Disability Management: Accept and Assist


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  • g.day. The last lecture. I hate being the last lecturer. People are tired, many haven’t sat in a classroom for 30 years. Ready to go home, unless there’s an after conference open bar. Some people have to catch rides and leave half way through – which as a lecturer – you never know if its because your presentation is lousy or simply a reflection of a child needing to be picked up at daycare. So , and I’ve never done this before, if you know you’re going to leave, I must ask you to move to the back now – that way I won’t be disturbed nor will you disturb other attendees. Now, of course if people start leaving from the front, I know I’m in trouble. If you stay, I think it will be worthwhile.
  • A little bit about BA,where we adopted this approach about 5 years ago.. While thought of as an Atlantic Canadian Company, we’re a major player in the ON and QC market. Muskoka, Mount Tremblant. Wherever there is a phone, there’s a BA ee within 100km. We’re not in the big metropolises, we’re in small towns. Our programs need to address the often virtual reality of our workforce. Tough, for a number of reasons, BA does not support telework. A decade ago we were operators placing long distance calls, now we’re remotely setting up internets. Generous benefits.
  • Everyone focuses on direct costs, but you don’t wake up one day too depressed to work! direct cost are only a small piece of total cost! As an employer, we need to look at TOTAL COST. No good closing an sdb or wcb claim if the ee does not rtw productive!
  • Some questions to ponder.
  • How does one become disabled? Who decides to go see the doctor, who decides that they are too ill to work?
  • This is the President of ABIME. Writing in the MEDICAL disability asdvisor.
  • Not just for MUDS, but headache, URIs, IHD…the decision on work is made by pt!
  • Not a medica
  • And if you don’t believe me, believe stats canada – because statistics can’t lie!Being in a Union doesn’t make you ill!
  • Lets stop focusing on the factor in red, and start looking at the others!
  • Opportunity to address issues affecting performance/attendance; ideally before there is a problem.
  • Start young and recur – employees for life.Unlike MIs or Gallbladder – sudden show up, get treated and move on; spiral in/out over months or year. Opportunity for early recognition and enhanced treatment.
  • Disability Management: Accept and Assist

    1. 1. De-medicalizing Disability Management “Accept and Assist”. Matthew Burnstein, MD, MCFP, MRO Chief Medical Officer – Bell Aliant Feb 13th, 2014 Page 1
    2. 2. Objectives • Understand Total Cost and the Drivers of Disability • Weakness in the Traditional Approach to Disability Management • Time for a Paradigm Shift? • A New Model • Study the results • Lessons Learned Page 2
    3. 3. Bell Aliant Regional Communications • 7000 union and non union members (>60% unionized) • 6 provinces, widely dispersed • Customer care workers, field technicians, engineers, marketing and sales, finance, support services • TV, internet, home security systems and phones – ever-changing product mix • Former monopoly • <2% staff turnover • In house team of Health and Wellness (H&W) professionals • Self insured for short term disability- up to 1 yr at full salary • Unlimited incidental absence at 100% pay Page 3
    4. 4. TOTAL COSTS OF DISABILITY DIRECT COSTS STD INCIDENTAL WCB INDIRECT COSTS (INDIRECT COSTS ARE 2.5-3.5 X DIRECT COSTS) Drug/health costs Presenteeismdouble this number! Page 4 Overtime Benefits Morale Increased stress for colleagues Customer Satisfaction Increased workload Lost Sales Opportunities Paperwork / Reporting Training/Retraining Cost to Employee and their Family!
    5. 5. What’s behind the high rates of disability today? We’ve never been healthier, never lived as long, never had such great medical knowledge, yet, as a society, we’ve never been so disabled. Page 5
    6. 6. How does an individual end up disabled? An Individual with a complaint becomes a Patient with an illness, who becomes a Claimant with a disability. In most cases, the evolution is driven by the individual, not by the illness or the physician. Page 6
    7. 7. Does the medical model explain disability? Page 7
    8. 8. • “The experience of disability is more related to society’s willingness to accommodate and individual motivation than any underlying impairment or limitation. Our narrow concepts of health and disability limit our potential. • Over the years, I have been impressed by the relative lack of correlation between impairment and disability….Much of disability results from learned experiences, lack of adaptive skills and reinforcements from physicians, family members, attorneys, employers and others. • We can no longer accept this societal illness; the costs are too enormous”. Page 8 Dr Chris Brigham President ABIME Preface the MDAs
    9. 9. Page 9
    10. 10. Only a small fraction of medically excused days off work is medically required – meaning work of any kind is medically contraindicated. The remaining days off work result from a variety of non-medical factors such as administrative delays of treatment and specialty referral, lack of transitional work, ineffective communications, lax management, and logistical problems. These days off are based on non-medical decisions and are either discretionary or clearly unnecessary. Participants in the disability benefits system seem largely unaware that so much disability is not medically required. Absence from work is “excused” and benefits are generally awarded based on a physician’s decision confirming that a medical condition exists. This implies that a diagnosis creates disability. ACOEM Guideline on Preventing Needless Work Disability by Helping People Stay Employed Page 10
    11. 11. Page 11
    12. 12. • “Disability is a complicated psychosocial problem that extends beyond the sole question of illness or injury. Many factors contribute to the complexity of the problem. • They include, but are not limited to an individual’s values and beliefs; the role of illness in the individual’s childhood..; the specific symbolic meaning of illness or injury to the individual; the individual’s relationship with his employer; economic issues; workplace accommodations made available by the employer; and the employer’s policies/practices, culture, and values”. Page 12 Dr Presley Reed The Medical Disability Advisor 4th Ed.
    13. 13. Disability is not a medical concept  Defined by a contract, usually related to occupation  Therefore, it is a legal rather than a medical concept  Influenced by non medical factors : – – – – Page 13 Employer, availability of alternate duties Training, experience, education Psychosocial factors Personality
    14. 14. Reality check: Doctors are trained to treat illness, not disability Page 14
    15. 15. Physician’s Perspective On Disability Determination • 86% of physicians believe that completing disability forms adversely affects the physician-patient relationship • 62% feel it represents a conflict of interest • 56% are willing to exaggerate clinical data to assist a deserving patient • Physicians report a lack of confidence in their ability to determine disability (self rated ability as 4.5/10) • 80% of physicians feel it would be better for an independent group to determine disability Journal of General Internal Medicine 1996 11(9) Page 15
    16. 16. Page 16
    17. 17. Certificate of Disability Canadian Medical Association Policy • The CMA believes it is the employer’s responsibility to supervise an employee who is absent from work for a short time because of a minor illness. The medical profession objects to being asked to police such absenteeism. • The association objects to the use of physicians as “truant officers”. • It is generally accepted that most minor illnesses are self limiting and do not require the intervention of a physician. Page 17
    18. 18. Page 18
    19. 19. Medical Post 4/5/99 Page 19
    20. 20. If illness was the cause of absenteeism, then absence rates should be similar across communities. But they are not: Gross Absence Rates Agriculture 1.7% Trade & Commerce 2.3% Finance 3.3% Construction 3.4% Manufacturing 4.8% Government 5.3% (Perspectives 1999) USA 3.5% Sweden 6.0% France 8.3% Italy 11.6% Unionized ees 13.2 days/yr vs Non Unionized ees 7.5 days/yr (Stats Can 2011) Page 20
    21. 21. What are the reasons we miss work? Global/Environment Organization Personal Region (NS vs AB) Culture Job Climate Type Gender Race Size Age Economy HR policy Schedule Pension Age Relationships Job Satisfaction Social Programs Quality of Supervision Transportation Health Services Sick pay/benefits Family Epidemics Turnover/Churn Personality Religion/Culture Working Conditions Individual Health Health Services Work demands Leadership Physical workspace Page 21
    22. 22. The primary determinant of work attendance is job satisfaction: Adding Value Being Valued Sharing Values Page 22
    23. 23. Drivers… • What makes people come to work? – Opportunity, Desire and Ability – Global / Environment / Organization / Personal variables can affect those • Who decides if working is possible? – Decision to work is made by the individual – The decision to offer alternate duties and provide accommodation is made by employer – Neither is a medical decision Page 23
    24. 24. Page 24 But beware the golden handcuffs
    25. 25. And you want employees to like their work………. Page 25
    26. 26. Hippocrates: “It is always more important to know what type of person has a disease than it is to know what type of disease a person has.” Page 26
    27. 27. Disability vs Disease • Disability and disease are distinct concepts; diagnosis does not determine disability • Doctors don’t know disability and are not truant officers • Disability from work is determined by a multitude of non medical factors • While supporting the concept of early return to work, doctors are patient advocates, and ultimately, patients determine their ability to work • The workplace/workplace policies must encourage employees to remain at work (even in the face of challenges) • Engagement may reduce absenteeism Page 27
    28. 28. So, if disability is not driven by disease, and doctors don’t know much about disability or the workplace, what do we do? How do we determine or manage disability? Page 28
    29. 29. The first paradigm shift Stop talking to doctors and start talking to employees. Page 29
    30. 30. Talk to employees • Doctors talk to their patients - they trust them and advocate for them, but they don’t know the workplace • Trust your employees – they are telling you the truth* • Treat them as you’d treat a manager or a colleague or want to be treated yourself • They know their job and what aspects they can do and can’t do • Allow them flexibility to do the job • It is their motivation which determines outcome – so what is motivating them to come to work or keep them off? * Most of the time. Why treat the 99% who are honest to catch the 1%? Page 30
    31. 31. What’s going on? What you see WORKPLACE SYMPTOMS ARE ONLY THE Troubled or Absent Employee “TIP OF THE ICEBERG” Lateness Withdrawal Mood Swings Spillover Emotional outbursts Spillover What you don’t see Life Issues • Stress/Emotional • Relationships • Legal/ Financial • Addictions Work Issues • Environmental • Interpersonal • Job-Related KNOWING THE SOURCE OF THE PROBLEM ALLOWS THE CASE MANAGER TO DETERMINE A Page 31 COURSE OF ACTION Health Issues • Heart Health • Nutrition • Sleeping • Depression
    32. 32. The Second Paradigm Shift • Accept them and help them • You cannot rehabilitate someone who is busy proving they are disabled • Malingerer’s are rare. Anxious and overwhelmed individuals are common. • Often the claimant is just in the wrong basket – needs family leave, needs to change jobs, needs to be on administrative leave or re-assigned while workplace conflict is addressed • Chronic diseases are chronic/recurrent and need to be addressed holistically (is public health up to the task?) • Whatever the barrier or reason for being off work, the outcome is better, and total cost reduced, if you support the employee and work through the issues Page 32
    33. 33. The Third Paradigm Shift: think long term • Employees are there for the long term, so you need to think long-term • An injured/ill employee who could be at work, but chooses not to rtw, generates a greater loss to the organization over the long term than the “extra” few weeks of sick leave. They are disengaged. • Presenteeism costs more than absenteeism • Forcing an employee to rtw when they feel they are “unfit” will cost the employer money every day Page 33
    34. 34. Tools to Assist the Shift: Health Assessment A complement to, not a replacement for, a discussion between manager and employee. Health Assessment Type When to use Health Status •Proactive •Accommodation Issues Attendance •Medical issues impacting attendance •Level 3-Attendance Support Ergonomic •Persistent Ergonomic Issues Return to Work •Assess fitness to return to work from LTD, Administrative Leaves, etc. (used infrequently) Page 34
    35. 35. Train Managers to Identify Employees at Risk • How to help employees stay at work – Identify employees who is having difficulties, as early as possible. • Absence is a predictable event – How to predict absences? • Know the workplace / know the people and know when action is necessary Page 35
    36. 36. Tools to Assist Shift: Attendance/Performance Improvement Program • Triggered when there is a demonstrated history of being over the average for the department for absence or not meeting performance targets • Absence is absence –– it’s not why you missed work, it’s that you missed work (assumed innocent). • The reasons for the absences/poor performance determine the help needed. • Early identification is key. • No fault, no blame but the absences/performance is an issue –What can you do? What can we do? • Non-disciplinary Page 36 36
    37. 37. Transitional Return to Work Page 37
    38. 38. Transitional Return To Work • Focus on ability not inability • Manager and employee (+/- health services) • Part of corporate culture - it should be expected (and employer should be prepared with options) • Time limited – it’s a transition not a move • Progressive (but flexible) • Must be safe (for ee, co-workers, public) • Goal is rehabilitation – it cannot be punitive • Work must have meaning • Workplace must be welcoming Page 38
    39. 39. Bell Aliant is Committed to Early and Safe RTW (as is the Union!) • 28.12 It is agreed that the rehabilitation of sick and injured employees is a priority. The Company and the Council will participate in programs that will enable early and safe return to work…The rehabilitation plan will be based on the employee’s functional capability, input from the employee’s existing health care providers, and other health care professionals as deemed necessary by the company. Page 39
    40. 40. Manager and Employee can decide on modified duties – LRA 2008-04. • If the employee’s restrictions are expected to last 30 days or less and the employee can be accommodated under the terms of the collective agreement, no action is required other than proceeding with the accommodation request. If however, the employee cannot be accommodated under the terms of the collective agreement, then medical documentation may be required. At any time, the manager can seek input from Health and Wellness. The manager must inform the local shop steward of the details of the accommodation and the duration. Page 40
    41. 41. Mental Health Initiative • 1/3rd of claims, last 50-100% longer • MH issues start young and recur • Often months of presenteeism before absence (opportunity to intervene) • There are often workplace drivers and workplace solutions! (another opportunity to intervene) • Mental health awareness training for Leaders of people • Educational sessions, communications • Focus on early recognition, highlight resources Page 41
    42. 42. Results of this Approach • • • • • • Gross Absence Rate* 4.5%>4.3%>4.1%>3.6%>3.6% (2013) SDB as % salary` 1.36%>1.28%> 1.24% >0.97% >0.99% Denials < 1% - usually wrong basket Grievances on denials – rare Relationship with Union - positive # of Health Assessments – increased (some referred by Union) • # of IMEs for SDB adjudication – rare • # of IMEs for HA’s and SDB mgmnt - frequent * Cdn GAR: Company >500 ee =4.4%;Unionized Workplace 5.3% (stats can 2011) `SDB % of Income Cdn average 1.5% (Towers Watson) Page 42
    43. 43. Lessons Learned • • • • • • • • • • Accept and Assist trumps Deny and Defend Think Total Cost and think long term Talk to employees, not doctors Engage HR/LR/Ops in program development – make them stakeholders/ambassadors; train mgrs/union Don’t under estimate cultural resistance Become health navigators – focus on Chronic Disease Orient new employees/managers Address presenteeism- its your next SDB claim, offer help Performance = Attendance improvement EE who can, but won’t participate in TRTW, is likely disengaged and a problem beyond their SDB claim Page 43
    44. 44. THANK YOU ……….Questions? Page 44