"When it all goes wrong" - Review of the barriers to return to work


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Tony Johnston
Principal Health and Safety Adviser,
Safety and Wellbeing, Human Resource Services
Queensland Health
(P52, Thursday, NZI 4 Room, 3.30-4)

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  • Abstract The healthcare industry is a dynamic and complex industry and although considerable efforts have been made to improve health and safety injuries still do occur. Generally, most workers can return to normal duties without any issues; However, successful return to work outcomes are often impacted by a wide variety of factors such as the nature and characteristic of the injury, characteristics of injured person, physical and psychosocial work demands, medical and therapeutic interventions, work organisation, workers compensation process. This presentation will overview the available literature and proposes a conceptual model for evaluating workplace rehabilitation systems (strategic level) and return to work plans (operational level).   Objectives: To develop a conception model to assist rehabilitation practitioners to identify the barriers impacting return to work for injured healthcare workers.   Method: A review of the literature was conducted of identify available models for identifying barriers and facilitators impacting return to work. The core dimensions were assessed and a model developed and trialled for use at: Strategic level for evaluating workplace rehabilitation systems; and Operational level for return to work planning.
  • Healthcare is a dynamic and complex environment A lot of activity has occurred to support safe moving and handling of people Union marketing campaigns Regulations Guidelines And you may have heard from previous speakers, or previous conferences some fantastic outcomes Significant reductions in Workers’ compensation costs in the order of 30-80% premium Improved satisfaction at work, and longevity …
  • Healthcare continues to be a hazardous industry And it does not seem to be getting any easier Average days lost per claim increasing from 20 days in 2007 24 days in 2011 And costly. From a litigation perspective Conversion to common law are increasing from 2.3% in 2007 5.5% in 2011
  • One research suggested the 80:20 rule also applies 20 percent of the claims attribute to 80% of the costs You can see from the graph, A good proportion of cost attribute to the Medical Expenses claims But majority of costs towards the longer tail claims ….. And no doubt the majority of time and effort managing the claims Long tail claims present a number of issues Complex and difficult RTW Frequently the obstacles impeding RTW have little to do with the initial injury Even work related injuries such as musculoskeletal and mental health conditions have been shown to benefit from activity‐based rehabilitation and an early return to suitable work. Research also shows that long‐term work absence, work disability and unemployment are harmful to physical and mental health and wellbeing. Further more, Return to work statistics indicate, the longer someone is off work, the less likely they become ever to return. Data concludes the following:   Off longer than 20 days the chance of ever getting back to work is 70%; Off longer than 45 days the chance of ever getting back to work is 50%; and Off longer than 70 days the chance of ever getting back to work is 35%. So the big question is ….. why
  • Psychologically or behaviourally determined by: Personality Perception of symptom Pain Psychiatric disorder Work, leisure, family issues Financial issues Legal issues
  • Behaviours Perception of symptoms, treatment and outcome System factors Medical language, “instability” Legal proceedings – Attorney-ogenic disability – legal advice to stay of work in preference for better outcome at settlement Compensation system Medical model Prove injury/illness for claim to be accepted Perpetuates a sickness model Insurance systems and civil law are based on physical biological model, ignoring psychological and social factors Can hinder or cause injuries to worsen
  • It is easy to first consider the barriers to RTW lie completely with the injured worker. They must have had a pre-existing condition They should have know better Or even worse … their a malingerer or “secondary gain” However this approach does not provide solutions for returning the worker to meaningful work. And is similar to the shift in safety preventative models from a traditional “careless worker” approach towards a systems approach reviewing various root causes or contributing factors
  • NSW WorkCover – FACTORWEB – personal and environmental risk factors (based on NZACC) WORKCOVER (NSW). 2008. FACTORWEB - Personal and environmental risk factors. Available: http://www.workcover.nsw.gov.au/formspublications/publications/Documents/factorweb_5523[1].pdf . WORKCOVER (SA). 2007. A guide to assessing and managing red and yellow flags for workers compensation patients. Available: http://www.workcover.com/custom/files/AssessingManagingRedYellowFlags_201004231418832.pdf . WORKCOVER (SA). Considering biopsychosocial factors [Online]. WorkCover South Australia. Available: http://www.workcover.com/site/treat_home/injury_management_by_health_discipline/key_principles_for_all_health_providers/considering_biopsychosocial_factors.aspx [Accessed 2012]. Adapted from WorkCover NSW FACTORWEB COMCARE – References NZACC
  • 3 necessary elements for successful RTW Value Expectancy Self-efficacy Interventions address basic coping strategies, perceptions about the “work role” following injury Blue flags In the contact of an injury may delay recovery, or constitute a major obstacle Perceptions of not only the job demands, but also the social context of work (management and co-workers)
  • International Classification of functioning, disability and health. Standard language for describing health and health-related states. The ICF model combines two constructs for disability Medical model – directly caused by disease, trauma or other health condition Social model – socially created problem and not at all an attribute of an individual Each have a natural direction towards the solution or treatment approach Biological  individual  social With disability viewed as outcomes of interaction between the health condition and contextual factors
  • Major categories under each of the headings
  • More about the concept and use of the flags model …..
  • With increasing age increasing number of claims of longer duration 40 yrs + around 9%, whereas <40 yrs 5.6% Interestingly the 60 yrs + group have one of the higher numbers on MEO claims
  • Psychological claims 29% of claims are 100+ days -- this may relate to the compensation criteria to prove illness and reasonable management action Whereas the back, leg and arm injuries are all very similar
  • Individual roles Reporting severe symptoms Comorbidities impacting recovery (pre-existing) Social issues Medical Lack of timeframes for RTW Psychological injury / overlay Injury not improving with treatment Workplace Physically demanding occupations Systems Insurer reactive Insurer not proactive in contacting stakeholders Rehab delayed.
  • Individual: Will not participate One site with significant legal and union participation in claims process Expectations (esp in Government) Injured workers expecting redeployment Managers expecting ill health retirement Communication PPI claims … email communication Especially in smaller districts with few staff and limited Medical Regional areas with few options for TMO and specialists System delays Parallel processes, esp complex PPI / Grievance process investigation Resources – High case numbers in some areas Delegations for financial sign-off Workplace Budget and funding SDP SDP not available esp operational areas: physical job, limited transferable skills Nursing: CPR issue Managers not aware of obligations (and cost impact on premium) Co-workers: SDP seen as preferable “light duties” Mx responsible – premium not devolved, no financial ownership/consequence
  • "When it all goes wrong" - Review of the barriers to return to work

    1. 1. “When it all goes wrong” Review of the barriers to return towork within the healthcare industry Tony Johnston Principal Health & Safety Adviser Queensland Health
    2. 2. Outline• Defining the problem • Method – No lift – Literature review – Investment in equipment, – Common resources used training within AUS – BUT, Increasing WC – Draft tool• Background • Findings – Safety model – Statistics – Traditional vs systems – Complex case review – Predicting RTW outcomes Flags models • Future directions Questionnaires
    3. 3. Patient Handling: Through the ages… 1998 2001 2007 2012
    4. 4. Healthcare Industry… Lost timeFrequency of Claims
    5. 5. Healthcare Industry… Lost timeTotal Cost of Claims >20 days RTW 70% >45 days RTW 50% >70 days RTW 35%
    6. 6. Objective• Develop a tool to predict / identify barriers impacting return to work – User: Injury Management Team (Strategic) Rehabilitation Coordinator (Operational) – Categories and language to inform decision making – Structured, targeted rehabilitation plans. – Educate decision makers – Organisational improvement
    7. 7. Barriers to RTW… Literature• 20-30% persistent adverse consequences• Strong predictive factors: – Catastrophising – Expectations/perceptions – Financial incentives – Physical demands of work – Loss of contact with work• 5-9% chronic problems regardless of initial injury.• Psychosocial obstacles impede progress, not because there is more serious injury. – Often unrelated to incident or injury
    8. 8. Barriers to RTW… Literature• Beliefs: – major underlying pathology. – avoidance of activity will help recovery. – need for passive physical treatments rather than active self- management.• Other post-accident factors: – Psychological maintaining variables: depression, anger. – Other adverse events, e.g. further trauma, independent illness, bereavement, frustrating legal proceedings.• Quality of care: – Failure to provide positive mobilisation and rehabilitation. – Iatrogenic treatment factors: poorly organised care, inconsistencies, ambiguities and failure to answer patients and familys worries
    9. 9. Systems Approach(Swiss cheese) Individual factors
    10. 10. Industry Guidelines • Flags models • Biopsychosocial factors • Personal and Environmental risk factors
    11. 11. Flags Models Red flags Black flags• Medical • Context – Serious pathology (people, systems, policies) – Co-morbidity – RTW policy – Failure of treatment – Threat to financial security – Litigation – Compensation system and qualification criteria – Lack of contact with workplace
    12. 12. Flags Models Yellow flags Blue flags• Psychosocial / Individual • Work Area / Perception – Beliefs, thoughts, feelings, – Social support at work behaviours – Unpleasant work (pain & injury) – Job satisfaction – Coping strategies – Excessive demands/low – Psychological distress control – Sick role – Unhelpful management – Passive role in recovery style
    13. 13. BiopsychosocialBody Functions & Activity Participation Structures Environmental Personal Factors Factors Work & Non-work Individual / Medical environment psychological factors
    14. 14. Biopsychosocial Individual / Work & Non-work Medical psychological factors environment Biological / Attitudes & Workplace medical beliefs Treatment & Emotions RTW process Diagnosis Health Behaviours Co-Workers Providers Compensation Family issues
    15. 15. Barriers Analysis ToolPurpose• Psychosocial obstacles impede progress, not because there is more serious injury. (Burton etal 2009) – May be unrelated to incident or injury• Identifying flags/barriers complements the diagnosis – Relevance as a contributor to the persistence of the problem – Facilitate problem solving, not prescriptive – Referral to appropriate assessment and intervention• Used to identify specific obstacles to: – Recovery – Activity – Work
    16. 16. Barrier Analysis Tool (Draft) Demographics DOI Individual/ factors Factors Medical Rehab Workplace Factors RTW status •Severe symptoms/pain •No TMP •Management support Restrictions •Co-morbidities • •Contact with workerSystem Factors No definitive diagnosis •Perception of for recovery/RTW • report injury •SDP•Worker does notNo timeframerecovery limited / unavailable • •Multiple injuries •Management not aware of rehab•Employer doesPerception about RTW not investigate incident • •Psychological•Rehab delayedCommunicationinjury/overlay obligations/benefits •Unrealisticnot •TMP will expectations •Co-worker support•Claim determination delayed support/participate in RTW •Social issues for case •Frequent treatment•Demanding job (physically or•No single person responsible(transport, •Not•Responsibility family)complying with treatment not clear psychologically •Total incapacitatedManagement responsibility for rehab•Inadequate plan/goal/timelines • >2 weeks•Admin focus rather than person focus•Funding for RTW•Insurer not communicating/coordinating•Insurer reactive, not proactive
    17. 17. Barrier Analysis Tool…MethodComplex Case Review•File review complex cases with Rehab Coordinator – > 2 weeks time lost•3 sites (metro and regional)•Barriers identified•Action plan documented•Data collated and evaluated – Local issues – Strategic impact
    18. 18. FINDINGS
    19. 19. Occupational GroupsAverage days lost
    20. 20. AgePercentage of Claims 15.6 21.9 30.1 31.4
    21. 21. Body Part effectedPercentage of Claims 24.3 24.9 29.4 86.1
    22. 22. Barrier Analysis ToolComplex Case Review
    23. 23. Barrier Analysis ToolComplex Case ReviewOutcome:•Tool practical and easy to use•Identifies barriers – Point-in-time – Potential future concerns•Encourages case planning and documentation•Identifies barriers at individual, work area and organisationallevel•Educational tool for Rehab Coordinator, Management – Individual factors  Workplace factors & System factors
    24. 24. Barrier Analysis ToolGlobal Issues• Individual factors • Workplace factors – Will not participate in – Management does not Rehabilitation support RTW – Unrealistic expectations – Suitable duties – Will not communicate directly limited/unavailable with employer – Management not aware of benefits• Medical/rehab factors – Co-workers do not support – TMO does not support RTW RTW – Physically demanding job• System Factors – Management not responsible – Rehab delayed for rehab – Claims determination delayed
    25. 25. Conclusion / summary• Rehab coordination can • Education all involved have a critical bearing on – Line managers the outcome – Rehab coordinators – Employment policy • Influence – Social contact – Health providers – Nature of work – Insurers – Coordination of RTW care
    26. 26. Future Direction• Ongoing trial• Review/modify individual elements for barriers specific to local environment – Utilised by other organisations• Integrate into Rehab Coordinator training – Case review and documentation – Prompt for case planning• Collation of data to inform organisational needs – Policy changes – Education and training: Managers, Rehab Coordinators – Influence external stakeholder: Insurer, TMO
    27. 27. Bibliography• ACC (NZ). 2006. Return to work and pschosocial issues. Available: http://www.acc.co.nz/PRD_EXT_CSMP/groups/external_providers/documents/guide/prd_ctrb113170.pdf .• FOREMAN, P., MURPHY, G. & SWERISSEN, H. 2006. Facilitators and Barriers to Return to Work: A literature review.• KENDALL, N., LINTON, S. J. & MAIN, C. J. 1997. Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain: Risk Factors for Long-Term Disability and Work Loss. . Available: http://www.kendallburton.com/Library/Resources/Psychosocial_Yellow_Flags.pdf.• WORKCOVER (NSW). FACTORWEB - Personal and environmental risk factors. Available: http://www.workcover.nsw.gov.au/formspublications/publications/Documents/factorweb_5523[1].pdf .• WORKCOVER (SA). Considering biopsychosocial factors [Online]. WorkCover South Australia. Available: http://www.workcover.com/site/treat_home/injury_management_by_health_discipline/key_principles_for_ [Accessed 2012].• WORKCOVER (SA). 2007. A guide to assessing and managing red and yellow flags for workers compensation patients. Available: http://www.workcover.com/custom/files/AssessingManagingRedYellowFlags_201004231418832.pdf .