What can you do to control rising medical costs in Workers’ Compensation claims? Bring your injured employees back to work.

Recently, the National Council on Compensation Insurance, Inc. (NCCI), reported on some of the trends impacting workers’ compensation across various states.  Some of the items the report covers include employment growth, information on the construction industry, and medical inflation (rising medical costs).

The workers’ compensation industry has a tendency to separate indemnity (wage) and medical costs.  Nothing exists in a vacuum, certainly not in workers’ compensation claims. 

Maybe you think I’ve oversold you with the title of this blog post. Consider the following questions.

What happens when an injured worker is injured and their employer cannot return them to work?

·     They are left to sit at home in their recovery.  Anyone who has spent time at home for a period exceeding one work week as the result of a medical issue or surgery can attest to the impact that being out of work has on you.  You may start to wonder what your co-workers are up to.  Maybe you try to stay connected by checking in or reading some emails from home, but it’s not the same.  You don’t have the context and the opportunity to ask questions – getting second hand information about the goings on at work can actually make you feel even more isolated.

·     The injured worker may begin to question if they’ll ever be able to get back to work.  What will happen if they have permanent restrictions?  Like reading hotel rating reviews, our minds tend to go to the most negative example possible.  The story of the neighbor who had to file bankruptcy because he lost his job after his work injury.  They’ve probably memorized the phone numbers for the attorneys who promise to get them huge sums of money.

·     The injured worker may become deconditioned from lack of activity.  If you’re a mason who’s used to lifting block every day for the past 15 years and now you haven’t lifted anything more than five pounds since your injury, you may have lost some of your strength and stamina.

 

What do these consequences have to do with medical inflation?

·     Isolation may have negative consequences on an injured worker’s motivation to get better.  It may also deplete their ability to cope with the aspects of managing their claim and their recovery.  For those of us who need people around us to support us, to guide us and to motivate us – when you take that away it can leave one feeling alone and without the wherewithal to get up and push through challenging physical therapy sessions or perform the home exercises that help in recuperation.

·     They may have an increased need for prescription pain medications or other medications.  These prescriptions may have negative side effects (and may require additional medications to treat the side effects).

·     Deconditioning may require additional physical therapy or work hardening.  It may also lead a physician to extend the time period between improved work status notes, resulting in increased office visits for progress checks.

Prudent, proactive employers should focus on preventing injuries in the first place.  But, when injuries do occur, a plan that focuses on the whole person (employee) and their return to wellness should be ready to go. 

 

What steps are you taking to prevent future injuries like this from happening? 

What are you doing to communicate regularly with the injured worker while they are totally disabled?

What are you able to offer based on what the anticipated restrictions? 

Are there other concerns that the injured worker has about their employment or benefits?  Address the concerns and to reassure your employees that you will work together reach the best possible outcome for them in their recovery. 

 

It’s never too early to have these discussions.  Start today.

Why bother with a job offer letter?

Time consuming, tedious, and seemingly unnecessary -- job offer letters for a worker's compensation claim are probably not an employer's favorite task.  As a RTW person, they're at the top of my reading list.  I realize this is not the case for most.

Why should employers offer a modified or full duty job in writing?

• It clearly communicates the expectations surrounding the return to work.
• What are the restrictions the employer is referring to base their offer on?
• What are the job duties?  Rate of pay?  Hours?  Start date?
• Where and who should the injured worker report to?
• How will other benefits be handled (accrued time, etc.)?
• Who should the injured worker contact if they have questions?
• It documents the offer
• So many times the employers state that they offered work or tried to offer work and the injured worker didn't show up.
• That may work in some states, but in many, employers need some type of documentation to demonstrate the offer.
• The letter is important in showing the amount of earnings the injured employee may be refusing as well as details that help a judge determine if the employee was unjustifiably refusing the work or if it was justified.
• This directly relates to whether the employer is entitled to relief under the WC laws or if the injured worker is entitled to ongoing benefits.
• IF an employer finds themselves in litigation over a job offered, they may need to testify.  This may not happen for months.  Are you going to be able to recall a conversation you had with any great level of confidence during a hearing?  Having everything written out will help ensure that you know what you offered months prior.
• It is a best practice
• Once an employer incorporates this practice into they disability management policies, it becomes routine and simple.
• It may be dictated by various laws other than workers' compensation (which is what this particular post pertains to).

Before issuing a modified or full duty job offer it's a good practice for the employer to contact the injured worker and let them know that modified work (or full duty work) is available.  This will allow them to ask questions in advance of receiving the letter and communicate things with a level of transparency that will hopefully make the process go smoother.

When the duties of a job change or the wages change, it may also be a good idea to send an updated job offer to document the changes.

Although they are sometimes time-consuming, job offer letters can be based upon a template that will pay for its initial investment time and time again.  If you have questions about what needs to go into a job offer letter, please contact your claim representative as each state has its own set of requirements (or lack thereof).

Defining Disability - Part III: The Regulatory Perspective

The disability time clock

We've said it before and we'll say it again, upon issuance of that work-related disability note, the clock starts ticking.  Before that work status report makes it to the employer or claim representative's desk,   Many states have some type of waiting period in which wage benefits are not due under a workers' compensation claim. Typically these waiting periods are something like 3, 5 or 7 days.  After this waiting period has expired, in some states, the injured worker is then entitled to wages from the first date of disability (retroactive to the first date of disability).  Other states, the retro period is longer.  An example of this is Pennsylvania.  The waiting period is 7 days.  So if you're disabled for 7 days or less, you are not entitled to wage loss benefits.  However, if you're disabled for 8 days or more, you're entitled to benefits from that day forward, up until the 14th day.  If you're disabled more than 14 days, then you're entitled to benefits retroactively to the first day of disability.  Not sure why people get confused by this...

Not only does the first date of disability impact the wage calculations, it also starts the compensability decision clock.  States have compensability due dates or deadlines that dictate how long a claim representative or workers' compensation carrier has to accept or deny a claim.  This is based on the workers' compensation laws in each state.

Impairment or Permanency Ratings

Whether or not an employee is back to work can have an impact on their permanency or impairment rating.  In some states, an injured worker is entitled to wage benefits based upon their earning capacity after an injury.  In others, they may qualify for an impairment or permanency rating.  This is a very basic generalization for explanatory purposes only, however, when an injured worker has an injury to a particular body part (or in some states, any injury) they may be found to have a permanent impairment.  In an attempt to compensate the injured worker for their permanent impairment, they receive a rating from a physician who evaluates the degree or percentage of impairment.  Many states have a schedule of injuries that indicates how many weeks of disability benefits an injury equates to.  This rating, given as a percentage by a physician, is then multiplied by the number of weeks to get the total amount of permanency.

There are also factors that can increase or decrease a rating, depending on what state the injured worker is receiving benefits.  Some states take into account the injured worker's RTW status.  If they are not back to work or of they are back to work can impact the amount of their rating.

Employers are encouraged to offer modified duty, not only to reduce an impairment rating, but because it also helps that injured worker's recovery.  This posts primarily focuses on the "laws" and "regulations" as they relate to disability, but that is what takes place from this perspective.

Much of what the laws look at is related to when benefits are due, how much the injured worker is entitled to, and what makes them eligible or ineligible.  The laws focus on earning capacity and residual impairment related to the work injury.

They don't take every circumstance into consideration, they may not even consider if the employer has work available or not - it may be that once and injured worker reaches maximum medical improvement, they are no longer entitled to a certain level of wage benefits.  The laws dictate the benefits due to injured workers and the actions of the workers' compensation carrier.

We hope you found this series of posts to be informative.  Each of us have our own perspective on disability and its definition depending on what we do -- as employers, injured workers, medical providers, and insurance carriers.  If we expect to understand what the other person is saying, we must understand where they're coming from and what the word "disability" means to them.

Defining Disability - Part II: The Workplace/Employer's Perspective

In our last post we introduced three different perspectives as they relate to how we define "disability."  The goal of these posts is to enlighten the respective participants in the WC/disability management community as to the various lenses through which others are viewing disability - doctors, injured workers, employers, and workers' compensation professionals.  With greater understanding, the hope is that we can cut out some of the miscommunication and confusion, creating a greater awareness of where people are coming from -- yes, we're talking about the radical idea of empathy in workers' compensation.

This post will outline some of the constructs we use to define disability when we're talking about it from the employer or workplace setting.

Workplace/Employer Perspectives - Workers' Compensation

We'll preface this post by stating that we're not going to address FMLA or short/long term disability - rather we will focus on disability as it relates to modified duty in the workplace.

It is common practice for an injured worker to bring their employer a "Return to Work" or "Work Status" note from their treating physician as a result of a work related injury.

The employer is now in a position to make a determination as to whether they can or cannot accommodate the restrictions.  Maybe the injured worker's pre-injury position falls well within their restrictions.  More often than not, the restrictions impact some aspect of that injured worker's job.  Consider a person who sits at a desk but has walking limitations.  They can perform their job, but may need a closer parking space or a wheelchair to navigate the building until they can reach their desk. 

With the exception of very large companies, most employers don't have one person who solely handles workers' compensation claims and manages the return to work of injured employees.  If they do, then the frequency of their lost time claims probably justifies their pay.  For the average employer, workers' compensation is not something they have to handle every day (and they're thankful for that). 

Considerations for Employers and Employees

We will assume that an employer has identified work within the injured employee's restrictions.  Much of the focus rests on the actual work the injured worker is performing and what work their doctor says they can and cannot safely perform. 

Employers aren't always considering the other factors that may impede or promote return to work outside of the "disability" note.  Does the supervisor understand what the injured worker is being asked to do on modified duty?  Do they understand that they cannot/should not ask the injured worker to do work outside of their modified duty work assignment if it falls outside of the work restrictions?  Who should the injured worker address concerns with? 

Does the injured worker have a good relationship with their employer and coworkers?  Have their been past performance issues that the employer may be weighing in to their ability or inability to offer work (right or wrong it happens)?

While many of these factors do not impact the injured worker's entitlement to benefits, it can impact the outcome of the claim and should not be overlooked.

From an employer's perspective, they are focused on the work that needs to be done to continue their operations, costs associated with having a workers' compensation claim, the costs associated with replacement labor/overtime to compensate for the injured worker's disability, and hopefully they're considering the positive impact that modified duty can have on all of these factors.

Tune in next time when we'll be discussing RTW from a regulatory perspective.  Rest assured, the title is far less interesting than the useful content provided in that post.

"Wait and see" is never a good approach to claims management, or anything else, really

It sounds obvious, right?  “Wait and see” is the antithesis of “pro-active claims management.”

If you’ve spent any time skimming articles in the workers’ compensation blogosphere, you’re fully aware of the focus on being a proactive employer or carrier, leveraging predictive analytics, and applying all sorts of programs or steps to impact your company’s bottom line.  It goes without saying that having a plan in place prior to a loss or accident occurring is generally accepted as a best practice.

Glad we’re all on the same page.

It begs the question then, as to why employers take the “wait and see” approach when it comes to returning injured workers to modified duty.  Most people agree that proactive claims management is a good thing.  Getting people the right medical treatment and returning them to work as soon as it is safe is also a good thing.  So why is it, time and time again, employers receive a copy of work restrictions and say, we’d like to wait and see what the next appointment tells us. 

It’s like driving down a highway with your fuel light on, and having no certain way of knowing if the next gas station is 6 or 65 miles away.  Sure, the sign said fuel - 6 miles ahead, but it may be closed for service.  The doctor’s notes said that the injured worker would likely reach full duty status in 6 weeks.  In cases of a cut finger or even a clean fracture, maybe the prognostications are accurate.  These projections are based on many factors – most of which are subjective and can be difficult to quantify.  Does the injured worker smoke?  Have they had an injury like this before?  Are they considered obese?  How old are they?  Do they have other co-morbidities or conditions that may delay recovery?  Do they have a support system at home to help them get to their therapy appointments or change wound dressings?  Are they compliant with their home exercise program? 

It's a well-known joke that the best occupation in the world is to be a meteorologist because you can be wrong every day of the week and still have a job.  Well, predicting recovery times can sometimes be a lot like predicting the weather.  There is plenty of data that has been aggregated and put into a model to predict when we think this person will come back to work, but the factors that we cannot measure with great precision are those specific to that injured worker – the psychological and social factors.  How motivated is the injured worker? What’s going on in their personal lives that may impede or speed up recovery?

So, like predicting the weather or mentally calculating your vehicle’s MPG vs. distance to the next gas station, use the information that you know.  Base your next steps on the given work restrictions and find something the injured worker can do within those restrictions.  You don’t know what you’re going to get in the future, so make an informed decision rather than “hoping” or taking a “wait and see” approach.

Think about the last time someone told you that they would “wait and see how things go."  How did that make you feel?  Most likely, it made you feel pretty uneasy. 

We’ll wait and see how that tire holds up.  We’ll wait and see how this year goes for your first year freshman son or daughter.  We’ll wait and see how this prescription medication works for your cardiac problems or blood sugar.  We’ll wait and see if that health problem worsens before we decide to do anything about it.

Would you accept any of those things with ease?  Probably not.  You would likely ask the doctor if there was anything you could do to improve or influence the outcome.  Would diet and exercise help?  Are there tutors available to help my son rather than having to  “wait and see” if he passes or fails his mid-term?  Waiting and seeing is basically relinquishing all control and influence over a situation.  Sure, you cannot control everything but there’s always something you could be doing now to positively impact the outcome.

 

Eliminating uncertainty does wonders for peoples’ confidence in their future, as well as their workers’ compensation claims.

If you find yourself saying that you'll wait and see if the injured worker is released to full duty at their next appointment, you should probably not wait and see how that approach works out -- do something now.

Uncovering commonly overlooked RTW options by inspecting the way we view inspections

Sometimes it may seem as if there is a bureau or a department to regulate just about every business these days.  In all fairness, these regulations are for good reason and we're thankful that there's someone there to do it.  With regulation come rules.  With rules come inspections.  The good news is that these inspections can be a fantastic source for productive and meaningful return to work (modified duty) opportunities.

Restaurant Inspections

Hopefully your restaurant is not worthy of Chef Ramsey and his camera crew.  If it is, well, you’re dealing with more than just RTW problems and I’m afraid our blog can only address so many issues in 500 words or less.

Restaurant inspections are conducted by various regulatory bodies at the state level to determine if a restaurant is operating within approved food-safety guidelines, has appropriately trained staff, among other requirements.  Many newspapers, as well as online sources, publish the health inspections of restaurants and other food service locations.  Copies of inspection reports are available by request from the agency responsible for completing the inspection.  The point is, this information is, for the most part, easily accessible and can have an incredibly positive or negative impact on your restaurant’s reputation (and subsequent sales).

Common injuries in the restaurant industry include cuts and lacerations, slips/trips/falls, and lifting injuries to the back.  The resulting work restrictions can include limited use of the involved body part such as:  no use of the right hand, no lifting greater than 10 pounds, must be able to sit most of the shift.  The old adage goes, “If there’s time to lean, there’s time to clean.”  Meaning, if you’ve got time to lean on the counter, you’ve got time to wipe said counter, polish said glasses on the counter, or refill said condiment containers under said counter – it’s like the military – there’s always something that needs to be polished, painted, or wiped down.

Restaurant inspections are based off of the codes in place.  Check with your local health department or state agency to see if they have any check list resources to help ensure your restaurant’s operations meet or exceed the standards.  Not only is it a good business practice, but it’s a great resource for modified duty.  A clipboard allows for ease of use.  Even if it is the injured worker’s dominant hand, they can probably check a box under “yes” or “no” with their non-dominant hand.  Most importantly, the work is meaningful, productive, and serves a legitimate business purpose.  This is the best kind of modified duty you can find!

Other types of inspections

 

Long term care facilities have many requirements to meet when it comes to Medicare compliance.  OSHA has numerous requirements related to various aspects of your business.  These include material safety sheets (are yours updated to meet the Globally Harmonized standards/hazardous communications documentation requirements).  Are your eyewash stations up to par?  (More importantly, does everyone know what the standards for an eyewash station are?)  When was the last time your fire extinguishers were inspected?  Are all of your crew members’ step ladders safe and free of cracks or damage?  Are your company vehicles properly maintained for safe operation?  Ask your Risk Management Consultant to help you identify some issues that OSHA may be concerned with and implement a checklist/maintenance system for compliance.  Use that checklist system as part of your modified duty options.  While it may not yield months of modified duty options, it will help you get an injured worker working and hopefully help prevent future injuries or citations.  The goal of course is to make your workplace safer, not just to avoid the citations.

I’m sure there are various other types of inspections that your business may face – be prepared and help return an injured worker to meaningful, productive modified duty.

Don't wait until you have a RTW note to start thinking about RTW

As an employer, when you have an injured worker who is out of work with restrictions, there should be no delay in having serious return to work (RTW) conversations.   Even if you don't have restrictions yet, there should be a return to work discussion taking place. 

How can I plan for RTW if I don't know what the injured worker can do?

Your claim representative and nurse case manager (if assigned) will be able to project roughly what the restrictions will involve.  There also other resources available to help, such as Occupational Disability Guidelines (ODG) and the Medical Disability Advisor (please note, we don't endorse either of these, but they are available).  A free, simple, and more accurate resource would be to ask the treating physician!  Most injuries do not require total disability for more than a few days so it is not unreasonable for an employer to make an inquiry as to when the injured worker will be released to return to any type of work and what type of work capabilities are likely.

Make sure the injured worker and their physician know that you have modified duty available?

Do not delay in communicating your intentions to bring an injured worker back to work.  From an injured worker's perspective, there is a great deal of uncertainty about their physical well-being, their financial stability and their future employment situation.  Reducing this uncertainty will help the injured worker focus on the recovery and return to normal activities, including work.  Physicians may not see the point in giving an injured worker a release to return to work if there is not modified work available. 

Are you unsure what type of work to offer?  There are several ways to identify meaningful, productive work.

We've all heard the stories of employers who bring injured workers back to count paperclips, separate nuts and bolts, or count cars in the parking lot.  What's the point?  How does that help anyone?  It damages the employer/employee relationship and makes an employer look unreasonable.

Instead, employers should review the injured worker's job description for less physically demanding tasks that fit within the injured worker's current or future restrictions.  Still can't find anything?  Look at other job descriptions or departments for work.  Before you dismiss this option, consider a few hours of cross training and what it could yield.  The benefits of training employees in various departments benefits everyone in the short term (as a modified duty solution) and in the long term.  Having skilled employees who are trained in various areas can go a long way to help reduce the time an injured worker is away from work and help your business. 

One of the most overlooked options is to ask the injured worker if they have any ideas.  Far too often decisions are made without involving the injured worker.  After all, they are the one who is going to push them to get better, to return to work, and to recover.  What are you doing to make sure your employees want to return to work?  Once you've identified return to work options, discuss the job with them and address any concerns up front.  Problems don't resolve on their own, they snowball.

If you have questions, find answers!

Rather than putting things off until someone contacts you, handle all workers' compensation issues proactively.  If you have questions about the job offer letter, call your claim representative.  If you are unsure if the work you’ve identified is suitable, check with the doctor.

There are few things in life that we can safely and confidently place on "auto-pilot."  Workers' compensation claims management is not one of them.  Put the time in up front and you'll be amazed at the outcomes.

Upset About your Workers' Compensation costs? What are you going to do about it?

There's ample research and discussion about factors that may lead to delayed recovery or poorer outcomes for workers' compensation claims.  We're all really good at pointing the finger and saying that it's because of the doctor, the unmotivated injured worker, or the employer who just doesn't get it.  I'd like to ask one simple question to those who are frustrated or angry about workers' compensation outcomes.  What are you going to do about it?

In the extreme case, an employer could shut down the business, throw in the towel.  Highly unlikely.  Realistically there are several steps employers and other stakeholders can take to GET INVOLVED in their claim management programs.  Here's just a few of my favorite.

• Report all injuries as soon as possible.  It's fairly common knowledge that the sooner everyone knows about an injury, the sooner it can be managed.  This leads to the next important point.
• Get the injured worker prompt appropriate medical care.  Get them the best care a workers' compensation dollar can buy.  If you want the best outcome, why would you skimp here?  Who would you want to see if it were your injury -- the doctor who just processes injuries and prescribes anti-inflammatories, tells you to follow up with your family physician if not better in a week or the occupational health physician who understands how to approach work injuries, what is necessary to help you get better and back to work, and what the signs of trouble may be?  Do you want a physician who follows what massive amounts of research says provides the best outcome, or the doctor who disregards evidence-based medicine in exchange for their anecdotal, 30 year old medical school training.  I wouldn't want a mechanic who only worked on cars from the 1970s to work on my 21st century car that's basically a computer running on gasoline (or electric, for that matter).  Get your employees to the best providers who are on top of the most current medical practices, and follow evidence-based treatment guidelines.
• Reduce delays in care by getting treatment approved, appointments scheduled, and referrals made TIMELY.  The sooner we can help that injured worker get the care they need, the sooner everyone can learn what the true injury is, what the treatment plan will look like and assess the RTW opportunities.  Nurse case managers can help with this process.
• Communicate effectively!  Communication is often the cause and the solution to all problems in a claim.  Keep everyone in the loop -- find a way to do it. Maybe it's a list of everyone who you need to update, written down on a sheet of paper.  Maybe it's an email distribution list that you create for each employee's claim.  Whatever your strategy is, keep everyone up to date.  As the saying goes, communicate by a factor of 10, and then say it one more time.  This group includes the injured worker, the employee's supervisor, the claim representative, nurse case manager, medical providers, and whoever else may be involved in the claim.  Documentation will be key in communicating technical, detailed information.  One example of this is the injured worker's pre-injury job description.  Document it, send it around for review and approval (including the injured worker) and then send it to the treating physician, physical therapist, and nurse case manager.  After all, how can you plan to get an injured worker back to work if you don't know what they need to do?  Identify barriers to return to work early on and develop a plan to address them.

These suggestions are based upon evidence.  Researchers from the Department of Physiotherapy and the Department of Epidemiology and Preventative Medicine at Monash University in Melbourne, Australia conducted a study involving the aforementioned interventions.  The results?  In their study, their intervention reduced costs associated with RTW claims by 34% and cut the days away from work by 58% (Iles & Wyatt, 2013).

References:
Iles, R. A., & Wyatt, M. (2013). Applying the evidence: a real-world example of an intervention to reduce workers' compensation costs. Physical Therapy Reviews, 18(5), 395-402.

RTW in the Health Care Setting - it can be done

Identifying modified duty options is incredibly important for those employers in the health care industry.  According to the Bureau of Labor Statistics, in 2012, employees in health care support occupations lost time from work due to a workplace injury or illness more than 2 times more often than all other occupations reported (U.S. Bureau of Labor Statistics, 2014).  

Barriers to RTW in hospitals and health care settings

While the incidence rate alone is a challenge, the usual 24/7 operations of hospitals can also be a barrier.  Employers are concerned about patient safety and cite this as a reason for not returning nurses with restrictions.  One of the most frequent obstacles is how hospital employers budget and account for wages paid while an injured worker is working on restricted or transitional duty.
 
Opportunities for RTW in hospitals and health care settings
Every industry has its unique challenges.  Generally speaking, there are always options for modified duty if one looks hard enough and thinks outside the box.  Recently, the Office of Disability Employment Policy (U.S. Department of Labor) funded a study to “identify promising practices and success stories related to RTW efforts and outcomes in the health care industry” (p. vi, 2015).  The following is a high level summary of some of their findings.  You are encouraged to read the full report here.

Health care employers and subject matter experts relayed several “best practices” that may benefit other employers:

·         Communication and training regarding RTW

o   Ensure that management and supervisors fully understand RTW, its benefits, and best practices 

·         Working with physicians  

o   Provide doctors with RTW plans or RTW options for the injured worker they are treating

·         Consider the utilization of occupational health providers and/or vocational rehabilitation  providers to assist with RTW

·         Identify outside sources for transitional work if no work can be found in-house

·         Support the case for RTW with financial figures

·         Create a system that pays for the transitional duty/modified duty work that ensures accountability for to motivate managers

o   Return injured workers to their department

o   Reduce injury rates

o   Employers may want to consider excluding injured workers on modified duty from productivity rates/counts

Some other highlights of the article include suggestions regarding a modified duty/transitional duty job bank.  We’ve always recommended employers maintain a list of tasks that need to be done in the event they have an injured worker on modified duty but these suggestions take it a step further.

Creating and maintaining a “living” job bank

The participants in the interview reported that they train supervisors and managers to find and share any modified duty positions prior to posting them.  These are often short-term jobs that need to be filled.  The respondents also reported that they contact the central staffing unit when looking for potential RTW opportunities within the hospital.  When long term or permanent restrictions are likely, the employers work with the injured worker, and sometimes a vocational counselor, to identify interests of the injured worker and their knowledge, skills and abilities.  If the injured worker would like to work in a different position that suits his/her restrictions, but requires training, the employer works to implement that training or provides unpaid volunteering in a particular department to train and trial the injured worker in that role.  The focus is upon retaining current employees.

 
Here is a link to the report for your own reading pleasure. The report also highlights seven very interesting and creative RTW success stories.

References:

 

U.S. Bureau of Labor Statistics. (2014) Number, incidence rate, and median days away from work for nonfatal occupational injuries and illnesses involving days away from work by summary occupational groups and ownership.  Available at:  http://www.bls.gov/new.release/osh2.t03.htm.  Accessed May 14, 2015.

 

Denne, J., Kettner, G., and Ben-Shalom, Y. (March, 2015).  Return to Work in the health care sector:  Promising practices and success stories.  Washington, D.C.:  Mathematica Policy Research.  Retrieved from Mathematica Policy Research  at http://www.mathematica-mpr.com/~/media/publications/pdfs/disability/rtw_health_care_sector.pdf

More tips to ensure your RTW program is worth more than the paper on which it's written

Last week we wrote a post about ways to measure the effectiveness of your return to work (RTW) program.  As you may recall, the prior week's post gave some tips to measure the effectiveness of a newly implemented RTW program.

Let's discuss the more mature RTW program.
For employers who have had more experience with modified duty and lost time claims, the methods to evaluate the effectiveness mentioned in the prior post will also apply.  If you're looking for more targeted or "next level" metrics, there are some simple ways to accomplish this.

• The window of opportunity to positively impact the outcome of a workers' compensation claim is very short and it begins closing the day the injured worker is taken out of work. Employers must create a sense of urgency with regards to RTW.  Most of our insured employers feel that they are "pretty good" "in most cases" at identifying modified duty.  Assuming this is how you perceive your company, and this judgment is factually substantiated, you may want to start measuring the days until a RTW opportunity is found/offered.  Measure the days that pass between the time the claim representative or injured worker provided a RTW note and the date they received an offer to RTW.  Employers can be even more aggressive in their standards and measure from the actual date the injured worker was released to modified duty until the day they returned.  This would assume that the expectation is for any release to modified duty to be reported to the employer as soon as possible, likely by the injured worker.  These "lag time" days are wasted days of productive, meaningful work -- and days where temporary total disability are unnecessarily being paid.  Setting a goal and starting the clock will create that sense of urgency that is essential in an effective RTW program, and give you something to measure against.
• If you're an employer who really wants to challenge themselves, take a look at the Occupational Disability Guidelines (ODG) return to work recommendations. These are evidence-based guidelines for expected RTW targets based on diagnosis and categories of work (light, heavy, very heavy, etc.).  Holding your RTW outcomes to these standards gives you a benchmark to measure against.  Obviously there are going to be scenarios that don't comport to a set of guidelines, but it gives you an opportunity to look at a benchmark and investigate what the deviation stemmed from -- was it due to complications with treatment, or lack of a modified duty offer?  Another benefit of using guidelines is that it gives realistic projections for various timeframes of when an injured worker reaches different levels of work.  The guidelines also consider certain comorbidities (things that will impact recovery times).  Here's an example:
• ODG Treatment and Return to Wellness guidelines: 724.2  Lumbago
• Severe, manual work:  14-17 days
• Severe, heavy manual work:  35 days
• Obesity comorbidity (BMI >= 30), multiply by 1.31
• Because this particular injured worker was considered obese, ODG projects their recovery time to take about 31% longer than an injured worker who has a BMI of 29 or lower.

While it is sometime difficult to measure results, it's best to measure something -- and be sure to do it consistently.  Put some thought into what your goals are and how you're going to measure them.  Communicate these goals (repeatedly -- we mean it, every chance you get!) and share your progress.  The gold standard would be to find a way to make managers/supervisors accountable for their results.  As "they" say, you manage what you measure.

Discharge planning begins upon admission

A very wise nurse once told me they had a saying in the hospital she worked at:  "Discharge planning begins upon admission."  The goal of any admission at a hospital is to discharge the patient, hopefully in a better, healthier state than they were when they arrived.

This same adage applies to workers' compensation claims.  The goal of any claim representative should be to ensure the injured worker receives appropriate medical treatment that will help them recovery, return to work, and hopefully a state of wellness.  This doesn't just miraculously happen!  A well-thought plan is needed to coordinate a successful return to work, but particularly if we're aiming to help the injured worker get better.

What can you do to help plan for success?

Start having the return to work conversation as soon as possible.  Employers should proclaim it to be their goal to return the injured worker to work whenever a claim is reported involving lost time.  That means having return to work discussion in the absence of a modified duty release.  You might be asking, how can we bring someone back to work if they don't have a work note allowing them to come back?  Generally we have an idea as to why type of restrictions correspond with the type and severity of injury.  For example, a rotator cuff strain/sprain may result in no overhead lifting, one handed restrictions, or lifting no greater than 2 lbs. over counter level.  How can you plan for RTW when there is such a variance in possible restrictions?  Plan for the worst, hope for the best.  Anticipate the most restrictive work note and go from there.  If they can lift 2 lbs. with their injured arm and you planned for, and found, one-handed work, then you have work available that fits restrictions!

When you have an injured worker with a note that totally disables them from working, it's never too early to try to identify a modified duty opportunity.  Sending this modified duty option to the treating physician may facilitate an earlier release to return to work, or it may not, but it's worth an attempt.

Communicate your intentions to the injured worker as well.  They are probably very concerned about their job, their income, and how they are going to pay their bills if they are taken out of work.  Letting an injured worker know, at the appropriate time, that you will try to find work available will be one of the best things you can do to reassure them that you value them as an employee.  Just be sure to do it in a sensitive manner at an appropriate time.

One more reason to offer RTW: Stop giving injured workers a bad rap

So much for the 80/20 rule.

According to a study conducted by Harris Poll on behalf of Summit Pharmacy, Inc., 2 out of 5 Americans believe that people who are collecting workers' compensation benefit don't want to work.  Not surprisingly, roughly 35% of respondents agreed that "You need a PhD to complete all the necessary paperwork associated with a workers' compensation claim."  That last question was a bit leading, and a tad dramatic for my liking, but I digress.

You can read more about the survey here.

While the survey may not be free of bias, I think there are some opportunities for further discussion.  The survey fails to consider whether or not the employer offered modified work to the injured worker.  If someone is offered suitable work and refuses it, that's a different story.  If the employer has done nothing to offer an injured worker modified duty, or if the injured worker remains totally disabled, then they are likely justified in remaining out of work.  I understand I'm arguing against a stereotype, but the stigma and stereotypes cannot be ignored.

In previous posts, I've written about injured workers who start to feel that they have to prove how disabled they are to justify their injury to people.  In an environment where a good portion of the American population thinks injured workers are just lazy, I can't imagine that makes anyone feel too good about being out of work.  It may even lead to them citing limitations and disabilities to demonstrate that they're not "faking" their injury. 

Conversely, when an injured worker is in a supported environment where they can trust that people surrounding them (including their employer and coworkers) believe their injury occurred and the subsequent pain is real, I'd venture to guess that they'd be less likely to point to their inabilities as they have nothing to "prove."

One thing we can do to fight this stigma (aside from preventing injuries from happening in the first place), is to offer modified duty to injured workers.  If they unjustifiably refuse the work, i.e., they really don't "want to work," then their benefits may be suspended and everyone can loosely conclude that they really don't want to work.  I'd like to see a survey that focuses on that.

We can also do a better job of helping injured workers fill out claim paperwork.  It may not require a PhD, but it is filled with jargon and legalese that those outside the WC industry have a difficult time understanding. A word of advice -- if you know the form you're about to mail out causes outrage or panic in injured workers -- give them a head's up that it's coming and what it means.  The wording on the forms typically makes it sound worse than it really is.

Nurse Case Managers are NOT the Claims Police

This week's post comes to us from Eastern's own Director of Medical Cost Management, Nancy Crago, RN, BS, CCIM, AIC.  Nancy has over 35 years of nursing experience as well as 16 years of insurance experience.  She has had the opportunity to work directly in many areas of workers' compensation claims ranging from telephonic case management, claims adjusting, and supervision of adjusters and case management teams.  

What is a case manager?

The Case Management Society of America defines a case manager as a health care professional who is responsible for utilizing the case management process for individuals with health-related needs, with the goal of maximizing their wellness, autonomy and appropriate use of resources.  

What experience do case managers have?
Nurse Case Managers are registered nurses with at least 10 years of nursing experience.  Many nurses have advanced degrees and have specialized clinical skills and knowledge.  In addition, many nurses have national certification from organizations which focus on case management.  These include CCM, CRRN, and CDMS.  Continuing education is required to maintain professional licenses and national certifications.

Nurse Case Managers who work in the workers’ compensation environment generally have backgrounds in orthopedics, neurology, critical care, emergency trauma, general surgery, rehabilitation, or occupational health.  

Exactly what is it that nurse case managers do?
Case Managers have several roles – they are advocates, facilitators, coordinators and educators.  The foremost role is advocate.  Whenever a case manager works with an injured worker, the nurse establishes a relationship with that person.  The case manager and injured worker establish goals and plans to meet those goals.  While working as a case manager in workers’ comp it is essential that the case manager inform the injured workers that any information related to the claim and its outcome will be shared with the physician(s), claims representative, and employer.

How can employers maximize the benefits of case managers?
Collaboration is the key to a successful outcome with a case manager.  Case managers are looking for a win-win situation – the injured workers returns to wellness and the employer regains a productive employee.  Although the case manager will be an expert about the injury and treatment, he or she may not be an expert about the injured worker’s job and specific requirements.  Share a detailed job description with the case manager.  This will foster understanding about your business.  This knowledge and a written job description helps the case manager to clearly discuss how the injured worker can safely return to work during recovery from the work injury.   Use the case manager’s medical knowledge to help design a job around any restrictions the physician may order.  Ask questions about the treatment plan – how long will treatment last, are there other effective treatments. 

Case managers are NOT the "claims police"
Injured workers (and some mistaken employers) may think that the case manager is assigned as a policeman.  Nothing can be further from the truth.  Medical care is becoming more and more complex.  The case manager will assist the injured worker to understand the treatment plan, medications, and why early return to work is essential for a full recovery. 

Because the case manager brings medical expertise to the claim, he or she will always be pushing toward the next outcome and goal.  Expect the case manager to provide suggestions and recommendations for next steps.

Through education and experience, a case manager brings medical expertise to the claim.  A case manager also helps to coordinate care with a variety of healthcare providers—physicians, therapists, pharmacists, etc.   Case Managers are not “claims police”.  Their only focus is on returning injured workers to wellness through appropriate medical care.  As nurses, case managers are advocates for the injured worker, which benefits the injured worker and the employer. 

Thank you to Nancy for sharing her experience and insight on some of the many aspects of case management!

 

Why employers should support employees before and after a work injury

When employees are treated fairly, they are more likely to have a stronger commitment to their workplace.  When employees feel they are not being treated fairly, they will be less motivated to return to work or put in extra effort to overcome even minor obstacles. 

In a 2006 study of social support as a factor in the return-to-work process, researchers found that social support was reported as a key contributor to a successful work re-integration (Lysaght & Larmour-Trode).  The authors of this study found that the so-called "soft" aspects of the RTW process were relevant to RTW and important to injured workers and supervisors alike. 

Relationships, in and out of the workplace, help us deal with stress.  When you have a work issue, you may confide in someone outside of work, or maybe a co-worker who understands the situation.  When you have an issue at home, a co-worker can be an objective third party to help make sense of things.  These forms of social support also apply to work-related injuries and the RTW process. 

Previous research has identified four sources of support in the workplace (p. 256):

• Informational:  information, suggestions, recommendations

In the RTW context, injured workers need information about how to complete paperwork, what the RTW process involves, as well as advice on what they can and cannot safely do within their work limitations.  While it would appear some that the onus to obtain this information is on the injured worker, supervisors or other parties, can assist injured workers by providing them with information or assisting them with obtaining that information.  Sometimes it just takes a simple conversation to alleviate mounting concerns.

• Instrumental:  compensation/wages, hours, work

Employers can provide instrumental support by providing ergonomic assessments, modifications of job duties, or work schedule accommodations.  Any step that an employer can take to increase an injured worker's sense of autonomy and contribution will aid in their re-integration into the workplace.  Meaningful work duties with a clear business purpose are ideal options for RTW.

• Emotional:  listening, genuine concern and caring about employees

Employees want to know that their employer genuinely cares.  The aforementioned study found that co-worker support was also repeatedly mentioned by the interviewees.  Some reported their coworkers worked to assist them, asked how they were doing, and included them in social activities outside of work before they returned to modified duty.  Others recalled negative experiences of co-workers making hostile comments, or ignoring the injured worker.  Management has a key role to play in addressing negative treatment of co-workers who return to modified duty after a work injury.

• Appraisal:  feedback regarding performance, social comparisons

While this can be a delicate topic, it's important for supervisors to understand an injured worker's need for feedback once they return to work.  This allows for open communication about the injured worker's recovery, the appropriateness of the duties assigned to them, and their overall experience back at work.  Treating employees fairly, whether on restrictions or not is key and should not be overlooked.

An employer's relationship with their employees should provide support in these four areas before an injury occurs.  Work to strengthen these relationships today and it will undoubtedly help when you are working with an injured worker on modified duty.

Source:  Lysaught, R. M., & Larmour-Trode, S. (2006).  An exploration of social support as a factor in the return-to-work process.  Work, 30, 255-266. 

Industrial athletes: Dip your toe in the pool before diving in to RTW

In his blog post, Dr. James Butler of Orthopedic Associates of Evansville, Indiana, writes: 

“30 years ago, as a young physician I was taught, as many of our parents were, that if you have an injury you must have complete rest.  We have discovered over the years that that is a fallacy and leads to other problems.  I often joke with patients that as a young doc we used to hospitalize patients with back pain and put them in bed for a week or two at a time, and many of them are still there.  The sports medicine specialists were in the forefront of changing that idea.  They began treating their athletes by resting only the injured part while continuing to actively use the rest of the body.  They found that people healed quicker, and were back in the game sooner.  Well, we have finally realized that workers are just a different type of athlete, an “Industrial Athlete” and they also need to be kept with their team while healing so they can get back up to bat again sooner.” 

Work must be a component of any injured worker’s recovery. 

Maybe you are an employer who wants a healthy, productive employee back to work or you're the spouse of an injured worker who wants things at home to return to the way things used to be. Maybe you’re a physician who wants to help your patient recover and achieve the best possible outcome.  Graded work exposure may help you attain these goals by making work a part of the recovery process.

What is graded work exposure?

It’s a predetermined plan agreed upon by an injured worker’s occupational therapist and the injured worker’s supervisor that returns injured workers to job duties in which the hours and duties are gradually increased until the injured worker can return to their pre-injury duties. 

An example is when an injured worker returns to work four hours per day, five days per week for two weeks.  After two weeks, the injured worker’s hours are increased to 6 hours per day for two weeks, and then eventually eight hours per day.  Graded work exposure may involve the injured worker only performing certain aspects of their job that are more physically challenging for just a portion of their day.  Graded work exposure can be particularly helpful for injured workers who question their ability to return to their pre-injury job, or are fearful of getting injured again.  Making progress toward goals through graded work exposure can help both employers and injured workers restore their confidence in the injured worker’s physical abilities. 

In a 2000 study conducted on therapeutic return to work (TRTW), researchers found that work rehabilitation programs that linked graded work exposure with traditional physical therapy for chronic low back pain resulted in 93% of participants working at two-year follow up.  More telling of the success of this program is that none of the participants reported back pain recurrence from working during the period of the study (p. 59, 2000). Of those participants who underwent traditional functional restorative therapy, 73% of participants were working at two-year follow up.  Participants in the TRTW group also indicated lower average disability scores, lower average pain intensity scores, and lower scores on fear avoidance beliefs measures (p. 60, 2000).

Speaking of industrial athletes…

Do you remember the first time you jumped off the diving board?  Your thoughts preceding that jump probably focused on every time you nearly drowned before that.  You’re teetering at the edge of the fiberglass board hoping that you won’t sink like a rock, hoping that someone will come to your aid if you suddenly swallow half the contents of the pool, and hoping that it will all be worth it.  The people on the side of the pool are telling you to just do it already, to trust them -- they’ve done it a hundred times before and it will be great.  Something tells you to linger on the board just a little longer, inch a little closer to the edge, and that you’ll decide when you’re ready.

Returning injured workers to modified duty requires trust.  Employers and injured workers are concerned about re-injury.  There may be doubts in either party’s minds about whether or not the return to work will, well, work.  These feelings of anxiety, uncertainty and doubt are also experienced by employers and injured workers who are contemplating a return to work after a work injury.  No matter how many times a doctor tells an injured worker or an employer they can do x, y and z, they haven’t seen it done yet and they aren’t really sure of the outcome. Without an attempt no one will ever know. 

When planning the return of an injured worker, focus on setting it up for success and consider graded work exposure as an option. 

References:

Durand, M. J., & Loisel, P. (2001). Therapeutic return to work:  Rehabilitation in the workplace. Work, (17), 57-63.