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. 

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!

 

Vocational Rehabilitation: Who has the best outcomes and why it matters

When an injured worker receives permanent restrictions that prevents them from returning to his/her pre-injury position a few things may happen.  The employer may modify the injured worker's pre-injury job to accommodate the restrictions.  The employer may offer the injured worker a different position within the organization.  Unfortunately, sometimes an employer is either unable or refuses to do so and the injured worker is without a job to return to.  While many of us would say, well I'd just go out and find another job.  As research has shown, if you're a married male, younger than 50 years in age, who has a solid education, not attorney represented for your claim, and who participates in a vocational rehabilitation program -- yes, you most likely will (Blackwell, Leierer, Haupt & Kampitsi, 2003).  That's because individuals who fit this demographic profile have been found to have the best return to work outcomes after a claim.  That is not to say that other injured workers won't benefit from vocational rehabilitation services such as retraining or on-the-job-training.  Generally speaking, the more transferrable skills and individual possesses, the more likely they are to find work in another setting.  A lower education level and being over the age of 50 may limit an individual in their job search.

It also makes sense that the less "employable" an injured worker is, the more it increases the exposure of the claim -- thereby increasing the value of the claim. The goal of any vocational rehabilitation plan is to assess an injured worker's employment history, transferrable skills, education, and provide services (re-training, job search tools) to identify employment opportunities.  The more dismal the re-employment picture is, the greater the challenge it is to return the injured worker to gainful employment.

Employers can take steps to avoid this process by identifying employment opportunities within their company, looking at potential modifications (see our post on AskJAN.org) or any cross-training opportunities within their organization.  When you can control or influence the outcome, your results will usually be better than when you let an injured worker's future be subject to the employment market.

Employers who have injured workers that are given permanent restrictions should think long and hard about providing modified duty, on a permanent basis to their injured workers.  It is not a decision to be taken lightly.  An unrestricted person may have a difficult time finding work, let alone adding in physical restrictions and a period of unemployment due to a work injury. 

References:  Blackwell, T. L., Leierer, S. J., Haupt, S. & Kampitsis, A. (2003).  Predictors of vocational rehabilitation return-to-work outcomes in workers' compensation. Rehabilitation Counseling Bulletin, 46(2), 108.

Concurrent employment conundrum: Return to Work for those who work more than one job

Some states provide benefits for concurrent employment if the injured worker is unable to work one or both (or more, I suppose) of their pre-injury jobs.  The workers' compensation policy covering the injury pays for the lost wages the injured worker sustains due to the work injury, which includes wages lost at another job.

Here's the scenario:

Steve works for No Leaks Plumbing as a plumber.  He also works part time as a bartender at Ps and Qs,Pub on the weekends.  While Steve is working to loosen a pipe under a sink at a customer's home (working for No Leaks Plumbing), he injures his right shoulder.  After going for treatment, he is given one-handed restrictions.  The good news is, No Leaks Plumbing is insured with Eastern Alliance and has a solid return to wellness program.  No Leaks Plumbing can bring Steve back the following day to work within his restrictions.  Unfortunately, Ps and Qs Pub cannot. 

What's the big deal, right?

Well, if the state that Steve files a claim in considers concurrent employment wages as part of the claim, then it can have implications for No Leaks Plumbing.

When calculating the compensation Steve is due as part of his injury, the claim representative would obtain wage information from No Leaks Plumbing and Ps and Qs Pub.  These wages would be combined to determine Steve's pre-injury average weekly wage (AWW).  Based upon the AWW, Steve's compensation rate, or temporary total disability rate, would be roughly 66 2/3% of the average weekly wage.

Let's say Steve makes $1000 per week at No Leaks.  He makes $200 working at Ps and Qs Pub.  One may think that since Steve is working for No Leaks without a loss of earnings, his wages from Ps and Qs Pub wouldn't matter. That is incorrect.

Steve's AWW would be $1200.  If Steve is able to earn his pre-injury hours, earning his pre-injury wages on modified duty, the compensation carrier would still owe Steve 2/3s of the difference between his post-injury earnings and his pre-injury average weekly wage.  In this example, it would be $1200 (AWW) - $1000 (wages working modified duty) = $200.  66 2/3% of $200 = $133.33.  Steve would receive a paycheck from No Leaks, and a temporary partial disability (TPD) check for a percentage of his lost wages from Ps and Qs Pub, in the amount of $133.33.

This puts No Leaks in a difficult position.  They support modified duty but Ps and Qs Pub does not.  The claim representative can attempt to work with Ps and Qs to bring the injured worker back to modified duty, but the pub really has no reason to, other than to have an employee performing some type of work. 

Keep in mind, as long as an injured worker's earning capacity is reduced, due to the work injury, then there is likely going to be benefits due to that worker.

What can be done in this situation?

• The claim representative can encourage the injured worker to discuss modified duty with their concurrent employer
• Obtain a job description from the other employer to help the treating physician determine what the injured worker can safely do at the pub.
• The primary employer (No Leaks) could consider placing the injured worker at a local not-for-profit organization through transitional duty to reduce exposure under the claim, rather than simply paying the injured worker their pre-injury wages.
• If all attempts fail to bring the injured worker back to work at the other employer, the primary employer (No Leaks) may be forced to cover the secondary employer's wages until the injured worker is recovered to perform the work at the pub.

Concurrent employment creates a unique challenge for employers and insurance carriers.  An effective RTW program can help control workers' compensation costs, and can help employers control the aspects of their claims that are within their control.  Sharing expertise and experience with the secondary employer may help them understand why it is a good idea to bring an injured worker back to modified duty.

You've heard of early RTW, but what about late RTW?

So much of what we hear about return to work focuses on early return to work. The majority of injured workers receive medical care, return to modified duty and then eventually their pre-injury jobs. But there's also a group of injured workers who receive medical care, and are given restrictions that are ultimately deemed permanent.  The injuries are typically more severe, or require more than conservative treatment.  Eventually, disability persists so long that we lose focus on return to work as a treatment goal. As Sullivan and Hyman (p. 1, 2014) put it,

     "Evidence-based clinical guidelines emphasize early return-to-work as a critical          
     treatment objective in the management of recent onset pain conditions.  However, 
     something changes when a pain condition becomes chronic.  For chronic pain        
     conditions, return-to-work is rarely put forward as a primary treatment objective.  
     Consequently, successful return to work is rarely an outcome in the treatment of chronic 
     pain conditions."

In their editorial, the authors emphasize the importance of remaining active in ALL phases of recovery, even after an individual's pain becomes "chronic."  If all the treatment that is provided (primarily prescription pain medications) does nothing to improve the individual's level of function, then they aren't really working, are they?  One can argue that pain medication alleviates the individual's pain, but if that doesn't result in an increase in function, is it worth it?  Why aren't we focusing on function?

There's also an assumption that individuals with chronic pain cannot work.  The authors cite a study in which 40% of chronic pain patients who underwent a return-to-work intervention program were successful in their return to work.  If you don't think it is an option, you will never look for information to prove yourself wrong.  Employers who adamantly proclaim that they don't have modified duty will not then go look for modified duty options.  Injured workers who believe that they will never return to work will most likely not look for opportunities to go back to work. 

"Beliefs are the roadmaps of behavior" (p. 2, 2014).  We must keep return to work on the table.  When I say "we," I mean insurance professionals, case managers, medical providers, employers, and injured workers.  The return to work may not be a pre-injury position, but there is work out there for those who want it.  Take workers' compensation, or any other type of benefits, out of the equation, and focus on the individual.  This is their life, for the rest of their life, not just until their benefits expire or their claims settle.  What are "we" doing to provide the best outcome and what are we doing to return them to wellness via return to work?  Can we really expect an injured worker to stay motivated if their physician has thrown in the RTW towel?

To read the editorial, click here.

References:
Sullivan, M. J. L., Hyman, M. H. (2014).  Return to work as a treatment objective for patients with chronic pain?  Journal of Pain Relief, 3(1).  doi:  10.4172/2167-0846.1000130