Defining Disability - Part I: The Medical Perspective

Whenever we have a discussion with someone, we’re processing the information they are relaying based upon our own experiences and interpretation of what the other person is saying.

It never matters what you think you said -- it’s what the other person heard.

If you asked 20 people to define the word “disability” you’d receive 20 different, albeit somewhat similar, responses.  They’d all most likely focus on comparable aspects of the word, maybe even involve like examples.  There would also be some stark differences.  This is because we’re all defining it based upon our personal experiences and where we sit in the world.

This series of posts will focus on our unique perspectives into the definition of disability – medical, workplace, and regulatory definitions.  I encourage you to ask a sampling of people to define disability to you.  Think about the frameworks they’re using – physical limitations, work situations, developmental limitations, etc.  Consider why someone is using that frame of reference – it’s based upon their experiences.

Medical

When a person sustains an injury or illness, their doctor, or other medical professional, often discusses what types of activities they should avoid and what activities are “safe,” often putting some type of limitation on a particular activity.  An example of this would be no overhead lifting or no lifting over 15 lbs.  These recommendations are based upon past experience, objective reference guides, and individual attributes of the injured or ill patient.  The healthcare provider is often considered the “expert” who is making these determinations.  As you can see, they play an incredibly important role in stating what the injured or ill person can and cannot do based upon their medical (physiological) condition.

The medical definition of disability does not contemplate what the injured worker’s job requirements are – if you cannot lift 15 lbs. at work, it is not safe to lift 15 lbs. at home.  In this respect, we’re focusing on what the injury is, what it has done to your body and what you’re subsequently not capable of safely performing as a result of the injury.

What types of challenges are presented?

In the various arenas that these restrictions are used, the information may not be considered adequate or sufficient from the end-users’ perspective.

Injured worker: 

• What does 15 lbs. really feel like?  I don’t carry a scale around with me, how will I know? The result is general avoidance behavior.  The injured person will avoid lifting things with unknown or uncertain weights.  I know I can lift that  5 lbs. bag of sugar because it says it weighs 5 lbs., but I know I can’t lift my dog because the last time we were at the vet, she weighed 27 lbs.
• There may not be a clear understanding of why the restrictions are in place, i.e., what additional damage could be done by exceeding the restrictions.  Conversely, fear or re-injury and avoidance behavior can result in unintended negative consequences such as “frozen shoulder.”  This can occur in shoulder injuries due to lack of motion.

Employer:

• Similarly to the injured worker, they’re not sure what each aspect of their employee’s position entails.  There’s probably a fear of re-injury as well.  This can lead an employer to say that they don’t have work and that it’s best to let the injured worker recover before returning.
• The employer may not understand fully what work the injured worker can and cannot safely perform. The employer may be trying to complete FMLA, short term disability, and/or workers’ compensation paperwork with the information provided.  Often times a disability note provides the date it was written and the current restrictions.  This is only part of the information needed to complete these forms.

We’re provided with some of the information we need, but not everything we need for every system that the injured worker maybe find themselves in.  This results in follow up paperwork that is generally specific to the employer or insurance carrier.  Each of these parties has their own “definition” of what disability means.

What can injured workers and employers do to navigate these definitions?

• Injured worker
• Understand what information your employer and/or their workers’ compensation insurance carrier needs.
• Ask questions
• How is disability defined?
• In some state workers’ compensation systems it solely depends on earning capacity as a result of your work injury/illness.  In others it may have differing definitions. If you don’t understand, keep asking questions until you do.
• Questions for your doctor:
• Can I safely perform duty x?  How does my activity level impact my recovery?  What are some of the signs that I’ve done too much or too little?  If I feel good can I do more?
• Employer
• Understand what information your company needs to make a determination about modified duty:
• What is the injured workers’ job?  What are the physical requirements?  Are there other jobs that fit these restrictions?
• Ask the physician to approve or comment on the pre-injury or modified duty job description.
• If you aren’t sure what they can safely do, ask!
• Communicate with the injured employee to make sure everyone has the same understanding of the work and the restrictions.  

It may be helpful to explain what framework you’re using when describing or defining disability.  An example of this would be a doctor saying, “From a medical standpoint, your rotator cuff is torn.  At this point in your rehabilitation, you’re able to use your injured arm to lift no more than 2 lbs., no higher than counter/waist-level height.” 

That’s informative for an injured worker to know, but what does that mean in terms of them returning to work? 

Be sure to check out the rest of this series on the different ways disability is defined and why it matters.

 

 

You've hear of Undercover Boss, what about Undercover Injured Worker?

Most of us are probably familiar with the concept behind the show, "Undercover Boss."  The removed CEO or owner of a large corporation changes their identity and goes "undercover" working as a new hire that needs to learn the ropes of the less than glamorous positions in the company.  They're stripped of the everyday luxuries and live in a motel room, etc. to experience what their lowest paid employees make -- all in an attempt to understand what it's like to work for their company.  The show is usually very emotionally charged, and ends with the CEO having a revelation that changes need to be implemented, improvements need to be made, and sometimes they even shell out thousands of dollars to help an employee pay for overwhelming medical bills or something of the sort. 

I propose that employers go to work as an undercover injured worker.

Before you diminish the value of a safety measure, process improvement, or a return to work (RTW) program -- put on a pair of the proverbial "someone else's shoes" or work boots and see what the experience is like to have a workers' compensation claim.

I guarantee the experience will be eye-opening.  It will open your eyes first hand to a system that is riddled with challenges, confusion, complexity and bureaucracy -- a system that was designed to be a no-fault system to promptly provide benefits to any person injured on the job.  What does your accident investigation feel like?  How well does your injury reporting process work?  How does it treat injured workers?  How do our employees treat injured workers?  How does RTW impact the injured worker?

You'll learn how coworkers and supervisors treat you -- maybe with respect, maybe with pity, or maybe with anger or suspicion.  You'll learn what it's like to receive confusing forms in the mail, feel the uncertainty of whether or not you'll get a check in time to pay your bills, and realize that life does not stop simply because you got injured.  You may be limited in returning to work but your supervisor determines that there's "no light duty" in your company.  You'll feel the isolation and detachment within a few weeks of being out of work.  The attorney commercials will get old quickly; the resentment may build between you and your employer because you want to come back to work, but aren't being offered work.  You'll feel that people don't believe that you're really injured.  You might even see a weird car parked outside of your house that you soon discover is a surveillance company hired to see if you're doing anything outside of your restrictions. 

Now, in this scenario, you're not truly injured -- as an undercover injured worker, you're lucky that you don't have to go through the physical pain that results from an injury.  You won't have to worry about how you're going to button your own shirt, make yourself dinner, find a position to sleep comfortably because you can't use your arm due to a shoulder injury.  Fortunately, you won't have to feel how tiring and exhausting constant, throbbing pain can be and how it takes a toll on your ability to cope with stress.  Luckily, you also won't have to experience the strain that it puts on your relationship with your spouse and/or children now that you can't fulfill all of the requests you used to, cooking a meal, doing the laundry, driving the manual transmission car-- you won't have to experience what it's like to give up a good bit of independence nor will you realize how much that impacts your psychological state.

When someone has an injury, it doesn't stop at the physical level.  It impacts the injured worker from a financial, social, psychological and physical level.  It impacts their relationships, their confidence in their ability to provide for themselves or their family, and their place in this world.

Thankfully, I've never experienced a work injury.  How do I know to write about all of this stuff?  It's called empathy.  I took the time to imagine what it must be like to go through this process.  We all like to say that "if it were me in that position I'd do X, Y, and Z" but you never know until you've experienced it firsthand.

I encourage all employers who are in the position to make decisions related to the safety and well-being of their employees to take 10 minutes out of their day, at least once a month, to consider the "other side of the coin" when making a decision, not just the coins associated with implementing a change or offering modified duty.

Can we agree on one thing...? Variance between providers' RTW recommendations

In a 2010 study of healthcare providers’ agreement related to return to work (RTW) capabilities, researchers found some areas of consistency and some, well, not so consistent (Ikezawa, Battie, Beach & Gross, 2010).  The aim of the study was to determine if there are differences between providers as it relates to the information providers use to make RTW determinations, and what their RTW determinations were for three different case scenarios:  fracture, dislocation, and low back pain.  The survey focused on collecting three types of information.  Participants were asked to determine the following:  if the person was fit to return to work, assess the physical demands of their job, address any restrictions due to injury, determine the injured workers’ work capacity, and make any other recommendations if they were deemed unfit to work.  The second part of the survey focused on what type of information the participants used to make their decision, as well as commentary on what type of information would have improved their ability to make these determinations.  The final section of the survey focused on demographic information about the participants (specialty, gender, age, years of practice, etc.).

Inquiring minds want to know! 

The results indicate that 97% of the providers were in agreement with each other regarding the RTW readiness case of the fracture (p. 370).  This is likely due to fractures being of clear cut pathology.  Similarly, 94% of the providers agreed with each other related to RTW readiness for the dislocation scenario (p. 370).  For the low back pain case (a nurse who had back pain for eleven months), providers were basically split as to whether the injured worker should return to work or not – 55.6%.  Of note, however, with regards to the back pain case, 56% agreed that RTW with restrictions was appropriate; whereas 44% believed RTW full duty was appropriate. 

What did the providers rely upon to make these determinations?

Not surprisingly, experience and training will influence a provider’s recommendations.  In this study, researchers found the providers relying mostly upon physical examination, current functional status, and occupational status (pp. 370-371).  Providers stated that functional capacity exam (FCE) results, information on availability of modified duties, and patient participation in an occupational rehabilitation program would help improve their ability to accurately address RTW opportunities (p. 371).

Another interesting point made in this study is that only a small percentage of providers considered the sustainability of RTW, motivation to RTW, recovery expectations, and guarding movements.  Not until more recently are practitioners focusing on the biopsychosocial, or multi-dimensional, aspects of RTW.  These differences in approach will more than likely yield differing RTW recommendations and should be considered when evaluating a provider’s recommendations for RTW (p. 372).

 Regardless of their agreement, the majority of providers gave some type of RTW recommendation involving restrictions –so no matter their perspective (biomedical vs. biopsychosocial), we can expect some type of restrictions from an injury and prepare for them accordingly. 

 As noted above, the availability of modified duty was emphasized as being one of the factors providers are looking at when determining the injured worker’s release to RTW.  If you have modified duty, be sure that the providers are aware of it!  For those employers that utilized a panel of physicians or a providers list, send them copies of your modified duty jobs to keep on file in the event one of your employers visits there.  If that’s not the case, it would behoove you to provide the treating physician with a pre-injury job description and/or a modified duty job description to keep in the injured worker’s file.  The more informed provider will more than likely make a more accurate RTW recommendation.

References:

Ikezawa, Y., Battie, M. C., Beach, J., & Gross, D. (2010).  Do clinicians working within the same context make consistent return-to-work recommendations?.  Journal of Occupational Rehabilitation, 20, 367-377. doi:10.1007/s10926-010-9230-z

Word of the Day: Return

Merriam-Webster defines return as "to restore to a former or to a normal state."

That's the promise we make when we say we're going to return someone to work or return them to wellness.  It's a tall order.  Telling someone you're going to return them to a former state is almost like telling someone to get the wrinkles out of a piece of balled-up aluminum foil.  Even with extreme measures, the likelihood of getting a smooth Hershey Kiss wrapper out of a pea-sized wad is nearly impossible.  I am in no way saying injured workers are like balled up scraps of aluminum -- but we cannot promise everyone the health and ability they may have experienced pre-injury.  Even without an injury my body has aged 24 hours more than it was the same time yesterday.  In the past 24 hour hours deterioration has occurred, plates of the earth's lithosphere have shifted ever so slightly, and maybe an ice cap has melted ever so slightly more today than yesterday. It is very unlikely, if not improbable that we'd be able to easily eliminate the effects of aging, prevent the earth's plates from shifting or restore the polar ice caps. 

The workers' compensation laws are designed to indemnify an injured worker, or to "make them whole."

For a larger proportion of work injuries, that’s likely the case -- the cut finger that doesn't leave a scar, the bee sting, the ankle sprain that has resolved.  We can't make the same promise for many, more severe injuries that require surgery, produce scars, or leave injured workers with permanent restrictions.  The law tries to indemnify injured workers for their loss of income, medical treatment and sometimes permanent impairment.  But the injured worker will never be the same as they were pre-injury -- it's impossible for me to be the same as I was a week ago.  The point is -- we cannot stop change, nor can we go back and prevent the future from happening.  That is, unless of course you're Marty McFly.

It sounds as if this goes against all that we promise -- Return to Wellness?

The Return to Wellness promise is alive and well.  I can't tell you that we can return everyone.  These cases demand a frank and honest discussion about what the injured worker's future looks like.  When there are likely permanent restrictions or impairment, how do we manage that going forward?  I'm not talking about mitigating losses, I'm talking about reconciling who you were before an injury occurred and who you are going to be in the future.  For that logger who is not going back into the woods, it can be devastating.  For the mason who has always taken great pride in their skilled work, it's like losing part of your identity. 

As soon as we recognize that this may be the outcome, the sooner we must discuss what the future looks like for that injured worker.  Yes, it may not involve chopping down trees or building stone walls, but it has to mean something else.   This is reality, albeit sometimes a harsh one.  Life goes on after the work injury and it goes on after the claims settlement.  Medical providers can only take an injured worker so far and they can't, unfortunately and in most cases, return you to where they were before the injury occurred.  All the more reason to work to get an injured worker the best possible outcome -- this is going to be their life and their future long after the claim closes.  We may be stepping out of the realm of statutory benefits, but we can never lose sight of the fact that these are peoples' lives that are impacted by work injuries.  We must do all that we can to minimize that impact.

 

References:

Return. (n.d.). Retrieved November 21, 2014, from http://www.merriam-webster.com/dictionary/return

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.

The Importance of an Ordinary Day at Work

In a recent meeting, I was encouraged, as I'm sure many others were, by a very simple, poignant observation.

We often wish away the ordinary days -- we pine to be on vacation, experiencing something exciting or adventurous, but when something happens to us or one of our loved ones, someone gets sick or injured, the one thing that we all long for are the ordinary days. We'd give nearly anything to have an ordinary day.

I've always believed that every day is a gift, and your health is a gift -- both of which we shouldn't take for granted.  It's unrealistic to spend every minute of every day focusing on how lucky we are to be alive and well, but as soon as something impedes our health or normal lives, we realize how fortunate we were.

I believe this is the case for most of us.  I also believe that is the case for most injured workers and employers of injured workers -- we all want the same thing.  We want to get back to the way things were.  We want things to be "normal" again.  Yesterday (Tuesday after Labor Day) was probably tough for most people -- getting back to work after a long weekend can be challenging.  Many people probably thought, why can't I win the lottery and get to stay home forever?! 

Work plays such an important role in our lives -- how we define ourselves, it is from what we derive our value, it shows what we can contribute to the world.  Think about the last time you met someone new.  After introducing yourself, the next thing you probably moved on to discuss was where you worked or what you did for a living.

Our job as workers' compensation professionals is to do what we can to restore injured workers to wellness.  To provide the appropriate medical treatment, guidance, and assistance to help achieve that sense of normalcy.  While it is true that not everyone will return to that old "normal," getting back to a state of wellness and productivity is our aim. 

We are creatures of habit.  We crave consistency.  We like routine and predictability.  Any disruption can cause us a great deal of strain and stress.  Think about the last unanticipated road construction detour you were faced with on your way to an appointment? 

Think about your morning routine.  You wake up, maybe you stop at the usual place to grab your coffee on your way to work, exchange some daily banter with the cashier, and continue on your way to work.  The average person spends 90,000 hours at work during their lifetime.  That's over 10 years, 24 hours per day.

Sure we all have our days we wish we'd win the lottery -- some more than others.  Those things that we'd rather be doing than working are probably also the same reasons we go to work.  There are probably aspects of everyone's job that would rather not have to do-- but that's why it's called work, right? 

When the ability to participate in work every day is taken from someone due to an injury or illness I'm confident in saying that what that person would like most is an ordinary day at work.  Employers have an opportunity to give the gift of ordinary days. 

Guest post! Physical Therapy may assist in recovery from a musculoskeletal injury, and depression, in the injured worker by Dr. Joseph Brence, DPT

As you know, we’re always interested in hearing others’ perspectives regarding the rehabilitation of an injured worker. We’re excited to share this guest post written by Joseph Brence, DPT, COMT, DAC.  Dr. Joseph Brence is a physical therapist practicing in Pittsburgh, Pennsylvania.  When he is not busy treating patients, he is involved in several, large clinical research projects.  He has a large interest in the brain's involvement in the pain experience as well as the neurophysiological effects of manual therapy techniques. You can read more from Dr. Brence at www.forwardthinkingpt.com

Physical Therapy may assist in recovery from a musculoskeletal injury, and depression, in the injured worker
Joseph Brence, DPT, COMT, DAC

Work-related injuries affect almost 500,000 individuals annually in the United States.  Over half of these cases are related to sprains, strains and other musculoskeletal pathology.  In addition, musculoskeletal injuries are the leading cause for work-related disability and lost productivity, and estimated direct and indirect costs range from 45 – 215 billion dollars.

Work-related injuries can lead to the development of chronic pain as well as changes in societal status and psychological variables such as depression. Research has suggested that one out of every three individuals who suffer from chronic pain also suffer from depression.  Research has also suggested that elevated levels of depression are associated with an increased risk for a poor response to Physical Therapy and are associated with elevated levels of pain and disability.  A recently published article examined the effects of Physical Therapy on depressive symptoms in individuals with work-related musculoskeletal injuries.

The authors in this prospective cohort study recruited patients who were between the ages of 18 and 65; had sustained a work-related, musculoskeletal neck or back injury (3-12 weeks since onset); were not currently working; and were receiving benefits from Worker’s Compensation.   The participants also had to have clinically relevant levels of depression (measured on a Beck Depression Inventory of 14 or higher) and had to state that they were not being treated for depression throughout their course of Physical Therapy (often the case in Workers Compensation).  The participants completed a course of seven weeks of Physical Therapy treatment interventions.

The outcomes of this study demonstrated that depressive symptoms resolved in 40% of patients who entered into a Physical Therapy program, following a work-related accident. This outcome is not unusual because of the neurological and hormonal changes that we know to occur with exercise.  The authors further reported that a reduction in depressive symptoms was related to a decrease in pain and disability at the one-year follow-up, which improved the likelihood for return to work.   For those who did not get better, it appears that combined elevated levels of depression and pain catastrophizing thoughts (ex. The pain is killing me) pre-treatment, predicted persistence of depressive symptoms post-treatment.  

So what does this mean?

These findings indicate that Physical Therapy can have a profound effect in decreasing depressive symptoms in a subgroup of individuals.  The authors go as far as suggesting that in certain instances, we may want to include a reduction in depression as a realistic and important goal of treatment.  Psychosocial variables, such as this, have been correlated to long-term disability and can often restrict an individuals ability to recover from a musculoskeletal injury (thus decreasing the likelihood for return to work).  Despite the notion that many in Workers Compensation field want to steer away from the assessment of these variables, I suspect they are important prognostic indicators for recovery and we should encourage early screening, detection and intervention.  In the end, we interact with the complex "human" and acknowledging the influence of biological, psychological and social variables, will only better enhance recovery and return to work. 
 

Dunning KK, Davis KG, et al. Costs by industry and diagnosis among musculoskeletal claims in state workers compensation system: 1999-2004. Am J of Indust Med. 2010: 53; 276-284.

Wideman TH, Scott W, et al. Recovery from depressive symptoms over the course of physical therapy: a prospective cohort study of individuals with work-related orthopaedic injuries and symptoms of depression. JOSPT 2012: 42; 957-968.

Kroenke K, Spitzer RL, et al. The Patient Health Questionnaire-2: Validity of a 2 item depression screener. Medical Care. 2003: 41; 1284-1294.

Why do some claims go sour?

No matter how you’re connected to a workers’ compensation claim, you probably share the same goal as everyone else:  to get an injured worker prompt, appropriate medical care and return them to work.  You want to get on with business and life as usual. 

Anecdotally speaking, the overwhelming majority of claims follow a fairly smooth path.  An injury occurs, it gets reported, and the injured worker seeks medical treatment.  After a few weeks of treatment, the injured worker is released to return to work without restrictions.  Any required state forms are signed and returned.  After paying any outstanding medical bills that may drift in, the adjuster reviews the file and determines it is appropriate for closure.  

I’d venture to say that this scenario is not what typically comes to mind when discussing workers’ compensation claims.  Maybe it’s the attorney commercials, maybe it’s the horror stories from your neighbor or distant relative, or maybe it’s because something simply went wrong in the course of a claim that resulted in a negative impression of the system. 

What causes some claims to go sour while others resolve without issue?

Information asymmetry due to weak communication.

Communication, by definition, is an exchange of information between people. 

In a workers’ compensation claim, there are a lot of people, all with asymmetrical quantities of knowledge, experience, and information.  Workers’ compensation is a system that has been historically filled with distrust.  Not to mention, a workers’ compensation claim impacts people on a very personal level.  When you combine the number of people involved with the emotional impact a work injury can have, it’s almost like a keg of gun powder and it must be handled with care and respect. 

Throughout the claim process, there are numerous potential “breaking points.”   I’d be willing to bet most of them revolve around communication.  Appropriate communication can quell the symptoms of information asymmetry and has great potential to prevent claims from going sour.

Some of these breaking points are provided below, with a simplified version of a solution, focused on communication and empathy.

Problem:  The injured worker receives a collection agency notice because of an unpaid bill.  I put this one at the top of the list, as it is one of the simplest problems to prevent.

Solution:  Injured workers should not ignore a bill or invoice.  If an injured worker receives a bill it does NOT always mean the insurance carrier denied it.  It may be that they didn’t have the correct billing information, it got submitted to personal health insurance, or to the wrong insurance carrier.  A simple fix is to call the billing number on the invoice, and update them with the correct insurance information.  Waiting until a collection notice is received makes it more difficult for the workers’ compensation carrier to get an appropriate bill and medical records to make sure it is related to the accepted injury to review it for payment.

Problem:  The injured worker doesn’t receive their wage replacement check on time.

Solution:  Someone can contact the injured worker to let them know it will be late.

Problem:  The injured worker hasn’t heard from their employer for weeks.  They’re starting to wonder if they still have a job.

RTW: It takes a village

Recently, someone brought up an excellent point about human behavior and accountability.  It’s easy to point the finger at the person who’s not in the room.  Who’s ultimately responsible for returning an injured worker to modified duty?  The injured worker’s physician?  The employer?  The claim representative?  Based upon the contextual clue in the title of this post, you’ve more than likely determined that it isn’t just one person’s responsibility.    

Employers have a responsibility to provide a safe work environment for your employees, report claims, and stay in contact with injured workers.  Too many times the claim starts out and the injured worker is a “great employee” and then 6 months later when they are still recovering from their work injury, they’re now referred to as someone who is “milking the system.”  How does that happen?  Think about a relationship that has dwindled to the point of “acquaintance” as opposed to close friend.  If you haven’t talked to someone in a few months, it’s easy to draw conclusions about the reason for the lack of communication.  I’d be willing to bet you aren’t looking introspectively or taking accountability for losing contact.  It’s only human to attribute a negative outcome to the actions or someone else. 

Injured workers have a responsibility to report injuries to their employers participate in their recovery, follow the advice and restrictions of their physicians, and to keep their employer and claim representative apprised of any changes in their work and treatment status.  Injured workers should participate in the RTW process.  How?  Injured workers can make suggestions about what parts of their job they think they can do. 

Claim Representatives can make or break the outcome of the majority of claims.  Yes, it is true that at the end of the day people will do what they feel they need to do, but we need to take a few steps back and think about what led up to the current situation.  Did the injured worker have unanswered questions?  Did they receive another collection notice for an unpaid bill (because the biller simply didn’t have the WC claim information)?  Did they hear rumors that their job was in jeopardy?  While we can’t prevent every outcome, we can lay the foundation for open communication, education, and understanding.  We should never lose sight of the fact that we’re providing a benefit to an injured worker on behalf of their employer.  The goal is to provide appropriate medical treatment to rehabilitate the injured worker to their pre-injury state, or as close as possible.

It truly does take a village.  We didn’t even mention the roles of the medical providers, case managers, or attorneys...  

I’m not saying that at the end of the day we’re all going to be “friends” on Facebook, or that we’ll go to happy hour together after work.  My point is, the sooner we all realize that we have a responsibility and an interest in getting an injured worker back to work, the sooner we will see RTW challenges resolve.

Modified duty job offer letters communicate more than just RTW details

Return to work date, restrictions, hours, wages…

These are important elements of a modified duty job offer letter.  A modified duty job offer represents much more than a letter – it sends long lasting messages about an employer’s relationship with their employees, particularly in a time of stress or uncertainty.

If I get hurt, my employer will work with me to bring me back to work.

When employers offer modified duty, it demonstrates that they are willing to make some accommodations for someone who wants to work.  Involving the injured worker in the return to work (RTW) conversation is an important step – after all, they are the ones who are doing the work.  Listen to the injured worker’s complaints.  Consider altering their assignments or scaling back their hours if indicated.  Not every RTW will be a success the first time around.  Instead of throwing in the towel, talk to the claim representative, nurse case manager, and ask them to address this with the treating physician. 

My employer offers modified duty, so getting injured at work does not equate to sitting at home.

This is an incredibly important message.  Employees learn from what they see happen with other injured workers.  While the overwhelming majority of claims are legitimate, there are a sometimes people who wish to file an illegitimate claim or “build” their legitimate claim.  Having a strong RTW program that consistently gets injured workers back to work can help eliminate the motivation for filing illegitimate claims or exaggeration of existing claims.  Modified duty job offers shorten the time and injured worker will be out of work.

What's the deal with blame in a 'no-fault' system?

Although this may sound like the intro to an episode of Seinfeld...it's not. No bulky white sneakers, classic cut jeans, or improv-funk music playing in the background here...

There's a lot of information about social support for people suffering from non-occupational illnesses, but it is less common to hear about the role that social support plays in an injured worker's recovery from a work injury. 

Why??
As humans, we tend to seek out the "why" and a justification to events that we can't explain -- some may refer to this as fault finding, or the blame game.  Maybe it's easier for us to give sympathy to people who are diagnosed with a non-work related illness because "it isn't their fault."  Despite work accidents being just that, accidents, it is human nature to attribute some individual responsibility for what happened.  However, come to think of it, I've never met anyone with a back injury or an amputated finger who wanted to experience the pain or fear associated with these injuries -- very few people ever intentionally cause themselves harm in an attempt to "get workers' compensation benefits."  We could just as easily say to ill individuals -- well, you really should have done a better job washing your hands, or perhaps done more exercise or improved your diet.  Either way, how we got here doesn't really matter (except for future injury prevention, and maybe subrogation potential -- but that's for another blog). 

So, you've experienced a work related injury -- what are you going to do about it?  

The goal of any workers' compensation program is to restore an injured worker to their greatest level of function and earning capacity by providing appropriate, prompt medical attention.  Early, suitable, return to modified duties is one of the best ways to assist in an injured worker's recovery. 

Instead of pointing a finger at an injured worker, point them in the right direction for recovery.
Numerous studies have shown that an employer's initial response to a work injury and continued follow-up can have a significant impact on the outcome of the claim - including when an injured worker returns to work, the amount of treatment they require, and their eventual return to full duties after a work injury. 

Sure, if there's a safety violation or concern, they should be investigated and addressed.  But focus on the processes your employees are completing and the environment in which they are completing them. Yes, we should be concerned if the individual is acting in unsafe ways, but don't be afraid to look at the big picture (or in the mirror) to determine if the structure and company culture "allow" it or make it the norm.  We all have a role to play in injury prevention...just don't forget about the role each of us play in an injured worker's recovery.

Ability to RTW: Is the glass half empty or half full and who is pouring the water?

 We've all heard the phrase "playing the victim" or have heard very different stories of two individuals with the same injury taking very different views on their ability to RTW.  Many employers tend to compare one injured employee to another, stating, "Well Tina had cervical fusion surgery and was back after three months, why is Sam still out after 8 months?"  Aside from physical limitations, we rarely consider the other elements that influence an injured worker's perception about their ability to RTW.

Why do some injured workers maintain a positive "can-do" attitude while others hold the "can't-do" attitude?

The way that we, as a society, as individuals, and as employers or coworkers react to those on disability may have something to do with it.  In a system where there is an increasing amount of fraud and stigma associated with being on workers' compensation or disability pay, individuals can react in one of two ways.  They can attempt to prove that they are not "one of them," that they are able to work with some assistance, able to carry on a fulfilling lifestyle and go to work every day with their pain.  On the other hand, if an injured worker doesn't believe that they are capable of performing work or their pre-injury activities, and they do not return to work they may feel that they have to justify their injury to others, or defend their inability to work -- not in an attempt to stay on disability benefits, but in an attempt at self-defense or self-preservation.  When you combine a strong social stigma with a perceived lack of control over a situation, it is human nature for an individual to look to examples of things they cannot do, or even catastrophize the situation. 

If you pay attention to earnings reports, there is a tendency to look to external factors, particularly those out of our perceived control, when the results are less than favorable.  However, when the results or outcome are desirable or exceed expectations, they are usually attributed to positive internal actions. 

Changing discourse by changing the injured worker's course

This week's post was inspired by another blog (Managed Care Matters) as two quotes in an April 10, 2013 post hit on two very important points when discussing RTW:

"... 'there’s no condition so disabling that there isn’t someone in the US with that condition working full time today.'”

and...

"You don’t get better and go back to work, going back to work is a part of getting better!”

Disability means different things to different audiences.  According to the U.S. Social Security Administration a person is "disabled" based upon their inability to work and if:

oYou cannot do work that you did before;

oWe decide that you cannot adjust to other work because of your medical condition(s); and

oYour disability has lasted or is expected to last for at least one year or to result in death.

Here's an experiment for you to try at home.  Ask someone what they think of when they first think of a disabled person.  I would be inclined to state that their initial response includes some description that focuses on the physical abilities or limitations of the person rather than the limitations placed on their ability to earn wages.  Now, ask someone what they think of when they think of someone out of work due to a work-related injury.  Was their response the same?  I'd be inclined to state that their response related to the monetary impact.

Why?

RTW and the Injured Worker -- It's all in their head!

Research demonstrates why we should be concerned about what the injured worker believes to be true regarding the outcome of their recovery.  When an injured worker is told, and believes, that they are going to return to their pre-injury duties, it is more likely that it will happen.  This obviously has to do with how accurate the doctor’s prognosis is, but also with how the injured worker aligns their behaviors with what they believe to be true.

Social psychology can help explain some of this.  The social psychological theory of confirmation bias posits that as humans, we will likely seek out information that supports our beliefs, and we will reject information that contradicts them.  If you hold a particular political view, you're likely going to be drawn to people, publications, and sources that support your views.  You will naturally reject ideas or points that are dissonant with your beliefs.  I, for one, will likely not search for articles that do not support RTW.

Another example is smoking.  Everyone seems to agree that it is not good for your health, but why do some highly intelligent, self-aware individuals continue to smoke?  They justify it in various ways, or reject information in an attempt to ease the dissonance between their actions and what they know.

In a 2002 study of 1566 injured workers who were receiving temporary total disability benefits, researchers found that workers' expectations about their recovery had a statistically significant impact on the duration of their disability.¹

When controlling for other suspected factors that could influence the injured workers' RTW, it was found that injured workers who felt their recovery would be slow or reported higher levels of uncertainty about the length of their disability were consistently associated with longer disability durations.  Conversely, workers who reported more positive expectations returned to work sooner. 

When measuring injured workers' recovery expectations, researchers found that 4 variables were able to explain 15.5% of the variance in the duration of receiving benefits. To put it another way, when a physician determines that an injured worker will recovery in x number of weeks, there is typically some variation between the prognosis (x) and the actual duration of disability.  If x is 10 weeks, and the injured worker actually returns in 13 weeks, 15.5% (or 1.5 days) of the 3 week variance can be attributed to the injured worker’s expectations about their ability to RTW.

So why is this study important?

·    Medical providers play an integral part of managing an injured worker's expectations about their ability to RTW.

·    Employers who offer modified duty can increase injured workers' self-efficacy by allowing them to prove that they are capable of doing more than what they initially thought.

·    Employers and medical providers must set realistic recovery expectations early in the recovery process. 

1. Cole, D. C., Mondloch, M. V., & Hogg-Johnson, S. (2002). Listening to injured workers:  How recovery expectations predict outcomes -- a prospective study. Canadian Medical Association Journal 166(6).

Reasons Injured Workers Return to Work

In a 2010 study of 168 individuals who sustained non-life-threatening orthopedic injuries, it was found that participants who reported "high social functioning" two weeks post-injury, were roughly 2 1/2 times more likely to return to work (Clay, et al., 2010).  This same study reported that financial security and perceived ability to return to work were not statistically significant. 

Clay et. al, (2010) also found that "Ninety-three percent of respondents who reported the need to use work "to fill the day" were back at work by three months, compared to 66% who indicated other reasons" (p. 7).

The psycho-social factors and environment are equally important as the physical injury in the return to work process.  While we cannot influence the injury we can influence the socialization of injured workers. 

What amount of effort does it take on behalf of an employer or coworker to make a phone call to chat with the injured worker, keep them apprised of any developments at their workplace, or even to send a "get-well" card?  Very little.  The ROI on a 99 cent get well card is potentially tremendous.

So when an employer feels as if they don't have control over the WC claim, and that all power rests in the hands of the injured employee and their treating physicians, remember this post, and it might be a good idea to reference this post as well, oh and this one is probably useful, too. 

When we discuss the concept of Return to Wellness as opposed to return to work, we’re focusing on all aspects of a workers’ compensation claim.  Not just the financial impact, but how we need to treat the injured worker as a person who has sustained an occupational injury and not as a claimant. Returning injured workers to wellness using a bio-psycho-social approach -- treating the injury, treating the individual and acknowledging the positive impact that returning to the workplace (environment) after an injury can have on recovery.

Source:  Clay, F. J., Newstead, S. V., Watson, W. L., Ozanne-Smith, J. & McClure, R. J.  Bio-Psychosocial determinants of time lost from work following non life threatening acute orthopaedic trauma, Bio Med Central Musculoskeletal Disorders 2010, 11:6. http://www.biomedcentral.com/1471-2474/11/6