Power to the employee and employer – what the research says

1. Power to the employee and employer – what the research says Dr Mary Wyatt

2. Workplace culture VWA data – claims by industry

3. Disability management • Where have we been and where are we going?

4. Introduction • Return to work management in most companies has moved from a passiveapproach to early intervention and case management. • Research suggests the next major improvement will come from empowering the employee andempowering management. It’s positive and achievable, and people feel good when they do it. This talk presents the relevant research studies.

5. Medical input to work disability • Evidence that medicalisation of conditions may increase disability • Little evidence for treatment reducing disability, eg for back pain • Investigations and treatment may raise level of concern, and increase the likelihood of progression to a chronic problem • Medicine is important, but not good at reducing work disability • Ehrlich, G. E. (2003). "Back pain." Journal of Rheumatology - Supplement 67: 26-31. • Nordin, M., S. Welser, et al. (2002). "Self-care techniques for acute episodes of low back pain." Best Practice & Research in Clinical Rheumatology 16(1): 89-104. • Tacci, J. A., B. S. Webster, et al. (1999). "Clinical practices in the management of new-onset, uncomplicated, low back workers' compensation disability claims.[see comment]." Journal of Occupational & Environmental Medicine 41(5): 397-404.

6. What can be done? The employee The employer • Positive messages about musculoskeletal conditions (sore body parts) • Improving self-efficacy • Problem solving • Supervisor care • Senior management leading • HR RTW coordinating • Systems in place • Having all the players on side

7. The employee • Most people do fine without any intervention • Most do better with positive support • Problem solving and more positive beliefs improve outcomes • A small proportion need a highly coordinated level of care from the employer, their treaters and claims managers

8. 90s workplace study • Pamphlet given to staff at UK company • Containing positive messages about the consequences of back pain • Demonstrated reduced work absence secondary to back pain

9. Victorian campaign • Positive messages about what the person could do for themselves • “Don’t take it lying down” • Famous sportsmen, actors, broad range of experts delivered message • Improved outcomes in • beliefs, • doctors’ stated management • back pain as percent of claims.

10. More positive beliefsChange in mean (95% CI) BBQ 30 Victoria 29 Mean BBQ Score 28 27 NSW 26 1 2 3 Survey

11. Less back claims as a percent of all claims Change in number of claims, 1993-4 to 1999-0 P=0.013

12. 80 70 60 Backs Days compensated rate (days per claim-day) 50 40 Non-backs 30 20 1/99 7/99 4/98 7/98 4/99 1/98 10/99 10/97 10/98 Month Change in rate of days compensated, 10/97 to 10/99 Slope = -1.2 days per 1000 claim-days per month Slope = -0.41 days per 1000 claim-days per month P=0.0003

13. Problem solving • People off work with back pain were placed into two groups • Graded activity program with education • Graded activity program with problem solving • 5 steps for problem solving • problem orientation • problem definition and formulation • generation of alternatives • decision making • implementation and evaluation. Secondary Prevention of Work-Related Disability in Nonspecific Low Back Pain: Does Problem-Solving Therapy Help? A Randomized Clinical Trial

14. Problem solving cont’d • Problem solving focus was skills training application of skills in daily life, rather than one specific problem area. • Patients were free to select their own problem areas, which did not need to be pain related. • Between sessions, homework assignments were given to practice skills in everyday life. • Homework assignments were discussed within the group at all sessions.

15. Results of the interventionsWork status at 12 months • GA = Graded activity • PST = Problem solving training • EDU = Education

16. Workplace based • Good evidence that early work place based intervention makes a difference • Involvement of all parties improves outcomes • Australian model – RTW coordinator • Canadian model – Disability management committee, like our OH & S committee approach http://www.backpaineurope.org/

17. Workplace interventions –IWH systematic review Components that reduce the duration of work disability • Early contact with worker • Return to work offer • Contact between healthcare provider and workplace • ergonomic visits, participatory ergonomics • Educating supervisors and managers • Labour management cooperation • People oriented culture • Conditions of good will and mutual confidence http://www.iwh.on.ca/sr/wd_rtw_interventions.php

18. Workplace based injury management • Participants off work 2 to 6 weeks due to back pain were randomized to workplace intervention • Workplace intervention consisted of workplace assessment, work modifications, and case management involving all stakeholders. • Outcomes were lasting return to work, pain intensity and functional status, assessed at baseline, and at 12, 26, and 52 weeks after the start of time off work. • RESULTS: Time until return to work for workers with workplace intervention was 77 versus 104 days (median) for workers without this intervention (P = 0.02). Workplace intervention was effective on return to work (hazard ratio = 1.7; 95% CI, 1.2-2.3; P = 0.002). Anema, J. R., I. A. Steenstra, et al. (2007). "Multidisciplinary rehabilitation for subacute low back pain: graded activity or workplace intervention or both? A randomized controlled trial." Spine32(3): 291-8; discussion 299-300.

19. Workplace intervention • Dutch modification of Canadian system • The workplace intervention consisted of a workplace assessment and work adjustments in which all major stakeholders in the return-to-work process participated: • the worker • the employer • the doctors involved • Interesting to compare to our model

20. Team collaboration • Getting all the players onside • Increasingly the focus of overseas studies and guidelines, including the European Back Pain Guidelines on prevention of back pain • Canadian model has partnership approach at its core

21. Team values • Getting the players onside has been a focus of research over the last ten years "The values underlying team decision-making in work rehabilitation for musculoskeletal disorders.“ • Loisel, P., M. Falardeau, et al. (2005). "The values underlying team decision-making in work rehabilitation for musculoskeletal disorders." Disability & Rehabilitation27(10): 561-9.

22. Team approach Expectations • Stakeholder endorsement of RTW • The concept of a shared vision is raised regularly • The team wanted a positive attitude and a high level of motivation from the worker • The team expected actions that were perceived as helpful to return to work (e.g., authorizing the program, giving messages consistent with the teams’ philosophy, acting promptly). Focus and time commitment • However, there was little time and focus invested in developing a shared and collaborative approach • Little focus on what are the motivators for the worker, and an approach exploring those issues • Little knowledge of how others in the team operate • Minimal work to develop team as a team, and to increase likelihood of a common message

23. Be nice Butler, R. J., W. G. Johnson, et al. (2007). "It pays to be nice: employer-worker relationships and the management of back pain claims." Journal of Occupational & Environmental Medicine49(2): 214-25.

24. Training of supervisors Study one - unpublished • 1.4% absenteeism with • RTW policy • Case management • Supervisor involvement • 5.3% absenteeism without them • Programs have saved 20 - 40% on benefit costs Study two • 47% reduction in new claims and an 18% reduction in active lost-time claims • Versus 27% and 7%, respectively, in the control group. Shaw, W. S., M. M. Robertson, et al. (2006). "A controlled case study of supervisor training to optimize response to injury in the food processing industry." Work26(2): 107-14.

25. Senior management • Michigan study of employer practices demonstrated senior management commitment had a strong influence on reduced work disability THE MICHIGAN DISABILITY PREVENTION STUDY RESEARCH HIGHLIGHTS Upjohn Institute Staff Working Paper 93-18 H. ALLAN HUNT, W.E. Upjohn Institute for Employment Research ROCHELLE V. HABECK, Principal Investigator Michigan State University April 1993

26. Identifying the areas for improvement Work disability management review • Informal audit • Injury Map • Consensus Based Disability Management Audit

27. Informal audit • List of areas to assess, eg • Procedures • system of early injury reporting • process for identifying return to work task • Outcomes • Days lost • Costs • And then plan how you will gather the information so you get important and relevant input

28. CBDMA • Rigorously developed and tested • $2 million spent in development • Comprehensive approach • Involves employees and employers • Varied instruments – consensus based discussion, surveys, review cases, to assess the situation • Clear report on the 16 relevant areas, with recommendations for action www.nidmar.ca

29. Uses • An evaluation tool, to determine current disability management program performance • A monitoring tool to show increases or decreases in effectiveness for each audit area • A corrective tool, to establish deficiencies and highlight ‘the next steps’ • A program promotion tool demonstrating management's commitment to workplace disability management practices

30. Benchmarking • Originated in Canada • Now used in a number of Canadian provinces, Germany, US, Australia, and New Zealand • Ability to benchmark against other organisations, reports include comparative performance

31. Supervisor training • Research results based on needs assessment • The teaching needs to be about how to do things, the actions that make a difference • Teaching about completing forms, timelines, etc without the how has not been shown to be effective

32. Return to work knowledge base website Content: Access: www.rtwknowledge.org RETURN TO WORK Knowledge Base When access is available, feedback is invited while information continues to be refined and improved upon

33. Knowledge Base Project Committee & Team • Committee: Mary Wyatt, ResWorks Janet Russell, Continuing Education Bendigo David Cragg, Australian Workers Union Robynne Dashwood, Eastern Health Andrea James, Medical Practitioner Tracey Browne, Australian Industry Group Paul Coburn, Physio, VWA Bianca von BlomBerg, TAC Chris Tsoukalas, QBE Insurance Michael Simpson, OccCorp Pty Ltd Coralie Hadingham, VWA Carol Lapeyre, The Rehab Factor • Project Team: Project Manager: Robert Hughes Translation Team Leader & Writer: Mary Wyatt Administration / Marketing: Cheryl Griffiths info@resworks.org.au RETURN TO WORK Knowledge Base

34. Stakeholders

35. Content Development Ideas Translation • Committee • Project Team • Focus Groups • International input and collaboration • Identify research • Multiple drafts • Feedback • Refinement

36. Table of contents • Research • Medical factors and RTW • Psychological factors and RTW • Consequences of being off work • Workplace factors and RTW • People factors and RTW • RTW approaches and intervention • Resources • Taking control series for Employees & Employers • Improving your effectiveness series for Practitioners & Insurers • Information on the processes / timelines involved • Returning to work, effective return to work plans • Medical and health information • Links / Glossary of RTW terms