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Beyond the injury

Successful return-to-work programs may need to address both workplace and personal factors

December 1, 2012

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What does it take to return an injured worker to the job in a reasonable amount of time? The straightforward answer is to heal the injury, but a singular focus on the cause of disability may not be enough. Some experts advocate a broader approach for returning people to work that includes addressing other conditions affecting the employee and his or her desire to go back to work.

To return an employee to work, multiple people play a role – the supervisor providing job accommodations, the physician treating the injury, the insurer handling benefits, and the individual worker drawing on personal motivation to recover. One broken link in the chain could delay or derail the employee’s progress. Research suggests injured workers benefit from a coordinated response, although having so many parties involved may present a challenge.

“It’s this whole system of relationships that have to be managed, and the problem for the employer is that they all have to be managed well and in concert,” said Benjamin C. Amick III, associate scientific director and senior scientist at the Toronto-based Institute for Work & Health.

Understanding the challenges

Due, in part, to the recent economic downturn, having people at work means more now than it did a decade ago, according to Thomas Parry, president of the Integrated Benefits Institute. Based in San Francisco, IBI provides resources for employers regarding health and productivity.

Parry said workforce downsizing has “elevated the importance of having people be at work” so they can deliver for the organization, and return-to-work programs can help reduce both lost work time and workers’ compensation payments.

Effectively managing a return-to-work process is about more than the injury. IBI research shows workers often have other health conditions that need to be managed. For example, the return-to-work process may be different for a worker who has a back injury if he or she also suffers from depression.

Amick agrees with IBI’s research. He is working on a study that is examining workers who filed workers’ comp claims for musculoskeletal disorders. When asked about the main determinants for getting people back to work and functioning well in their jobs, respondents cited mental health problems such as depression as obstacles that needed to be managed along with their injury.

“We can’t build a system where everybody is treated the same,” Amick said, “and by that I don’t mean we shouldn’t be equitable, but rather each person is going to bring their unique set of circumstances to their injury and the return-to-work process.”

Some cases are going to be easy; others, challenging, Amick said. The question for employers, he added, is how to identify early in the process who will need a lot of resources to return to work and who will need moderate help.

Citing research from Boston-based insurance company Liberty Mutual, Amick said the nature of the injury and whether the worker also is dealing with mental health problems are possible indicators of difficulty.

Depression may be a particularly important issue, based on an analysis published in the Journal of Occupational and Environmental Medicine (Vol. 54, No. 9). In the analysis, NIOSH researchers found that injured workers were 45 percent more likely to be treated for depression. Treatment was, on average, significantly more expensive for injured workers than non-injured workers, and costs were not covered by workers’ comp.

Supportive workplace

Another important factor is how the employer responds to the injury. The Institute for Work & Health recommends that supervisors show concern for the injured worker rather than focus on blame or financial considerations.

“If you think about this as a model of self-efficacy, a person that’s in a hostile environment is not going to feel very confident that they can get back to work and work well, because they are not being supported,” Amick said.

A 2007 article from IWH outlines seven principles for a successful return-to-work process based on a literature review. The principles are:

  1. The workplace has a strong commitment to health and safety, which is demonstrated by the behaviors of the workplace parties.
  2. The employer makes an offer of modified work (also known as work accommodation) to injured or ill workers so they can return early and safely to work activities suitable to their abilities.
  3. Return-to-work planners ensure the plan supports the returning worker without disadvantaging co-workers and supervisors.
  4. Supervisors are trained in work disability prevention and included in return-to-work planning.
  5. The employer makes early and considerate contact with injured or ill workers.
  6. Someone has the responsibility to coordinate returning people to work.
  7. Employers and health care providers communicate with each other about the workplace demands as needed, and with the worker’s consent.

Along with job accommodation, employers should consider work schedules. Researchers from Ohio State University in Columbus found that injured workers with unconventional work schedules, such as long hours or night shifts, have a harder time returning to work. Compared to people working a standard day shift, workers with atypical schedules were more likely to be fired, quit their jobs and return to work at less than full capacity, according to the study, which was published online in October 2007 in the Journal of Occupational Rehabilitation.

“Basically, people face additional challenges in successfully returning to work if the nature of their job requirements themselves are in some way unusual or especially demanding,” said study co-author Allard Dembe, professor and chair of the Division of Health Services Management and Policy at OSU.

Dembe said accommodations should go beyond physical redesign to include job organization – work hours, length of commute and type of shift scheduling. One of his suggestions is to phase in a worker whose job involves extended hours. If the usual shift is 10 hours, perhaps the employee starts with six-hour days and works his way back up to 10 hours, he said.

Worker attitude

How the worker feels about his or her recovery may boost or impede return-to-work progress. A study conducted by the University of Leuven in Belgium and published in the journal Spine (Vol. 37, No. 17) reported that employees on medical leave for low back pain returned to work sooner when they received reassurance that their condition would improve as well as medical advice on staying active.

Amick stressed the importance of self-efficacy, which he said is created through the employee’s interaction with the workplace, health care system and insurer. “If the worker feels confident that they can manage their health in the context of work, then they are more likely to return to work quickly,” he said.

In the workplace, it is a matter of organizational culture. Amick asked, Does the employer care about workers? Is communication effective? Do employees trust each other and the supervisor?

“You’re more likely to get a person back to work quickly if you have supportive organizational policies and practices,” Amick said.

Jason Busse, formerly of the Institute for Work & Health, is an assistant professor in the Department of Anesthesia and joint member of the Department of Clinical Epidemiology and Biostatistics at McMaster University in Hamilton, Ontario. He cautioned against considering only the medical aspects of any employee’s return to work.

When someone says he or she cannot work, people look for a disease or injury to explain it, Busse said. That approach can be helpful, but in some cases, a non-medical factor may be the dominant contributor to the employee’s inability to work. “And failure to look for those contributors means that they remain unaddressed. And if they remain unaddressed, you can have the best medical care possible but you’re still going to find a number of individuals that fail to recover to a degree that is commensurate with their objective medical improvement,” Busse said.

He gave an example from his time spent consulting for an insurance company. A teacher was on disability for what was diagnosed as chronic fatigue syndrome. No obvious medical reason explained her extreme fatigue, but Busse identified several personal issues when he spoke with her. The teacher’s husband was abusing drugs and she was fighting with her stepchild. The woman also had switched to a new school where she had a poor relationship with the principal and found her classes difficult to manage.

In Busse’s opinion, focusing solely on sleep studies and sleep-inducing medications would not have solved her problem. He recommended getting the spouse into recovery and improving the teacher’s work environment. Such issues fall outside the usual scope of workers’ comp, however, and employers may say treating a worker’s spouse is not their job.

“Well, maybe it’s not,” Busse acknowledged. “But if you want to get that person back to work and off disability, that may be something that has to be done.”

Case management

A sometimes overlooked but important part of the return-to-work process is the role of health care workers.

“Never underestimate the impact of the health care and insurance system on the process of care; really pay attention to that,” Amick said.

He noted that physicians typically receive little training in occupational safety and health, so employers should take steps to ensure the doctor understands the worker’s job, such as sending a videotape demonstrating the job tasks.

Dembe made a similar observation. He said physicians often make decisions about a worker’s readiness to return to work, but rarely ask questions about the exact nature of the job requirements.

“To really do return-to-work planning well and to coordinate between … the medical personnel and the employers, staff and the insurance company – that takes a lot of time and effort and communication and coordination, and it can be a taxing process,” Dembe said.

His comment underscores the larger issue of coordination. Having someone oversee the return-to-work process can make a big difference. Titles for this role vary – case manager or return-to-work coordinator, for example – and the person may work for the organization or a third party. The key responsibility is to make sure everyone involved in the process communicates and works together to support the employee’s recovery.

Employers should not assume cases are being managed simply because someone is responsible for that role. Amick advised employers to demand quality evidence that case management is working “because how [the case managers] engage with the worker can significantly nullify all the good work that the employer may be doing or all the good work that the [health care] provider is doing.”

Busse’s research supports that argument. In a survey published in the Spring 2012 issue of the Institute for Work & Health’s At Work newsletter, employees from an insurance company who had been out on short-term disability were asked about the disability management process. Many indicated that case management was a critical piece of their recovery, but some reported lack of follow-up and conflicts with the case manager that negatively affected their experience. Another study, which has not yet been published, found that workers with long-term disability claims tended to recover faster when their claim was approved in a short period of time.

“All of these studies are building the argument for a broader approach toward case management and disability management in general,” Busse said.

Avoiding the 'vortex'

The Washington State Department of Labor & Industries is offering employers a financial incentive to provide light-duty or transitional jobs to employees recovering from an injury.

Through the “Stay at Work” program, the employer pays the worker and can recoup up to half the amount from L&I for 66 days or up to $10,000 per claim. Employers also can receive partial reimbursement for training, tools and necessary clothing.

The program, created by legislation signed in June 2011, is based on a similar initiative in Oregon. As of July 31, 2012, 1,114 employers had received reimbursement for light-duty work performed by more than 2,800 injured workers, thereby avoiding 75,867 days of time-loss compensation, according to William Smith, manager of the program.

Smith said “Stay at Work” aims to keep the employer and worker connected through the recovery process and help the injured worker stay grounded. He gave the example of an employee who is already going through a rough time and then suffers an injury that prevents him from working. “All those demons can bubble up in a hurry, and things that were just barely on the edge are really serious now,” Smith said.

The key is getting workers back sooner rather than later. Smith cited L&I research that shows employees who have been off the job longer than six months have only a 50 percent chance of returning to work.

Smith noted that under state guidelines, injured employees who are unable to work do not receive their full salary, so the person is essentially dealing with a pay cut on top of everything else. “It can really rock your foundation of who you are and what you do,” he added.

Although “Stay at Work” is still new, Smith has heard anecdotally that the program is causing some employers who did not have light-duty programs to develop them.

That fits with his recommendations for an effective return-to-work process: Management must be on board, and the program should be set up in advance, rather than the supervisor scrambling to come up with a light-duty job.

Without work options, injured employees may be vulnerable to depression and other mental health conditions, especially if more bad things occur.

The worker can “get caught in a vortex of things not going right, and it’s hard to break out of that,” Smith said. “And this is to help to keep them from ever going there.”

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