Vocational Medical Assessments Best practice, what does it look

like?

Written by:

Dr Rob Griffiths MB ChB (Hons), FFOM, FACOEM,

FAFOEM, FAFPHM, FFOMI, FACAsM, MPP, DipAvMed, DIH

Senior Medical Adviser Accident Compensation Corporation

Gillian Anderson

Category Manager, Accident Compensation Corporation

1 – Background

The Value of Vocational Medical Services to ACC

The services are:

• integral to a sustainable return to work outcome for the client and ACC

• supported by robust clinical advice that informs good decision making

ACC primarily purchases medical assessments to:

• determine treatment and rehabilitation interventions

• determine a client’s eligibility for cover and entitlements

• assess a client’s functional capacity to undertake work (vocational independence)

3 Copyright (c) ACC

The Service Philosophy of Vocational Medical Services

• Vocational Medical Services are designed to support our client’s

vocational rehabilitation through:

Providing ongoing support and advice throughout the client’s

rehabilitation

Being flexible

Being responsive

Encourage teamwork

Promote openness and transparency

4

Copyright (c) ACC

Assessments within Vocational Medical Services

• Initial Medical Assessment (IMA)

• Vocational Independent Medical Assessment (VIMA)

• Vocational Medical Review (VMR)

5

Copyright (c) ACC Author/Unit

Key features of the Vocational Medical Services

are:

• encouraging integration

• enabling conversations

• helping to problem solve

• providing clinical leadership

Liaison services and medical review

Vocational Medical Services – key service elements

Copyright (c) ACC

6

Client

Provide expert guidance and reassurance on

return to work practices

Improve the likelihood that the client will retain

their job

Encourage participation in 'Better at Work'

culture

GP

Provide expert guidance on safe return to work

practices

Provide confidence in a safe recovery process for

their patient

Assist with the management of their

patient

ACC

Provide expert rehabilitation for ACC

clients

Advance the client’s rehabilitation in the workplace, where

appropriate

Improve rehabilitation rates for clients

VRS Provider

Provide expert guidance on safe return to work

practices

Ensure timely completion of Vocational

Rehabilitation Service programmes

Employer

Improve staff retention and productivity

Provide expert guidance on safe

return to work practices

Encourage 'Better at Work' culture

3 – Best Practice clinical skills

Written by:

Dr Rob Griffiths

MB ChB (Hons), FFOM,

FACOEM, FAFOEM,

FAFPHM,

FFOMI, FACAsM, MPP,

DipAvMed, DIH

Senior Medical Adviser

Accident Compensation

Corporation

Promoting Independence

“Work is good for you”

Harms of not working/participating

50% of long-term dependents are fit to work

“Trajectory of disability”

50% of disability is unrelated to injury; importance of motivation and RTW

“obstacles

The role of pain in disability

Leadership Roles

Clinical

Client-centred

Personal responsibility/autonomy

Confidentiality

Comprehensiveness of information

Maximum Medical Recovery?

Bio-Psychosocial Approach

Process considerations

Consistent use of terminology/measurement

Complex VIMA: History

Age 13

Missed +++ school

Unexplained serious illness

Multiple tests inconclusive

Poor adolescent school performance

Age 19 diagnosed with “chronic colitis”

Age 21 “gravely ill” but video footage swimming on beach days later

Age 21 onset Chronic Lower Back Pain & back brace use

Age 24 fails job pre-placement examination

Several months later passes same examination

Fellow employees note good health while at work

Age 26 permanently unfit for same job

Age 27 failed lumbar disc surgery –

high dose narcotics

Age 29 Endocrinological Diagnosis and Treatment

Age 30 high rate of work absenteeism

Age 34 “unceasing” low back pain trigger point injections for lumbar spasm

Age 37 lumbar fusion; Failed back surgery and depression GP notes “0 degrees flexion or

extension”

Age 42 “exhaustion & trembling at work” Reluctant to work, Asleep during meeting Concerns re performance at work

Age 43

“unbearable back pain” at work

Attends multiple specialists

Age 44

Psychoactive stimulants and anabolic steroid use

Multiple medications for sleep and anxiety

Disrupted sleep: “groggy and fatigued”

What is his fitness to work with these symptoms?

0

No work

1

Minimal

Cognitive

Demands

2

Moderate

Cognitive

Demands

3

Difficult

Cognitive

Demands

4

Hardest

Job

Demands

“Motivation for improvement may be key

factor of an individual's ability to lead a

productive life despite a challenging

impairment ...”

“…motivation is a significant link between

and impairment and resulting disability”

Return To Work Motivation

The Obstacle Question

• What is specifically the obstacle preventing you

from working today?

The Mole Hill Sign

• When an apparently minor health condition having

a major effect on daily life and function, there

maybe a motivational issue.

Jennifer Christian, MD

Pain Behaviour Observation System

Rubbing

Guarding

Bracing

Grimacing

Sighing

Frequency correlates with VAS and 0-10 pain ratings

Keefe & Block Behav Ther. 1982;13: 363–375

Pain Catastrophizing Scale (PCS)

Measures:

• Magnification

• Rumination

• Helplessness

Risk range is total score > 20

sullivan-painresearch.mcgill.ca/pcs.php

Waddell’s Signs

Axial compression

Simulated rotation

Nondermatomal sensory loss

Superficial tenderness to light touch

“Cogwheel” (give-way) weakness

SLR discrepancy between sitting and supine tests

Over-reaction

Non-organic Signs are not...

“Nonorganic signs also correlate with ….disturbed mood, psychological

distress, and dysfunctional beliefs and coping strategies…they are simply

a screening test that should alert the clinician that this patient needs more

careful clinical and possibly psychological assessment”

Spine 2004;29(13): 1393

Assessment of Chronic Pain

ACOEM Practice Guidelines, 3rd ed.

Chronic pain chapter (200+ pages)

• History

• Examination

• Work relatedness

• Diagnostic testing

• Treatment

• Disability durations (MDA)

(ACOEM APG. Hegmann, 2010)

Pain Status

Impairing symptoms

Severity

• Intensity

• Frequency

• Duration

• Precipitants and effects on functioning

Perceived work barriers

Pain Management

• Reduce emotional reactivity and fear response to pain - mindfulness/

relaxation/Cognitive Behavioural Therapy (CBT)

• Promote sleep habit recovery

• Check for psychiatric comorbidities and Substance Use Disorder

• Treat any nociceptive aggravation

• Target approaches for neuropathic pain and Complex Regional Pain

Syndrome (CRPS) - tricyclic antidepressants (TCAs), neuroleptics,

serotonin and norepinephrine reuptake inhibitors (SNRIs)

• Increase physical activity/balance

• Normalise, maintain and enhance social activity and participation

Fatigue and fatigability

• Fatigue limits an individual’s tolerance of tasks

• Fatigue can make some work tasks more risky

• Take a really good history: Fatigue means different things to different people

• Clarify the cause of fatigue

• Find out what makes it better and worse

Mood

• Depression

• Anxiety

• Cognitive dissonance

• Anger

• Resistance

• Malingering?

Know the Job!

• ACC Work Detail Sheets

• O-Net

• University of Calgary site

• Medical fitness guidelines

• Ideally job site visits

• Recovery expectation

• Job satisfaction

• Work relationships and support

• Did work cause the injury?

• Adequate training?

• Disciplinary action pending?

• Fears that work will worsen pain?

• Unusual work absenteeism patterns

Ask about:

Functional Capacity

• Capacity

• Limitations

• Restrictions

• Tolerance

AMA guides to the evaluation of Work Ability & Return to Work 2nd ed.

Tolerance

Ability to sustain work or activity

Not scientifically measurable

Frequently less than capacity

Dependent on the rewards

“Believable” or not?

AMA guides to the evaluation of Work Ability & Return to Work 2nd ed.

Barriers

Diagnosis/severity (red flags)

Environmental (blue/black flags)

Patient responses (yellow flags)

Illness behaviours/perceptions:

• Fear-avoidance

• Catastrophising

• Deconditioning

• Compensation

Factors Associated with Level of Delayed Return to Work

Geographical Organisational Personal

Climate Region Ethnic origin Social insurance Health services Epidemics Unemployment Social attitudes Pension age Taxation

Nature Size Industrial relations Personnel policy Sick pay Supervisory quality Working conditions Environmental hazards Occupational Health Service Labour turnover

Age Gender Occupation Job satisfaction Personality Life crises Medical conditions Alcohol Family responsibility Journey to work Social activities Length of service

Mental Illness and Employment Barriers

• Participation in education

• Cognition

• Type of employment

• Contact with the public

• Need for a support person

• Difficulty in changing jobs

• Need for reduced hours

• Concentration

• Irritability

• Labile mood

• Fatigue/sleep/shift work

• Social

• Medication

31

Copyright (c) ACC Author/Unit

Systemic Issues

• Self esteem

• Career immaturity

• Community Stigma

• Peer stigma

• Employer reluctance

• Health professional expectations

32

Copyright (c) ACC Author/Unit

Elements of Supported Employment

• Job-seeking & resume writing

• Individual Placement & Support

• Disseminate IPS programmes

• Integration of IPS with clinical services

• Improving fidelity of IPS

• Augmenting IPS with education

• Skills training

• Work trials

• Benefits counselling

33

Copyright (c) ACC Author/Unit

When motivation is unclear

Personal

• Rewards of work?

• Depression & anxiety

• Self-assessed competency

Environmental

• Infrastructural effects for work –readiness

• Social supports

• Stigma

• Past experience

Occupational

• Good jobs

• Flexibility

34

Copyright (c) ACC Author/Unit

Motivational Interviewing

• Express empathy

• Develop discrepancy

• Roll with resistance

• Evaluate motivation

• Support self-efficacy

• Support change discussions

35

Copyright (c) ACC Author/Unit

Medical evaluation

• History of mental & behavioural disorder(s)

• Current mental & physical examination findings

• Comorbidities

• Current status/future plans

• Diagnosis

36

Copyright (c) ACC Author/Unit

Analysis

• Effects on normal life activities

• Stability

• Adverse effects of participation?

• Access to work modifications?

• Relate clinical findings to impairment

• Effect of impairment on ability to function

• Severity of impairment

37

Copyright (c) ACC Author/Unit

Assessment

• Motivation

• Activities of Daily Living

• Life Skills Profile

• Occupational Self Assessment

• Specific barriers

38

Copyright (c) ACC Author/Unit

Special considerations

Understanding & memory

Sustained concentration & persistence

Social interaction

Adaptation

Effects of medication

Substance abuse

Personality

Cognition

Pain Malingering

Motivation

Personal & public safety

Severity of impact:

• ADLs

• Social functioning

• Task completion & pace

• Deterioration or decompensation in work settings

39

Copyright (c) ACC Author/Unit

Recommendations

• Functional ability

• Further investigations or Rx

• Functional restoration

• Employment suitability

• IRP barriers

• Illness behaviours

Content Guidelines

ID/Assessment Information

Documents reviewed

Introduction & consent

statement

History of the injury &

management

Current situation/function

PMH

Medications

Personal/social history

Previous occupational Hx

Most recent employment

Examination

Diagnosis

Rehabilitation barriers

Recommendations

Restrictions and/or Limitations

Sustainable employment options

Completeness of Rx and Rehab

Specific recommendations/comments

Client comments/feedback

3 – Questions/discussion

• How can you tell if you are doing well?

• Do clients think you are doing well?

• What can we share about what we do well?

Questions

Copyright (c) ACC

44

Contact us

Rob Griffiths

Senior Medical Adviser

Phone: 04 816 6075

rob.griffiths2@acc.co.nz

acc.co.nz

Gillian Anderson

Category Manager, Vocational Assessments and

DHB Relationships

Phone: 04 816 7155

gillian.anderson@acc.co.nz

acc.co.nz