Maximising Capacity: A Functional Approach to Injury Management Presented by: Marcella Romero MHlth...

Maximising Capacity: A Functional Approach to Injury Management

Presented by: Marcella Romero MHlth Sc (OT) B.App.Sc (OT) Grad. Cert (Occ Rehab)

Managing Director – Rehab Management [Aust] Pty Ltd

October 2014

SESSION OUTLINE

Introduction

Medical model to a whole person model: paradigm shift

Evidenced-based approach

Using a functional approach and best practice framework to maximise capacity

Case Study: How do we integrate this functional approach into effective case management?

Stakeholder collaboration

Summary / questions

Introduction

International & National Recognition

To improve health outcomes when managing injured persons; we need to adopt a biopsychosocial / ‘whole person’ approach.

The whole person approach is accepted and supported by:World Health Organisation (WHO)Heads of Workers Compensation Authorities (HWCA) and Heads of Compulsory Third Party (HCTP).TIO and NT WorkSafe Federal government agencies including Comcare and DVAInsurers within the life insurance framework

Medical Model to Whole Person Model: Paradigm Shift

Traditional Medical Model

The Biopsychosocial Model“Whole Person”

Individual-centred model considers the whole person, their health problem and their social context:Biological—refers to the physical or mental health condition.Psychological—recognises that personal/psychological factors also influence functioning. Social—recognises the importance of the social context, pressures and constraints on functioning.

Evidence Based ApproachWhat Does the Research Say?

Research-Based ComparisonMedical Model Biopsychosocial (‘whole person’) Model

Too simplistic

Promotes concept that day-to-day functioning and disability is dependent on both personal/psychological and social/occupational factors.

Over emphasises impairment

Preventing incapacity requires framework that addresses all the physical, psychological and social factors

Fails to take sufficient account of the personal and social dimensions of disability.

Fundamental in achieving better outcomes from clinical and occupational rehabilitation management

Focused on illness and fails to promote overall health and wellbeing

Considers the whole person – physical, social, psychosocial and emotional needs of the worker, underpins effective injury management.

Encourages reliance on health care professionals

Effective in improving function, facilitating recovery and maximising independence

Industry Research: Realising the Health Benefits of Work

It’s therapeutic Promotes recovery and rehabilitation Better health outcomes Minimises the harmful physical, mental and social effects Reduces the risk of long-term incapacity Promotes full participation in society, independence and human

rights Reduces poverty

Did You Know?

The longer someone is off work, the less likely they become ever to return.

If the person is off work for:20 days the chance of ever getting back to work is 70%45 days the chance of ever getting back to work is 50%; and70 days the chance of ever getting back to work is 35%.*

*2011 The Royal Australasian College of Physicians, Australian & New Zealand Consensus Statement on the Health Benefits of Work: Position Statement: Realising the Health Benefits of Work

Using a Functional Approach & Best Practice Framework to Maximise

Capacity

Functional Evidence-based Framework

Principles:1.Measure and demonstrate the effectiveness of treatment

2.Adopt a biopsychosocial approach

3.Empower the injured person to manage their injury

4.Goal setting to maximise function, participation and RTW

5.Evidence-based intervention / treatment

Principle 1:Measure and demonstrate the effectiveness of

treatment

Why measure?Information on health statusTrack and monitor progress or any changes in statusContinue, change or cease treatment, Target treatment and improve treatment outcomes.

Principle 1: Measure and demonstrate the effectiveness of treatment

What to Measure?

Outcome measures must be related to the functional goals of therapy and relevant to the person’s injury.

Customised Outcomes - Practical Examples:A change in work status (RTW program)A change in participation at home (ADL functional upgrading program)

Principle: 2Adopting a biopsychosocial approach

Factors affecting function and participation at home, work and in the community.

Early identification and management of risk factors helps to address issues that can impact on an optimal outcome.

Identifying risk factors using the Flags Model

Early identification of risk factors (biological, psychological and social domains) - important during the assessment phase as it informs and guides treatment.

Principle: 2Adopting a Biopsychosocial approach

The Flags Model *

* Based on Main, CJ, Sullivan, MJL and Watson, PJ 2008, Pain Management: practical applications of the biopsychosocial perspective in clinical and occupational settings, Churchill Livingstone, Edinburgh, New York.

Principle 3: Empower the injured person to manage their injury

Empowering the injured person to manage their injury is key:EducationSetting expectationsSelf-managementPromoting independenceHealthcare professionals


Education and Setting Expectations

Injured person is empowered when they:Set expectationsKnow respective roles Know nature of their injury, expected recovery timeframes and prognosisActively participate in activities at home, work and the communityKnow risks of prolonged inactivityKnow risks and benefits of the treatment proposedHave collaborative treatment goals Learn to manage their condition as independently as possible


Influencing Beliefs:Fear avoidanceCatastrophysingLack of acceptanceBlaming others

Practical Strategies: Education and motivational interviewing


Active strategies that support self-management and independence:Collaborative goal settingActivity schedulingPacing strategiesFunctional upgrading programsExercise program

Principle 4: Functional goal setting to maximise function, participation and RTW

Setting GoalsFunctional and SMARTRegularly assessed

SpecificMeasurableAchievableRelevantTimed

Current Evidence – where the injured person has a role in selecting treatment, better health outcomes are achieved.

Principle 4: Functional goal setting to maximise function, participation and RTW

Poor Goals To return to work

To improve driving confidence

To improve activities of daily living

To reduce depression

Good Goals To return to work in two days on

modified duties To be able to drive between home

and work within three weeks. Independently manage preparing

breakfast three mornings per week within four months.

To be able to concentrate on reading for 30 minutes four days per week within one month.

Principle 5: Evidence-based intervention / treatment

Research evidence to inform decision making Referencing MD guidelines in relation to expected recovery and

treatment timeframes Systematic reviews Trials Evidence-based treatments

Case Study:

How do we integrate this functional

approach into effective case management?

Case Study: A Functional Approach

Case Profile

John – 41 year old landcare worker Cervical disc injury Referred for physiotherapy Graded RTW attempted but reports pain

when attempting to upgrade closer to PIDs

Employer unable to provide modified duties on a permanent basis

Social: an active touch football coach


Case Information

Case referral date February 2014

Case closure date July 2014

Case duration Five Months

Rehab goal Different job, different employer

RTW Pre-injury option? No – employer unable to provide duties on a permanent basis.


Barriers Identified for John

Employer is not able to provide him with suitable duties in the long term.

Has not been compliant with his exercises, and his progress with recovery has been slow.Work experience has mainly involved manual labour and this may not be possible for him in the future.Worked in the same type of role for most of his adult life and considers this to be part of his identity.Believes that he needs to be ‘100%’ before he can return to any type of work.


Principle 1: Measure and demonstrate the effectiveness of interventions

Evidence of capacity:Program Start

Evidence of capacity:Program finished

Work Not demonstrated (not at work) Commenced in new job with a new

employer as a traffic controller, working full hours.

Home Limited housework, no gardening Able to mow lawn on fortnightly basis and complete all home maintenance tasks independently.

Community Limited social activity Has re-commenced coaching role with touch football team.


Principle 2: Adopt a biopsychosocial approach

Interventions designed to consider the individual, injury & circumstances

Use of screening tools: e.g. DASS, OMPQ, VAS

Use of targeted questions for assessment


Principle 2: Adopt a biopsychosocial approach (Cont.)Flag Type Findings

Red Flags – Medical Nil currently identifiedYellow Flags – Psychosocial

Beliefs about pain and injury (that there is a need for passive physical treatments rather than active self-management).

Psychological distress (bereavement of inability to perform previous role).

Distress that his employer has not been able to provide alternative duties.

Blue Flags – Social/Features of Work

John’s work involves manual handling tasks which he reports will cause him intense pain.

John is distressed that due to his physical restrictions, he is currently unable to meet his commitments as a volunteer coach for a local touch football team.

Black Flags – Other Factors

John’s employer has withdrawn alternate duties. John is concerned about coverage to mortgage payments if he

cannot locate another full time position in a timely manner.



Teaching independence

Use of positive encouragement to develop self-efficacy

Collaborative goal setting

Activity scheduling

Pacing strategies

Functional upgrading program


Technique (Motivational Interviewing)

Question

Ask Evocative Questions Why would you want to make this change?

Ask for Elaboration How do you see this happening?

Ask for Examples Have you ever had to overcome something like this before?

Query Extremes What would be the worst outcome if you don’t make this change?What would be the best outcome if you do make this change?



Principle 4: Goal setting to maximise function, participation and RTW

Example GoalsTo be able to lift ten kilograms from waist to shoulder height for five repetitions whilst maintaining pain level at no higher than 3/10.To be able to return to all coaching duties with touch football team by [date]. To be able to move the lawn on a fortnightly basis by [date].


Principle 5: Evidence-based intervention / treatment

Injury Example Recommendation

Findings Consultant Action

Cervical Displacement

Strengthening / Stabilisation Home Exercise Program

Doctor had referred John for home exercise program but John had missed multiple appointments. Physiotherapist indicated John had not been completing agreed exercises.

Confirmed already receiving appropriate treatment: issue identified is compliance.Referenced MD guidelines. Provision of education to John clarifying expectations around recovery and treatment.


Outcome Domain Success Achieved? Comment

Work John commenced in a new job as a traffic controller, working full hours.

Home John is now able to mow his lawn on a fortnightly basis as well as being able to complete all home maintenance tasks independently.

Community John has successfully recommended his role as a volunteer coach with a local touch football team.

Claims Cost Reduction As John returned to full-time work, his wage

component was reduced to $0 therefore, reducing total claim liability

Stakeholder Collaboration

Stakeholder Collaboration

Collaborative Approach by:Treatment providersClaims managers Rehabilitation providers

Shared Goals:Early intervention and tailored programsUse of a functional approach to case management Work on the premise that ‘work is good for you’Return to pre-injury / pre-accident activities (including work) Active engagement of injured person and working towards a common goal Progress review and management of risk factorsEvidence-based decisions.

THANK YOU

NT Contact

Julie Moore

Regional Manager – Northern Territory0429 936 514 | 1300 762 989 [email protected]

Office Location Unit 2/4 Berrimah Road, Berrimah NT 0828

Rehab Management [Aust] Pty Ltd

www.rehabmanagement.com.au

Ph: 1300 762 989

[email protected]

Maximising Capacity: A Functional Approach to Injury Management Presented by: Marcella Romero MHlth...

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