Exploring the Boundaries of Return to Work and Disability Management

Practice by

Looking Beyond Medical Diagnosis

Piotr S. BaranowskiPiotr S. Baranowski M.Rehab., M.Psych., CCRCM.Rehab., M.Psych., CCRC

ReSolutions ConsultingReSolutions Consulting Forward thinking at work!Forward thinking at work!

Halifax, Nova Scotia, CanadaHalifax, Nova Scotia, Canada

Contents

1. A Story of an Absence (from Work)

2. Objective Medical Evidence

3. Disability vs. Impairment

4. Beyond Medical Diagnosis

5. Discussion

Traditional/Diagnostic

Looking for only medical reasons Trigger: a life event Action: visit a doctor to ask for help Method: search for medical reasons Outcome: discovering medical answers (professional bias)

Roles and Attitudes Employee: efforts to prove disability Employer: efforts to disprove disability Doctor: patient advocate Insurer/Employer: sponsor of the disagreement

Parties’ needs are not met gradual decrease in cooperative behaviour

Mutual Losses Employer attempts to control the perceived abuse Erosion/Loss of Relationship Employee – symptoms magnification & extension of absence Increased cost

Systemic issues

On average a MD visit is less than 8 minutes.

Symptoms history, physical examination, diagnosis, order lab tests, write prescriptions & treatment, arrange referrals or follow up and perhaps discuss secondary health issues (smoking cessation, stress, family, etc.)

When is CM/DM or RTW supposed to be discussed?

Patient Bias

“(…) doctors do not care about the employer or insurer – their only customer is their patient.”

OMA Committee on Medical Care and Practice O.M.A. November 1994

Patient Bias

“(…) Most physicians rely on their patients for information about the conditions in the workplace and on his or her ability to do the original job.”

“(…) Ultimately, the patient makes the decision that they are too ill to work and then asks their physician to agree.”

OMA Committee on Medical Care and Practice O.M.A. November 1994

System - Patient Bias

Medical support for a partially disabled employee during a prolonged absence from work is often driven by policies which require disabled workers to claim total disability in order to maintain their income benefits.

Some recovering patients, willing and able to do modified work, find their employer unable to provide it, and their disability insurer unwilling to continue partial benefits for limited impairments.

Family physicians often feel they must certify their patients as totally disabled to prevent loss of disability benefits

OMA Committee on Medical Care and Practice O.M.A. November 1994

Impairment vs. Disability

Impairment: an injury, illness, or congenital condition that causes or is likely to cause a loss or difference of physiological or psychological function.

Disability: the loss or limitation of opportunities to take part in society on an equal level with

others due to social and environmental barriers.

“Disabilities Studies Manual” - Leeds University, Leeds, UKThe Equality Unit - Sheffield City Council, Sheffield, UK

Disability

Disability may be defined as an alteration of an individual’s capacity to meet personal, social or occupational demands, or statutory or regulatory requirements, because of impairment. A disability arises out of the interaction between impairment and external requirements, especially those of a person’s occupation.

Disability may be thought of as the gap between what a person can do and what the person needs or wants to do.

American Medical AssociationGuides to the Evaluation of Permanent Impairment, p.2

Disability vs. Impairment

Impairment is a medical term usually defined by a set of relatively objective and measureable parameters (e.g. diagnostic tests) determining the extent of pathological changes.

Disability: is a legal and social term defined by social/cultural context, contractual definitions, personality/attitude, economic conditions, etc.

Loss of Hearing – Ability to Communicate

Disability vs. Impairment

Physicians are educated to determine impairment not necessarily disability

Position Statement on Early return to work After Illness or Injury – Alberta Medical Association, February 1994

Position in Support of Timely Return to Work program and the Role of the Primary Care Physician – Ontario Medical Association, March 1994

The Attending Physician’s Role in Helping Patients Return to Work After and Illness or Injury – American College of Occ. & Env. Medicine, April 2002

In the clinical model the treatment is matched to a diagnosis, which is derived from a specific pathology.

Appendicitis, diabetes, a bone fracture, etc.

We can usually agree on the cause, the medical findings, the recommended treatment and the recovery timeline.

Medical

Stress?

Depression?

Mental Illness?

Multiple diagnoses?

Medical

Medical

Beyond Diagnosis

Beliefs

Fears

Distress

Economic

Personality

Coping

Vocational Issues

ChoiceChoiceMedical Issues

Personal Issues

Beyond Diagnosis

1. Medical issues legitimate functional impairments

2. Vocational issues relationships at work job satisfaction, job performance, perspectives burnout, disengagement

3. Personal issues personality (catastrophising) relationships with self & with others secondary gains

Medical

Medical Status Evaluation (MSE)Identifies diagnosis, current status, medication, clears individual to participate in activities: FCE, Tx or RTW

Independent Medical Evaluation (IME)Answers specific questions re: impairment, treatment, medication

Functional Capacity Evaluation (FCE)Identifies functional abilities, gains some insight to person’s beliefs

File ReviewOffers chronological perspective on documented medical history, helps to draw conclusions and plans

Psychological EvaluationGain in-depth inside to personal beliefs, motivation, coping strategies, support systems, family dynamics

Medical to Functional

Job demands:

irregular work hours may need to work O/T must be able to drive

shortand long distances

fast paced environment ability to make quick

decisions direct dealings with

public safety sensitive position

Functional Abilities/limitations:

regular medication regime & balanced diet

difficulty with night vision symptoms aggravated by

stress side-effects of medication

may temporarily affect judgment

performance may vary significantly during the day

VocationalJob demands:

JDA Category: Degree of self-Supervision required

JDA Definition:The extent of self-supervision required

in the course of duties.

JDA Ranking Scale: No self-supervision required

(fully supervised) Occasional self-supervision

required (supervisor frequently provides work direction)

Frequent self-supervision required (supervisor occasionally provides work direction)

Predominantly self-supervised throughout the shift (may contact supervisor to obtain work direction as needed)

Functional Abilities/limitations:

FAE equivalent: Ability to self-supervise

FAE Definition: The ability to work effectively

without supervision.

FAE Ranking scale: Cannot self-supervise,

requires constant work supervision

Requires frequent supervision

Can tolerate infrequent supervision

Able to carry out work tasks in a self-supervised manner

Work Environment

Positive relationship with the supervisor and work environment is considered one of the primary determinants of work success.

Interpersonal aspect of supervision and communication with co-workers are considered as equally important for the successful outcome, as the physical job accommodation.

Practice

Job Accommodation means changing the way job expectations are met.

Empathy and Compassion are good healing strategies and introduction to a relationship yet not always sufficient for building a long term business relationship. Equality and Productivity form a much stronger foundation for sustainable employment.

Beyond Diagnosis - Personal

“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”

Hippocrates

Beyond Diagnosis - Personal

Patients’ beliefs about their pain and ability to work warrant as much attention as the anatomical and pathological aspects of their condition.

V. Wilk, MD

Beyond Diagnosis - Personal

“People experience what they expect to experience”

“If you can only do 1 thing in a return to work support program, sit down with the person and explain to them what to expect health- and symptom-wise during their disability event, then what is and what is not indicative of a health risk (…)”.

Dr. Presley Reed

Perception of disability within two days of injury predicts likelihood of time loss

%

In

juri

es w

ith

tim

e loss

Disability score at time of Injury

Tate et al., Spine 1999

Beyond Diagnosis - Personal

Beyond Diagnosis - Personal

1. Catastrophising is considered the primary driver of health-related absence from work

2. Approx. 40% of EU federal funding is now directed to early psychological services to decrease the negative influence of catastrophising on RTW success

Int’l Forum on Disability Mgt, Berlin 2008

Personal - Relationships

Relationship with self and the Universe:

Questions in the “first half” of life: What does the universe expect of me? How can I get there?

Questions in the “second half” of life: What do I expect of myself? What is the meaning of my existence? How can retain this feeling and this connection?

Personal – Secondary Gains

Secondary gains: Justifiable:

caring for sick child caring for ill elder an addiction

Non-Justifiable: avoiding dealing with performance concerns magnifying loss for a benefit (MVA, WCB) holding another job simultaneously

Piotr S. Baranowski - ReSolutions Consulting – 2011 ROSE Conference

Guiding Principles

1. Medical/Treatment component address functional limitations (Tx, OT)

2. Vocational component addressing work environment issues

3. Personal component offering assistance in managing personal

matters

Expected plan outcomes:1. reduced anxiety

MD

VR

Psych

CM

(…)

Client

MVP

Guiding Behaviour

Strategies: Medical issues ----- give control Vocational issues ----- take control Personal issues ----- give support

Outcomes: Clearer options for employee &employer More informed choices Greater individual responsibility for results

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Piotr S. Baranowski M.Rehab., M.Psych., CCRCPiotr S. Baranowski M.Rehab., M.Psych., CCRC

ReSolutions ConsultingReSolutions ConsultingDisability Management Programs & Services Disability Management Programs & Services

Halifax, Nova Scotia, CanadaHalifax, Nova Scotia, Canada(902) 476-2131 rehabsol@telus.net(902) 476-2131 rehabsol@telus.net

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