distraction from family care needs, personal problems, etc (Stevens, 2003). • Chronic health problems such as diabetes, asthma, depression, pain disorders & allergies can have a major presenteeism impact. • Heath Productivity Questionnaire (Harvard Medical School & WHO) • Work Limitation Questionnaire (Health Institute, Division of Clinical Research at Tufts-New England Medical Center).

Evidence-based DM practice • Entails • Integrating DM practice expertise with best available observable evidence regarding a specific disability obtained by systematic research. • Case manager can then understand the accuracy of vocational functional capacity, diagnostic evaluations and base recommendations for prevention or intervention strategies on empirical information & reliable research findings. (Rosenthal, Hursch, Lui, Zimmerman & Pruett, 2005)

Workplace Disability Management