Indiana Worker's Compensation Institute

For nearly two years, the partnership of Indiana University School of Medicine (IUSM) and the Rehabilitation Hospital of Indiana (RHI) has been one of sixteen rehabilitation centers designated as a Traumatic Brain Injury (TBI) Model System site. This designation has allowed RHI/IUSM physicians, researchers and clinical staff to collaborate with other national leaders in brain injury care and research.

For TBI, RHI offers an interdisciplinary approach of physicians, other clinicians, and researchers specializing and credentialed in working with individuals who have a TBI including those with disorders of consciousness. This team consists of neuropsychologists, physiatrists, physical therapists, occupational therapists, speech and language pathologists and nurses.

The TBI Model Systems began in 1987 through grants from the United States Department of Education and the National Institute on Disability Rehabilitation and Research (NIDRR) and is a network of the leading centers in medical rehabilitation research and patient care that focus on tracking and improving recovery of individuals with TBI. Sites selected to be a part of the TBI Model Systems provide a continuum of care from the initial onset of injury through return to community and work. Grants are awarded to facilities in five year cycles.

Each Model System like RHI/IUSM collects data to be entered into a longitudinal national database managed by the Traumatic Brain Injury Model Systems National Data and Statistical Center at Craig Hospital in Englewood, Colorado. Data on long term outcomes for individuals with TBI has been collected through the TBI Model Systems for over 25 years. Participation in this national database allows RHI to follow its patients with TBI over the long term. In addition to contributing to this longitudinal database, each TBI Model System center pilots its own studies. Currently, the Indiana TBI Model System at RHI is studying the effect of irritability and aggression following TBI through a research initiative called the Brain Research in Irritability and Aggression Network (BRAIN). BRAIN researchers are developing methods to better understand and reduce the negative impact of irritability and aggression on those with TBI and their families. It is estimated that 29-71 percent of those with TBI have irritability and aggression that negatively impacts social interactions and employment.

Clinical staff at RHI benefit from the TBI Model System designation in numerous ways. Each year, RHI staff attends an annual leadership conference in which they are able to collaborate with other national leaders in TBI rehabilitation. RHI clinicians have the opportunity to discuss best practice diagnostic and treatment plans, analyze cutting edge therapeutic equipment and materials, and gain insight into the practices of the leading brain injury specialists in the country. For example, RHI staff learned the benefit of a car transfer simulator and has implemented a TRAN-SIT® Car Transfer Simulator in which patients can practice safe car transfers from the convenience of the therapy gym without regard to weather conditions. Also, once a month, TBI clinicians from RHI participate in teleconference meetings in which they are able to discuss pertinent topics related to rehabilitative care of patients with TBI. To review the article in its entirety, please click here”

The entire TBI staff at RHI are proud to be recognized as part of the TBI Model Systems and assume the responsibility of this recognition by continuing to offer the highest level of rehabilitation services in Indiana. In the words of Dr. Daniel B. Woloszyn, CEO and Clinical Neuropsychologist at RHI: “As the sole traumatic brain injury model system site in the state of Indiana, this award further validates best practice in rehabilitation care. It is comforting for RHI patients, acute care hospital physicians, and the Indianapolis community to know that patients with brain injuries, those sustaining strokes, spinal cord injuries, multiple trauma and other injuries or illnesses have available to them outstanding rehabilitation professionals at the Rehabilitation Hospital of Indiana and Indiana University School of Medicine.”

The Return-to-Work or Fit-For-Duties Evaluation is a type of assessment designed to identify whether an individual has the physical ability to perform part or all of his or her usual job tasks at some point in time following an injury. The Fit-For-Duties Evaluation is usually performed following a rehabilitation program or work absence, but may also be performed immediately following an injury. Fit-For-Duties Evaluations determine an injured employee’s functional requirements with respect to his or her job-specific, pre-injury job duties, or functional capacity with respect to generic job duties. This same evaluation may also be used as a placement tool in qualifying an individual for modified or transitional duties.

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It is no mystery that there are significant costs and loss time associated with soft tissue injuries in the workplace. Sprains and strains account for 41 percent of all workplace injuries and illnesses requiring days away from work. The musculoskeletal disorders or MSD’s as they are called in the Industry, are difficult to assess and ultimately are handled differently by providers across the country. With little standardization and consistency of care delivery, the outcomes are varied from one provider to the next. The solution is the development of an integrated approach that manages and reduces risk throughout the continuum of care.

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Addressing safety and health issues in the workplace saves the employer money and adds value to the business. Recent estimates place the business costs associated with occupational injuries at close to $170 billion – expenditures that come straight out of company profits. With an ever increasing aging workforce that is less conditioned than ever before combined with a constant threat to the employer of “pre-existing” conditions, hiring and retaining qualified and physically “able” workers is one of the greatest challenges employers face today.

A properly implemented physical screening process provides security in the placement of workers who will be able to meet the physical demands of the job and continue to be injury free in the workplace.

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Focusing on the health and well-being of all workers throughout their working lifetime will address the needs of our aging workforce; however, due to the rapidly increasing numbers of older workers in the workforce there is an urgent need to give particular attention to understanding and addressing the needs of older workers now.

Workplace injuries and illnesses

Older workers required more days away from work to recover from a workplace injury or illness than did their younger counterparts. Elizabeth Rogers, of the Bureau of Labor Statistics Office of Safety and Health Statistics, reported that work-related injury and illness was more severe for older workers based on census and survey data from her bureau. They took longer to recover with a median of 12 days away from work for those ages 55 to 65 and 16 for those 65 and older compared with just seven days for workers overall. Their workplace injuries were also more disabling, with more fractures and multiple injuries than seen among younger workers. Also, similar events (for example, falls) lead to more severe injuries in older workers than in others. An example of the severity of injuries and illnesses sustained by older workers can be seen by looking at the nature of the injury or illness sustained. The nature of the injury or illness is defined as the principal physical characteristics of the injury or illness, such as a cut, a bruise, or a sprain. Sprains, strains, and tears make up the largest single category at all ages.

We need to act now!

Employers must address these health and safety issues for older workers simply because there is and will be more and more of them in the workforce. The older population–persons 65 years or older–numbered 39.6 million in 2009 (the latest year for which data is available). They represented 12.9% of the U.S. population, about one in every eight Americans. By 2030, there will be about 72.1 million older persons, more than twice their number in 2000. People 65+ represented 12.4% of the population in the year 2000 but are expected to grow to be 19% of the population by 2030. Older workers will also be working longer schedules. More than half of all older workers now work full-time, which is up 44 percent since 1995, according to BLS data.

We now anticipate more older workers will remain in the workforce longer because they must in order to survive economically. Baby boomers — born in the post-World War II years from 1946 to 1964 — are nearing the cusp of retirement age. But, they already fit into the U.S. Department of Labor’s definition of “older” as over 40 in some cases and the Bureau of Labor Statistics’ definition of over 45 in injury and illness reporting.

According to the Bureau of Labor Statistics (BLS), productivity increases as the percentage of over-55 workers increases, while the accident frequency in the older demographic declines. The BLS also reports that 41 percent of the overall number of work-related injury claims recorded annually come from new employees (i.e., on the job for a year or less). Older workers (64 or older) have the lowest number of workplace injuries, according to the Department of Labor (DOL). The National Institute for Occupational Safety and Health also reports that younger workers (i.e., under the age of 24) are two times more likely than their older co-workers to be injured. The catch for employers, however, comes into play when these older workers get injured.

Recovery from Injury: Younger versus older workers

For older workers, it takes approximately two to three times longer to recover from an injury than a younger worker, says the BLS. A recent National Council on Compensation Insurance (NCCI) study found that claims costs for workers aged 55 to 64 are generally 64 percent higher for indemnity claims and 40 percent higher for medical claims (compared with workers aged 20 to 24). Claims costs and days away from work are directly related. For injuries and illnesses, the BLS reports, for workers aged 65 and older the median days away from work is 15 days. For workers aged 16 to 24, however, the median is 4 days.

“Older workers are more productive and have an overal higher work?��Ǩ���?��Ǩ��place safety”

The new work environment

A variety of economic hardships are influencing and changing the age of the workforce. We no longer work for one employer our entire career and then take the company pension. Many employers have terminated or stopped funding defined benefit retirement programs entirely. From the economy deflating the value of 401(k) programs to employees having children (and college bills) later in life, people simply cannot retire, lay back and enjoy their “golden years.” According to a 2008 survey by AARP, one in five people between the ages of 55 and 64, and one in four between 45 and 54, plan to delay their retirement due to the economic turndown. Employers need to plan and prepare for this expected growth in the labor market.

What can employers do?

Employers can start by revisiting job descriptions and knowing every detail each work task entails in order to help prevent costly and unnecessary workers’ compensation claims. Meanwhile, they should continue to promote health and wellness programs for all employees. Because older workers bring many benefits, from their experience and knowledge to their motivation and good work ethic, the advantages of employing older workers will outweigh the possible worker’s compensation claims, with preparation and planning.

Companies must utilize and implement preventative safety efforts. Specifically, companies should develop slip-and-fall prevention tactics, considering that slips and falls account for 33 percent of all injuries sustained by workers 65 and older, according to the National Safety Council.

Safety training should consist of more than just scripted lectures, distributed pamphlets and orientation videos. Employees should be taken through the physical movements and tasks that are specific to their job description–a hands-on learning experience. Because younger workers account for the majority of accidents while older workers have longer recovery periods, safety training benefits all employees and the employer. Bring in external experts such as Physical therapists from the community to teach proper techniques and protocols.

Modification of your work environment

Older workers are good for companies so it pays to modify work environments in order to prevent their injuries and limit severity when injuries do occur. The American Society of Safety Engineers urges employers to keep their older workers in mind when designing workplaces so that productivity is maximized and the potential for accidents is minimized.

A well-designed workplace helps new hires and experienced workers, young and old. Options include:

• Increasing task rotation
• Designing work floors with smooth, solid decking and skid-resistant flooring
• Lengthening time requirements between task steps
• Reducing static standing/sitting time and noise levels
• Using high-contrast colors on risers and treads on stairs
• Considering reaction time when assigning tasks, and match work with ability

Ergonomics and wellness programs

Shoulders, backs and wrists are body areas with high musculoskeletal claim severity in older workers. Employers should identify causes of strain and fatigue through an ergonomic evaluation of workstations and workspaces, and apply corrections. Promoting and implementing health and wellness programs at work have a positive and productive outcome as well.

“A company does not need to overhaul their entire structure to suit older workers, but adjusting job tasks and tools to fit the employee are good best practices to follow–no matter the employee’s age.”

Exercise and the Industrial Athlete approach

Employers can either develop on or off site exercise and strengthening programs around the body parts most likely affected (based on injury and illness data) to prepare the employees for changes in their body due to age. This direction, also covered in previous articles such as the Industrial Athlete” approach has proven to be an effective way to minimize future injury. Always approach outside expertise to validate the protocols and exercise plans prior to implementation.

Return to work accommodations

Employers can work to contain medical and indemnity costs associated with a worker’s compensation claims for their older workers through an aggressive return-to-work program. This includes modifying work duties and transitional assignments for the injured older worker. When a worker becomes injured or ill, concerns are raised over loss of income and how and when the person can return to work. With an older worker, these issues can be intensified by worry surrounding the ability to remain productive and employed.

Studies connect the amount of healing time to the age of the worker, so a highly responsive and vigorous return-to-work effort can benefit the employer and increase healing time. Not only are these overall good riskcontrol practices for employers–and an injured employee of any age–but being aware of older workers will benefit companies’ bottom lines as our workforce continues to age over the next 10 to 20 years.

Rehabilitation and return to duties

Just as we have developed work environment changes, we also need to ensure that rehabilitation directives are job specific and if possible include essential or high risk task simulation as part of the Physical Therapy treatment continuum. Secondly we need to have a validated return to duties assessment that accurately reflects the demands of the job thus providing a safe and sustained return to work. You have the choice of your care providers and you need to qualify them such that you are making the best choice for your employee and of course your expedited return to work directive. A simple point of interest is if they do not ask for a copy of your job demands analysis and yet purport to offer job specific care, then how is this possible?

Preventative Maintenance Programs “prevent Injury…maintain worker on the job”

Looking ahead, many employers are now implementing regular on the job strength and range of motion measures for those employees in high risk jobs in an effort to monitor patterns of degradation. If the employee decreases in physical abilities then this is a trigger to introduce them to exercise and even rehabilitation outside of work hours.

In conclusion

All workers are aging, but those that are older continue to grow as a proportion of the population and as the available worker population changes, many employers have jobs for which they want to attract and retain more experienced workers. American workers are living longer than ever before and many are staying in the workforce past age 55. The current economic crisis has placed great pressure on workers’ families and their retirement plans by forcing older workers to postpone retirement and stay longer in the workforce. Both older and younger workers have similar frequency of work-related injury and illness, but the consequences of injury are, on average, more severe for older workers. Older workers more frequently sustain severe injuries than younger workers and require more days away from work to
recover and it is also known that older workers die as a result of workrelated injury at higher rates than younger workers.

Current knowledge about keeping older workers safe and healthy at work is insufficient, yet enough is known to mount campaigns to protect the health and well-being of the current and growing numbers of aging workers. Reports presented at the February 17-18, 2009 Conference on “Healthy Aging for Workers” validated the recommendations of the earlier 2004 National Academies of Science panel report on “Health and Safety Needs of Older Workers” and made recommendations for more research to understand how to prevent work-related injury, illness and fatality among aging workers. It is no mystery that knowledge gaps need to be filled to better understand the physiochemical, biological, biomechanical, and psycho social factors that affect aging workers. Evaluation research is needed to determine the aspects of polices, programs, and intervention techniques and strategies that are effective and those which are not effective in addressing the health and safety of aging workers.

A sustainable workforce

As a whole we need to ensure that those workers who choose to work longer are able to do so in work environments that enhance their work ability, safety, and health. It is our role as employers to understand our challenges and prepare for the future through implementation of strategies now that will positively affect both injury rate and loss time. The old cliché that we are only as good as our employees is an important one to ponder on. Our experienced and talented aging workforce is an important asset to our companies and an integral component to our success. It behooves us to begin to look at ways to care for them today in a way that will secure a healthy and sustainable workforce in the years to come.

The information noted above is a summary of one of the components of Fit2WRK by USPh. This integrated model is available through USPh in close to 400 facilities and 44 states nationaly. For additional information on how the Fit2WRK Model could help your organization, visit; www.Fit2WRK.com or call 1-877-Fit-2WRK.

References:

CDC. Web-based injury statistics query and reporting system (WISQARS) (2002). http://www.cdc.gov/ncipc/wisqars.
U.S. Census Bureau. Resident population projections of the United States by age, sex, race, and Hispanic origin: 1992 to 2050. Available at http://www.census.gov.

Hausdorff JM, Rios DA, Edelberg HK. Gait variability and fall risk in community-living older adults: a 1-year prospective study. Arch Phys Med Rehabil 2001;82:1050–6.

Shekelle P, Maglione M, Chang J, et al. Evidence report and evidence-based recommendations: falls prevention interventions in the Medicare population. Baltimore, Maryland: U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services and RAND, 2003.

Antoine, M. (2007). • Strategic Workforce Planning, Aging Workforce IFMA Utilities Council Meeting, http://www.utilitycouncil.org/uploads/ Aging%20Workforce-Entergy.pdf.

Charness, N. (2000).• “Can Acquired Knowledge Compensate for Age-Related Declines in Cognitive Efficiency?” Psychology and the Aging Revolution: How We Adapt to Longer Life (Editors: Qualls, Sarah Honn and Norman Abeles). Washington, D.C.: American Psychological Association.

Edington, DW. (2001).• Univ. of Michigan Health Management Research Center. Amer. Journal of Health Promotion.

Feinsod R, Davenport, TO. (2006).• “The Aging Workforce: Challenge or Opportunity?” World at Work Journal.

Perrin, T. (2005).• “The Business Case for Workers Age 50+: Planning for Tomorrow’s Talent Needs in Today’s Competitive Environment.” A report for AARP, www.aarp.org/employerresourcecenter.

Toossi, M. (2006).• A New Look at Long-term Labor Force Projections to 2050. Monthly Labor Review, November 2006, page 19-39.

Links:

Agency for Healthcare Research and Quality http://www.ahrq.gov
Centers for Medicare and Medicaid Services http://www.cms.hhs.gov
National Center for Health Statistics http://www.cdc.gov/nchs
National Institute on Aging http://www.nia.nih.gov

It is no mystery that there are significant costs and loss time associated with soft tissue injuries in the workplace. Sprains and strains account for 41 percent of all workplace injuries and illnesses requiring days away from work.* The musculoskeletal disorders or MSD’s as they are called in the Industry, are difficult to assess and ultimately are handled differently by providers across the country. With little standardization and consistency of care delivery, the outcomes are varied from one provider to the next. The solution is the development of an integrated approach that manages and reduces risk throughout the continuum of care.

Every Industry has a job that is simply a difficult one that has historically run an increased rate of injury occurrence. These jobs for the most part have been reviewed from an ergonomic hazard standpoint, but they can-not be easily changed. This leaves the question, how do we be proactive and go about reducing risk of injury in this type of environment? Quality care after injury is certainly important, but are there other areas where we can minimize exposure going forward? These injuries, and these high risk jobs make up for the majority of the premium costs and need to be looked at from all aspects. A general review of past injuries and claim duration will help to direct you to the high risk jobs in question.

“The high risk job is responsible for the majority of cost and concern”

All programs for employee care begin with the details of the job demands. If job demands are not clearly stated, then in the course of evaluation, individuals may be over or under-tested, rehab will be misdirected and there will always be a potential for re-injury upon return to the workforce. The first place to start in the development of an integrated program for reducing risk is to update and/or redo existing job demands, specifically for the high risk jobs. They need to properly reflect essential and high risk duties of the work environment. In accordance with the ADA and EEOC, the Uniform Guidelines on Employee Selection Procedures states that a thorough job analysis is needed for supporting a selection procedure. Remember “garbage in – garbage out” – if the job demands analysis is not concise, then your testing and treatment protocols will not be prop¬erly representative of your employee’s work environment. You can cer¬tainly have a general laborer which represents a multitude of jobs or for that matter a series of jobs on rotation represented by a single JDA, however in both the above cases, you need to include the highest risk and or essential duties for all jobs included. The most essential duty may not always be the highest risk – for instance you may sit all day, but at the end of the day you lift your 30lb files over the shoulder to store them away. The seating task may be your essential duty, but the highest risk component is the lift. Stresses on the joints due to excessive force, repetition, sustained posture or simply “awkward” movements involving twisting or rotating could increase risk of injury.

In the development of an Integrated Model you need to take into account not only how to reduce cost and loss time with existing injured employ-ees, but you also need to look at all individuals who may find their way into working in that high risk job environment. This means looking at new hires, transfers and, of course, the present aging workforce already on the job.

The following illustration depicts the Fit2WRK model of care and it clear¬ly displays the way all the individual services need to work with each other.

“No one service will suffice in the continuum of care, instead you need to be prepared to handle all situations that may arise with both the employees in the high risk job and those coming into it. Further-more, you need to ensure all aspects of testing and treatment are in tune with existing legislation and that your approach is legally and ethically sound.”

One of the most common practices to reduce risk of injury is to review the work environment for areas that may be causing increased strain on the employees. Start with reviewing the type of injuries found in that particular job detail and then begin a thorough review of equipment, tools and processes that may increase risk through perhaps repetition, force, sustained posture or unique tasks such as twists or turns. This is es-sentially the foundation for a more formal ergonomic hazards analysis. If the environment cannot be changed then move on to the next phase of management

New Hires can be effectively managed with the incorporation of a post offer pre-employment screening protocol. If not previously incorporated into your risk management model, then a formal validation study needs to be completed and you need to ensure both ADA and EEOC compli-ance. This evaluation qualifies any pre-existing conditions that may hin-der his/her ability level and also provides a solid baseline of abilities to compare with if a future injury occurs.

Understanding that you most likely already have a relationship with a qualified Occupation Health Group or Urgent care Delivery Model, the Physical Therapy component needs to be seen as a separate entity.

It is well established that combining the two components in the same entity results in increased rehabilitation refer¬rals and subsequently higher costs and loss work time. Once defined as a pro¬vider of choice, the Physical Therapy program for handling your employees’ MSDs needs to be driven by the job demands analysis. Start with functional restoration and then focus on simulated essential work demands as are dictat¬ed by the job demands analysis. This combined work simulation model helps to build endurance for activities consid¬ered to be high risk and subsequently allows for an expedited return to a sus¬tained and safe work environment.

Rehabilitation Baseline Evaluations will display actual injury loss and help to direct treatment while ongoing progress evaluations will display range of motion and strength changes of the employee. This method provides immediate real time data to determine changes in treatment direction or for that matter an assessment of when the employee has reached Maximal Medical Improvement (MMI) or a return to work target (full duties and or transitional/modified duties).

Return to Work and or Fit for Duty evaluations need to be directed to a match with existing full duty requirements or transitional/modified du¬ties as is directed by the employer. The purpose of this evaluation is to ensure a safe and sustained return to duties. There are two very impor-tant considerations in this evaluation; first, it needs to be relational to both the essential job demands and any previously designed post offer pre-employment screen protocol, and secondly, the protocol needs to be medically legally sound and designed in such a way as to not over or under test the employee.

Transitional or Modified Duties can be developed to allow for early re-en-try into the work environment. It is well documented that time on the job provides an expedited return to full function and also that the more time off from the job the less chance the employee will return back.

Job Transfers are a significant risk if an employee is moving from a low risk (low weight, low repetition) job environment to that of a higher risk job. This has become increasingly apparent with employees with senior¬ity wanting extended overtime hours that workers in other departments are getting. Going from a white collar to a blue collar environment is a concern due to de-conditioning and change in function. Of course indi-viduals cannot be fired, but a transfer can be stopped if it poses a risk of injury to themselves or their fellow co-workers.

One of our primary concerns is that of the aging workforce already in-volved in the high risk job. With the existing workforce an evaluation qual¬ified as a “Preventative Maintenance” evaluation can be developed and implemented. It is essentially designed to prevent injury and maintain the worker on the job.
The purpose is to monitor patterns of degradation for both range of motion and strength of the em¬ployee in comparison to themselves versus the job. Example: Meat packer with extensive historical hand/wrist injuries: Test the wrist range of motion and hand/ pinch grip strength every three months to review any significant changes in function.

Strengthening and exercise can be a positive factor either onsite at the place of employment or offsite after hours at a local clinical facility. As we are aware more and more employers are embracing the Industrial Ath¬lete concept and are incorporating programs during and after the work day to assist the employees on high risk lines in keeping Fit for Duty. Like an athlete they are involved in training their body to be able to effectively and safely manage their required tasks.

Education of the employee base in topics ranging from tool handling and lifting to nutrition can assist the employer in keeping the wellness direc¬tive on track. Wellness coaching as part of this model provides increased interest on the employee’s part to participate.

Throughout the entire process it is important to maintain and increase communication with all parties involved. From the Treating Physician to the Occupational Health Team and the Physical Therapist, communica-tion is the key to early re-entry into the workforce and ultimately posi¬tive interaction with the injured employee. The primary goal with any risk management program is to minimize loss work days and to reduce over¬all direct and indirect medical costs. By incorporating a program such as the one above, versus individual services, we ensure all aspects from “Hiring to Retiring” are accounted for in the continuum of care for the employee.

The program noted above is a summary of the Fit2WRK model by USPh. This integrated model is available through USPh in close to 400 facilities and 44 states nationaly. For additional information on how the Fit2WRK Model could help your organization, visit; www.Fit2WRK.com or cal 1¬877-Fit-2WRK

REFERENCES:
1. Lindsay, R., Watson, G., Hickmont, D., Broadfoot, A., & Bruynel, L. (1994). Treat your own strains sprains and bruises. New Zealand: Spi¬nal Publications.
2. Lovering, R.M. (2008). Physical therapy and related interventions. In P.M. Tiidus (Eds.), Skeletal muscle damage and repair (pp. 219-230). United States of America: Human Kinetics.
3. Subotnick, S. (1991). Sports & exercise injuries. California, USA: North Atlantic Books.
4. Flegel, M.J. (2004). Sport first aid: A coach’s guide to preventing and responding to injuries. Hong Kong, Japan: Human Kinetics.
5. Bureau of Labor Statistics: The Injuries, Illnesses, and Fatalities (IIF) program provides annual information on the rate and number of work related injuries, illnesses, and fatal injuries, and how these statistics vary by incident, industry, geography, occupation, and other charac¬teristics. (BLS). Workplace Injuries and Illnesses in 2003. BLS News. Publication No. 04-2486, Dec 14, 2004.
6. BLS. National Census of Fatal Occupational Injuries in 2003. BLS News. Publication No. 04-1830, September 22, 2004.
7. Leigh, J.P., and Robbins, J.A. Occupational disease and workers’ compensation: Coverage, costs, and consequences. Milbank Quar-terly 82(4):689–721, 2004.
8. Steenland, K., et al. Dying for work: The magnitude of US mortality from selected causes of death associated with occupation. American Journal of Industrial Medicine 43(5):461–482, 2003.
9. Liberty Mutual Research Institute for Safety. 2005 Annual Report of Scientific Activities, Research Spotlight, Workplace Safety Index,10. More information available at www.libertymutual.com/research-insti-tute-report2005/html/Research_AR_2005FNL.pdf;Oct31,2006
10. National Institute for Occupational Safety and Health (NIOSH), NORA. More information available at www.cdc.gov/niosh/nora; ac-cessed October 31, 2006.
*BLS. Incidence rates for nonfatal occupational injuries and illnesses in-volving days away from work per 10,000 full-time workers by nature of injury or illness and selected sources of injury or illness, 2001/2005(*)

For more than a century, case management has meant better coordinated care for patients with complicated health needs. Over the past two decades case management transitioned from a narrowly applied function to a ready tool to manage complex cases in workers compensation, behavioral health, insurance and managed care organizations. Today, tens of thousands of case managers are employed in a range of health care settings and in independent practice, and case management is among the job categories projected to grow much faster than the average for all occupations.

Donwload the complete article from CCMC.org

As defined by the Case Management Society of America, the textbook definition of medical case management is:

“Case management is a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality cost-effective outcomes.”

However, because medical case management is almost always an ancillary service, subordinate to the statute/policy driven claim management process, the role of medical case management is often defined by the entity that employs it. Medical case management has generally been regarded as a service utilized to accomplish certain goals in the management of a claim (workers’ compensation, disability, liability, group health, etc.) and represents an added cost to the overall cost of that claim. Some reasons medical case management might typically be employed include:

Serious and/or complicated medical issues that require close coordination

• Uncertain or conflicting diagnoses
• Ambiguous, questionable, or varied treatment plans
• Medical issues and associated disabilities are not resolving timely
• Unfamiliar with providers

Generally speaking, when a claims professional feels that a claim is getting out of control or is approaching a juncture that requires special attention to keep it on course they consider employing a medical case manager. In addition, the value of the case management intervention is usually assessed in context with the specific goals the claims professional had in mind at the time of their referral. Accordingly, medical case management becomes just another tool in the claim professional’s toolbox. In this context, the value of medical case management is highly subjective. In this context, the cost of medical case management may, at times, be difficult to justify.

For the reasons noted above, we often see companies attempt to contain the cost of medical case management services by limiting case management activity to specific tasks or by limiting the scope of the case manager’s involvement in the treatment, rehabilitation, and/or return-to-work process. This cost based approach to utilizing medical case management only sees the service as a costs factor, ignoring or discounting the significant savings effective medical case management can deliver.

To evaluate the real potential value of medical case management services, one only needs to look at the area of workers’ compensation. Over the course of two decades, Gallup, Inc. and then the National Council on Compensation Insurance (NCCI) looked at the cost of treating and resolving work related injuries versus similar non-work related injuries. Both organizations found that work related injuries will have an average cost that is about 70% than the same injury treated through an individual’s group health insurance. The main reason for this phenomenon has been linked to the fact that work related injury claims will be open about 4 times longer than similar non-work related injuries. Because the claims are open that much longer, utilization of medical services more than double. Compounding this apparent overuse of medical services is the fact that, even with a plethora of discounted medical services, supplies, and diagnostics, the cost of medical services experiences an inflation rate at least twice the CPI, often reaching double digit increases.

How does this affect workers’ compensation claim costs? In all but 2 of the last 18 years, claim frequency has decreased. But while fewer workers are experiencing work injuries, the overall cost of work related injuries continues to increase. This can be attributed to the fact that medical costs continue to escalate at nearly double the pace of indemnity compensation for lost work time. If medical costs are the driving force behind the growing cost of claims, doesn’t it make sense that effective medical case management can make a difference in controlling claim costs?

While medical costs seem to be the driving force behind escalating workers’ compensation costs, this does not mean that we should not look at ways to reduce an injured worker’s time away from the workplace. In any given year between 3% and 5% of an employer’s workforce will experience a work injury. According to Department of Labor statistics, 30% of those injured workers will miss at least 2 days of work. When a worker misses work due to a work injury, the employer (or their insurer) must, by law, bear the direct cost of medical treatment, wage replacement, and any settlement costs due to permanent impairment. In addition, OSHA has noted that indirect costs ( lost production, temporary employees, training/retraining, etc) associated with missed work days is approximately 4.5 times the direct costs. When you consider that the average cost of a lost-time work injury is estimated by the Workers Compensation Research Institute to be ~$ 27,000, the real cost of the claim for the employer could easily approach $ 150,000.

In addition to being costly, time away from work can be detrimental to an optimal and timely medical recovery. Valid reasons for an injured worker to not report to work include:

• The worker must attend a medical evaluation or undergo treatment at a provider facility
• Injury is severe enough to require confinement at home or in bed
  • Acute nature of injury requires “bedrest”
  • Work related illness is contagious and would put other workers at risk
  • Injury requires protected environment to prevent contamination or exacerbation of injury/illness
• Work activity of any kind or commute to workplace has the likely potential to aggravate the work injury or lengthen that stage of recovery/rehabilitation

A survey of over 3000 occupational health physicians asked, “How often is disability medically required?” 90% of the physicians surveyed said less than 10% of the work injuries they see would require more than 2 lost work days for purely medical reasons. The fact is, most lost work days arecaused by discretionary or unnecessary factors such as:

• The employer’s perception is that the injured worker could possibly do something useful but…
  • “There’s no way to get the injured worker to/from the workplace”
  • “There is nothing the injured worker can do to make any substantial contribution”
  • “The support required to allow the injured worker to return to work is more than makes good fiscal sense”
  • “There are no jobs the injured worker can do that are within their medical restrictions
  • “Existing company policy and/or labor contract prohibits returning injured worker to light duty”
• Non-medical psych-social issues affecting the injured worker’s recovery are not addressed because they have not been identified and may be masquerading as additional medical issues.
• For whatever reason, medical treatment has been inadequate or inappropriately delayed
• Time lost from work attributed to medical issues but is really due to:
  • Poor communications/information flow
  • Lack of cooperation of any stakeholder due to the decision maker’s lack of understanding of dynamics of the injury/treatment/return-to-work process
  • Bureaucratic issues creating administrative/procedural delays
  • Disjointed management structure, leading to poor accountability and shifting of responsibilities on important decisions

Effective medical case management can proactively address and diminish the discretionary and unnecessary factors that hinder an injured worker’s attempts to have a successful return-to-work.

As you can see, in workers compensation, costs associated with both medical treatment/rehabilitation and lost work days can be optimized by attacking the barriers that delay progress in the treatment, rehabilitation, and return-to-work processes.

The medical case manager is uniquely positioned to evaluate, coordinate, and facilitate the injured worker’s progress in this endeavor. Injury management in any scenario is time sensitive. Delays and/or diversions in the diagnosis, treatment, and recovery process can result in less than optimal outcomes and increased costs. Injury management in the world of workers’ compensation is time critical!

This world is prone to delays and diversions in the diagnosis, treatment, and recovery process. Without proper intervention, work injuries are likely to result in less than optimal medical and vocational outcomes and costs that almost double the cost of treatment for similar non-work related injuries. Medical case management, when properly implemented, will generate results and associated savings that more than offset the cost of the case management services.

Medical case management is most effective when it is allowed to develop and implement a comprehensive case management plan that considers all aspects and all stakeholders in the treatment, rehabilitation, and return-to-work process.

An effective medical case management program should have goals that include:

• Assuring an accurate and thorough diagnosis of injury
• Coordination of the total span of an injured worker’s medical treatment
• Assuring a timely compliance with all medical treatment to facilitate an optimal functional outcome
• Avoiding unnecessary/unproven medical care
• Assuring appropriate utilization of resources (concurrent utilization review)
• Attaining medical stability/maximum medical improvement (MMI)
• Facilitating an early return-to-work (RTW)
• Avoiding complications and/or re-injury
• Achieving a reduction in the overall cost of the claim

These goals will be accomplished when the medical case manager focuses on:

• Educating the disabled worker about their injury and the rehabilitation/RTW process
• Guiding the disabled worker to the most appropriate provider for their injury
• Educating the employer about their disabled worker’s injury and the rehabilitation/RTW process that lies before them
• Educating the provider(s) about the functional demands of the disabled worker’s pre-injury job and any transitional work activities available, facilitating the earliest possible safe RTW
• Motivating the disabled worker in their compliance and completion of the rehabilitation/RTW process
• Keeping everyone involved in the disabled worker’s rehabilitation/RTW process fully informed at all times regarding progress, developments, and setbacks

To accomplish these important components of the medical case management process, it is vital that there is accountability. The company employing the medical case manager should have some way to evaluate case management outcomes and value, but should not be responsible for managing the way the case manager performs the various aspects of their job. The key to consistently realizing effective case management results is to employ a medical case management company that employs best practices, quality assurance, and ongoing supervision and coaching on the files assigned to their case management team.

Effective medical case management will transform routine case management activity from a task oriented service that adds cost to a claim toward a process integral to the successful, cost effective resolution of the claim. Effective medical case management is truly an investment that will generate a real return in the form of better medical and vocational outcomes, avoidance of unnecessary utilization of services, and overall lower claim costs.

Effective medical case management will motivate the injured worker to take full advantage of their medical treatment and rehabilitation programs. This will generally result in better functional outcomes, less lost work days, reduced pain and suffering, and a faster return to “life as normal.”

Effective medical case management will assist the employer in finding meaningful transitional work opportunities for the injured worker. This will mitigate production deficits experienced when a worker is not able to return to their normal job duties. Meaningful transitional work will be therapeutic, therefore, hastening the recovery process and diminishing the time the injured worker will be away from their normal job duties.

Effective medical case management will drive the medical treatment process forward at a pace appropriate to the recovery process. Providers will be reassured that the injured worker is receiving appropriate supervision and follow-up in their attempts to achieve rehabilitation goals and early reentry into the workplace.

Effective medical case management will assist the claims professional in closing files more quickly. By facilitating expeditious progress through the medical system, better functional outcomes, and safe/early returns to work, costs associated with medical treatment, lost workdays, and impairment permanency settlement will all see significant reductions.

The simple question – “What is case management?” – does not seem so simple when we examine how it is typically utilized versus all the potential benefits an effective case management program can deliver. Understanding what the medical case management process can really accomplish provides a better understanding of ways to really lower claim costs while optimizing service to the employer and the injured worker. With all this in mind, I would say we need to define “effective” case management, and I would offer that definition as follows:

“Effective medical case management is a results oriented, collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s medical andvocational needs through effective communication and coordination of available resources to promoteoptimal, cost-effective outcomes.”

About the Author

Vernon Poland is co-owner and General Partner of PDM, a full service medical case management company providing case management services throughout the Midwest. Vernon has worked in disability management industry for 15 years, developing and implementing programs and services to minimize lost work days while facilitating optimal medical and vocational outcomes. Prior to joining PDM, Vernon worked as a consulting engineer in the chemical industry for 17 years, working in varied industrial environments while consulting with clients on chemical applications and associated safe work practices.

On Tuesday March 9th, I took a road trip to Washington and attended the OSHA Public Meeting to review the Proposed Rules changes put forth in the Federal Register Vol. 75, No. 19.

Brief Summary of Information in the Register:  In the opening paragraph of the document, the rule change is summarized as follows: “OSHA is proposing to…restore a column to the OSHA 300 log…to record work-related musculoskeletal disorders (MSD) ie an MSD column.” On page 8 of the Register, OSHA goes on to state their intention to “remove language from the Record Keeping Compliance Directive that says…”minor musculoskeletal discomfort” is not recordable under § 1904.7(b)(4)   as a restricted work case if a health care professional determines that the employee is fully able to perform all of his or her routine job functions, and the employer assigns a work restriction for the purpose of preventing a more serious injury.’ (restriction language)

Meeting Attendees: For the most part, the meeting was attended by Union Leaders (AFL-CIO, Unite Here, ORC Worldwide, UFCW, Communications Workers, etc) and Attorneys. To present at the meeting, attendees were required to submit in advance, a brief on their presentation for review and acceptance. All speakers were affiliated with a Union or sub-section of workers (Construction Trades Department, Nat. Federation of Independent Businesses) with exception of the last speaker, L. Halprin, Attorney.

My goal in attending: I wanted to hear first hand why OSHA felt it appropriate and imperative to remove the interpretive language that allowed for restrictions to be placed by the employer in an effort to avoid aggravation of minor discomfort.

What I heard: All speakers affiliated with a Union or Trade group pledged full support to the addition of the MSD column. In general they felt this was necessary to hold employers to higher standards for injury prevention. I heard more than once the phrase “if you don’t count the injuries they will not be prevented”. Further most echoed that MSD’s are the result of bad ergonomics….thus should be the leading indicators of a process that needs to change. Overall, the Unions had NO feedback and offered no resistance to the elimination of the “restrictions language.”

However, ORC Worldwide, while supporting the MSD column, did not support the elimination of the “restrictions language”. They pushed very strong on the importance of giving employers a method for handling minor discomfort and protecting workers from aggravation of symptoms. OSHA’s reply to this was that if the complaint is minor, it is not a recordable case, thus the employer can do “whatever” they like with changing work tasks.

The last scheduled speaker, L. Halprin, through representation of the Nat. Assoc. of Manufacturers, was the lead attorney on the case brought in front of OSHA in 2001 that lead to the inclusion of the interpretive language ALLOWING restrictions for minor musculoskeletal discomfort. He strongly argued that not only should OSHA not eliminate this language, they CAN NOT eliminate the language by simply rolling it into another rule change. This comment drew a lengthy debate as to what was proper and necessary steps for rule changing. He went on to state that while the language is a simple interpretation not a Rule, because cases have been managed by the interpretation for the past 9 years – it in effect IS a Rule

Mr. Halprin, having spoke with me earlier in the day about how we handled minor complaints of discomfort, then referred to me and our programs. He stated that there was a “lady in the audience” that had successful programs that would be significantly limited if this language disappeared.

Mr. Halprin, as well as the representative from the Independent Businesses made a strong pitch that adding the MSD column would add significant burden to record keepers, result in greater confusion on the logs and subsequent under reporting. In addition, they argued that this addition was not necessary in that the cases are already being reported under the “general” column.

OSHA’s Comments: Throughout the day, OSHA commented to several speakers that their goal was to get a better picture of just how serious the MSD injuries were in the workplace. In addition, they are pushing for all employers to have a system for electronic reporting and have plans to rollout an OSHA Electronic Reporting System – this received mixed response from the speakers.

In addition, OSHA indicated on numerous occasions that it was their opinion that employers through interviewing employees would not be able to differentiate between minor discomfort, discomfort and pain; alluding to the fact that regardless of degree of the complaint, they should be recorded. [ K. Harned of Indep. Business responded to this by stating with an aging workforce, discomfort is a common occurrence and it would be (ridiculous) to record these complaints]

OSHA then opened the floor to any other attendees that would like the opportunity to speak.

My Presentation:  I introduced that our organization had been working with a wide array of companies in the design and implementation of injury intervention programs. I emphasized that the success of our programs hinged on 3 points:

1.       Early reporting of Minor discomfort is essential:   We discussed how we distinguish between severity of symptoms and they requested copies of some of the language that we use in working with employees.

2.       Intervention through First Aid: I gave a brief overview of how we intervened using First Aid guidelines. I then made an appeal that they relook at including Exercise under First Aid. This thoroughly confused the OSHA panel as they did not remember excluding it. I presented them with the ‘self administered physical therapy language and they “promised” to review it.

3.       Application of limitations (restrictions) to protect employees: I gave general examples (no mention of any employer names) on how this worked. They were intrigued and ask a number of questions.

I ended my time with a plea to reconsider the removal of this “restriction language” and to reconsider including Exercise under First Aid.

Summary: In talking with most of the meeting attendees, it is the consensus belief that the MSD column will be added, but the “restriction language” will not be removed.

Per their request, I will be writing a summary paper for OSHA on information presented during my address. OSHA further encourages any of our clients to also submit their comments on the proposed rule changes. These comments must be received by OSHA by March 31.

I am happy to talk with anyone having questions regarding the above information.

Sheila Denman, MA, MS, PT
Chief Operating Officer
Advanced Worksite Solutions
sdenman@advancedpt.com

The short unequivocal answer is NO.

Surveillance is a Legal/Claims action that directly impacts the compensability of the file. While Case Managers face medico legal and ethical issues they do not have a role in claims.

Case Management has many benefits to your case but most importantly as the claimant’s advocate. That person who is neutral at all times. The person you can rely on for unbiased communication with all parties for the sole purpose and goal of assisting the claimant to return to the pre-injury state of the injured worker. The Case Manager is always assessing, planning, implementing, evaluating and communicating all pertinent information to the worker’s compensation team. By doing this, the Case Manager ensures the case progresses toward resolution of the medical injury in the most effective and timely manner.

The CMSA Standards of Practice dictate the Case Manager’s central focus is on the claimant. Ideally, the Case Manager should advocate both for the claimant and for the payer to facilitate positive outcomes. However, when a conflict arises, the needs of the claimant must be the priority.  The Case Manager will advocate for the claimant at the service-delivery level.  The Case Manager has to establish an effective and respectful relationship with the claimant, payer, physician, other health care providers and other relevant parties.

Case Managers are able to and should provide information to the adjuster as requested regarding the case. This can include the known schedule of appointments and work as well as a physical description of the claimant. This falls in the realm of communication. The Case Manager provides identification of issues affecting the claimant’s progress through the medical process toward recovery. This will include inconsistencies in behavior and barriers to recovery.

Case Managers can, under no circumstances, take part in claims activities. This includes surveillance. It also includes knowledge of, handling, viewing, offering opinions on surveillance. To do this puts the Case Manager in the adjuster/claims role and is outside the Case Manager’s scope of practice.

Does that mean that the Case Manager is not “key” in identifying inconsistencies? NO. Working as the advocate of the claimant, the Case Manager does and should identify inconsistencies in behavior. Is the claimant limping after the appointment but not on the way back to the exam room? A claimant with a back strain who brags about the engine he is working on in his spare time. Does the claimant have dirty fingernails, post-surgery, for a hand injury? These are issues of compliance and affect the progress of the medical care and are directly related to our role to assist the claimant progress through the medical maze toward the goal of successful return to the pre-injury state that includes RTW.

In order to be effective in the case, the Case Manager has to maintain the claimant advocate role. If surveillance is necessary in the course of the claim, that surveillance MUST be initiated, carried out and communicated to the physician outside the presence/knowledge of the Case Manager.

Samantha Garrison, RN, BSN, CCM
GENEX Services, Inc.
Assistant Branch Manager/Case Management Supervisor