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Starwood Analysis September 9, 2002

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A Cognitive Behavioral Model. to Enhance Return to Work ... 2% of population 20% of Rheumatology practice. Defuse pain, multiple tender points, depression, ... – PowerPoint PPT presentation

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Title: Starwood Analysis September 9, 2002


1

A Cognitive Behavioral Model to Enhance Return
to Work Outcomes Kristin Tugman, MS, CRC,
LPCDirector, Corporate Program
DevelopmentCarrie Palmer, MEd, CRCDirector,
Clinical and Vocational Services
2
Presentation Overview
  • The Psychology of Return to Work
  • At Risk Impairment Groups
  • Incidence Clinical Characteristics
  • Symptom Amplifiers The Disability Mind-Set
  • Strategies for Prevention Management
  • The Basics within the Employer Organization
  • A 7 Step Model to Enhance Return to Work
    Outcomes
  • Who should use this Model? And How?
  • Tracking Impact
  • Discussion

3
The Psychological Perspective
  • There is psychology involved in a return to work
    attempt for every injury or illness.

4
The Psychological Coping Process A Daily,
Hourly Event
  • A Cognitive Appraisal of the Event and Associated
    Events
  • A Threat, Loss, Danger, Attribution/Cause
  • An Affective/ Emotional Response to the
    Perceived/Real Threat
  • Shock, Fear, Anxiety, Worry, Anger, Embarrassment
  • Defend Protect
  • Denial (beneficial/pathological), Secondary Gain
  • Locus of Control
  • Internal vs. External, Learned Helplessness,
    Stigma
  • Timing, Scope, Severity and Permanency of
    Disruption (threat)
  • Immediate, Short term (lt 6 months), Extended (gt 6
    months)
  • Cognitive Distortions The Big 3
  • Premature Conclusions, Dichotomous Thinking,
    Catastrophization

5
Interventions (Preventing the Disability Mind-Set)
  • Adjustment, Adaptation, Acknowledgement
    Acceptance
  • Where do we begin? - What should we expect?
    Where do we end?
  • Educate, Plan, What Ifs
  • Who steps up to be the coping coach?
  • Waiting for the Divine?
  • Does religious faith and practices make a
    difference?
  • Incremental Steps Patience
  • Delayed gratification, early mobilization and
    clear reinforcement
  • Hopefulness, Hopelessness Helplessness How,
    not When!
  • Where do they begin, how am I doing and to what
    end
  • Its all in my thinking?
  • But my back hurts?

6
Guidelines to Moving Forward
  • Understand that change is natural
  • Significant degrees of quick change are the
    threat
  • Incremental change is the goal
  • Faith, hope and realistic expectations facilitate
    the perception and capacity for success
  • Be aware of the individuals readiness to change
  • The silent saboteur in the coping process is
    Ambivalence. Ambivalence is the middle ground
    between perceived costs and benefits to change.
    The result is a sense of being emotionally stuck.
    Being stuck can be interpreted in many ways by
    the outside observers.

7
At Risk Impairments
  • Depressions (Bipolar - Unipolar - Post Partum -
    Reactive)
  • Fibromyalgia
  • Chronic Fatigue Syndrome
  • Irritable Bowel Syndrome
  • Multiple Chemical Sensitivity
  • Repetitive Stress Syndrome
  • Back Pain/Injury
  • Heart Disease

Functional Somatic Syndrome
8
Clinical Characteristics
  • The clinical nature of these diagnosis groups
    leads to a high risk of extended disability
    durations.
  • Explicit and elaborate self-diagnoses
  • Not responsive to standard medical care
  • High rates of co-occurrence - by MD specialty
    alignment
  • Subject to stigmatization disability cynicism
    by family, friends, co-workers claims managers
  • Self-perpetuating self-talk cycle of disability
  • Things will get worse
  • The belief that a serious disease exists
  • Litigation and compensation are prominent
  • Portrayal of the condition as catastrophic
  • All encompassing in the persons life their
    identity.

9
Incidence Clinical Characteristics
  • Depression
  • 10 of working population 9 of all absences
    from work
  • Triple digit growth in claims submissions
  • 12 Billion in lost work days
  • Estimated 15 - 20 of total corporate health
    care costs
  • Clinical depression seen 21 female to male
  • Manic depression seen 11 female to male
  • Person less capable of acting assertive in
    care, stuck, fatigue,
  • low self confidence, symptoms not
    recognized by patient,
  • internal focus, socially stigmatizing,
    access to care is limited
  • Primary care management may not be effective
    with
  • a solution that requires time and focus to
    achieve complex

10
Incidence Clinical Characteristics
  • Fibromyalgia
  • 2 of population 20 of Rheumatology practice
  • Defuse pain, multiple tender points,
    depression,
  • sleep disorders, invisible symptoms
  • Performance tasks, memory and concentration
    deficits
  • Chronic Fatigue Syndrome
  • 112/100,000 in medical practice

Fibromyalgia Triangle
Chronic Pain Sleep Disruption
Depression
11
Incidence and Clinical Characteristics
  • Back Injury
  • ? Over 80 of adults have experienced low back
    pain.
  • ? A symptom, including discomfort of the
    lumbosacral area of the back, including radiating
    pain and/or numbness into the legs, hips and
    buttocks. Low back pain often has unknown causes
  • ? Direct cost estimated to be over 30 billion
    dollars annually.
  • Psychological factors play a major role in not
    only the onset but, also, in the progression to
    chronic disability. The literature also
    indicates that low back pain historically has led
    to a fear of activity.
  • Interventions for workers in the early stages of
    disability are a combination of active
    rehabilitation, progressive exercise, working
    toward overcoming fear-avoidance beliefs,
    encouraging self-care, and intervention at the
    workplace to assist patients in making an
    incremental return to work.

12
Incidence and Clinical Characteristics
  • Heart Disease
  • ? 4 of the population inflicted with heart
    disease.
  • ? A heart attack results in damage to the heart
    wall caused by the formation of a thrombus (blood
    clot) or plaque (cholesterol build-up) that has
    developed slowly within a coronary artery
  • ? After an AMI people are often afraid of relapse
    but, according to the MDA, 90-95 of individuals
    who experience an AMI leave the hospital.
  • ? According to the American College of Cardiology
    Foundation (1999), cardiac rehabilitation is
    often the treatment of choice during the recovery
    period.

13
Economic Burden of Illness
  • Hypertension (392 per eligible employee per
    year)
  • Heart Disease (368)
  • Depression and other Mental Illnesses (348)
  • Arthritis (327)
  • Presenteeism costs were higher than medical costs
    in most cases and represents 18 to 60 of all
    costs for the 10 health conditions studied
  • Total cost of health, absence, short term
    disability and productivity losses was
    synthesized

Goetzel et al. JOEM, 2004 46(4)
14
Symptom Amplifiers (Secondary Gain/Motivation)
  • The belief that one is sick - Application for DI
  • The emerging disability mind - set
  • The reinforcement of sick role - Awarding of DI
  • Stress distress (Fear and Avoidance)
  • Greater/new job demands with incongruent skills
  • Perceived loss of control in job
  • Real or perceived job insecurity
  • Less camaraderie or social isolation with
    co-workers
  • Fear of the unknown leads to avoidance
  • Fear of relapse/re-injury
  • Disability insurance paradox (DIP)
  • Anyone who invests great amounts of time in
    proving
  • they cannot work will not work.
  • Iatrogenic disability
  • Excessive medical testing treatment
  • Evidence based medicine
  • Physician reinforcement of sick role
  • Advocating

15
The Emerging Disability Mind - Set
  • Declining Performance
  • ShameGuilt
  • Treatment
  • Advocacy
  • Defending the Impairment
  • Disability InsuranceReinforcement
  • Identified PatientIdentity
  • EARLY INTERVENTION

16
Lost Time Management Aligning Corporate
Strategies
  • Core - Compliance
  • Information and data management Know who is
    off work
  • Plan design aligned with corporate lost time
    expectations
  • Timely, accurate and consistent claims
    reporting and administration
  • 2nd Level - Stay _at_ Work
  • Establish Supervisor functions, expectations
    incentives
  • Manage job performance problems
  • Build work site accommodations transitions -
    SAW/RTW
  • 3rd Level - Return to Work
  • Influence/Direct employees lost time
  • Develop medical support for SAW/RTW
  • Re-engage employee - How?...Preparation

17
Preparation A 7- Step Cognitive Behavioral
Intervention
  • Validate the Persons Feelings and Concerns.
  • Baby Steps
  • ABCDE Technique
  • Five Fears of Return to Work
  • Relapse Prevention
  • Boundaries
  • Work Adjustment

18
Preparation Step 1
  • Validate the persons feelings and concerns.
  • Recognize that you have an illness not a
    character defect.
  • Express Empathy
  • Sense of understanding and acceptance of the
    person's feelings and perspective.
  • There is no judgment, blame or criticizing.
  • It is not an agreement or endorsement of how the
    person feels but only recognition that this is
    how it is for that person.
  • Build a relationship that includes trust.

19
Preparation Step 2
  • Baby Steps.
  • Incremental steps toward recovery
  • Focus on what is possible
  • Slowly increase activity based on medical
    capacity
  • Activity promotes recovery

20
Preparation Step 3
  • ABCDE Technique.
  • Cognitive Restructuring
  • A Activating Event
  • B Belief or Thought about the Activating Event
  • C Consequence of automatic Belief about A
  • D Dispute
  • E Effect what would have happened had D been
    the automatic thought?

21
Preparation Step 4
  • Five Fears of Returning to Work.
  • Name 5 of your biggest concerns associated with
    going back to work.
  • What if I cant do it?
  • What if I get sick again?
  • What do I tell my co-workers?
  • Are these fears rational?
  • Make a plan.

22
Preparation Step 5
  • Relapse Prevention.
  • What if I get sick again?
  • A fear of relapse often leads to the avoidance of
    RTW
  • Plan
  • What is it like to be well?
  • What is it like to be sick?
  • What are the early warning signs of a relapse?
  • What is my concrete plan if my warning signs
    appear?

23
Preparation Step 6
  • Developing Appropriate Boundaries.
  • What type of work environment will you return to?
  • How do your co-workers/supervisors perceive you?
  • What are your realistic limitations?
  • How can you make your abilities and work
    expectations congruent?

24
Preparation Step 7
  • Work Adjustment.
  • Work adjustment outside of the employer
  • Transitional Return to Work within an employer

25
Transitional Work Model
Transitional Work
Transitional Work
Absence from Work
Agreed Upon Accommodations
Absence from Work
Stay at Work (preserve productivity)
Return to Work (restore productivity)
26
Transitional RTW Pathways
RTW Planning tool generates communication
27
RTW Options
Tool identifies options to transition employees
back to work.
28
Sample Transitional Return to Work Plan Back
Injury
29
Sample Transitional RTW Plan - Depression
30
Who should use this model? How?
  • Employer Human Resources departments
  • Develop pathways for RTW in advance of an absence
    from work
  • Communicate with the employee regularly
  • Utilize pre-determined pathways to write-up
    transitional RTW plans
  • Partner with Occupational Health where possible
  • Partner with EAP where possible
  • Train managers and serve as a resource to them
    regarding RTW policies and procedures
  • EAP organizations
  • Serve as a RTW preparation resource for employer
    human resources department
  • See the employee regularly in order to implement
    7-step preparation model
  • Partner with human resources to implement
    transitional RTW plans

31
Who should use this model? How?
  • Disability Management Vendors Vocational
    Rehabilitation Professionals
  • Work with Employer to ensure RTW and lost time
    prevention foundation exists
  • Communicate with the EE regularly
  • Use 7-step indicators to assist in preparing an
    employee for RTW
  • Partner with the Employees physician
  • Use Pre-determined Transitional RTW pathways in
    order to write appropriate TRTW plans
  • Partner with the Employers human resource
    department in order to implement the TRTW plan
  • Actively track outcomes

32
Tracking Outcomes
  • Decrease duration of lost time claims
  • Increase in successful returns to full
    productivity
  • Decrease in repeat lost time claims
  • Improvement in employee morale and presenteeism

33
Case Scenario
  • 50-year-old Elementary School Teacher on long
    term disability due to Fibromyalgia Syndrome with
    secondary depression. The individual voiced
    anxiety and resistance related to the idea of
    returning to work.
  • Step 1
  • A vocational counselor worked w/client and used
    the first step in the 7-step model - Led to
    additional work around increasing daily activity,
    as the individual was anxious about challenging
    herself both mentally and physically.
  • Step 2
  • The client began with the baby step exercise and
    slowly increased her daily tasks until she felt
    comfortable participating in medically approved
    physical activity.
  • Step 3
  • The client began cognitive exercises in order to
    assist in improving memory Led to enhanced
    confidence
  • Step 4
  • The client explored fears related to return to
    work Led to vocational counselor addressing
    fears and a plan was developed for each fear.

34
Case Scenario Contd
Fear Plan
35
Case Scenario, contd
  • Step 7, work adjustment
  • The clients work adjustment included
    coordinating a special assignment with her
    school, allowing the client to acclimate herself
    back into the work environment.
  • As a result of the clients participation in the
    7 step activities, she gained enough confidence
    in both her psychological and physical capacity
    to ultimately set a return to work date.

36
International Discussion Points
  • STD and LTD Benefits
  • Healthcare
  • Laws related to worker discrimination and job
    protection
  • Resources

37
7 Step Model Indicators
38
Suggested Bibliography
  • New Mental Health Care Market, Health Affairs,
    Project Hope. September/October 1999, Volume 18,
    Number 5, 1999.
  • Hannan, Anderson, Pincus, and Felson,
    Educational Attainment and Osteoarthritis
    Differential Associations with Radiographic
    Changes and Symptom Reporting. J Clin Epidemiol.
    Vol. 45, No. 2, pp.139-147, 1992.
  • Hadler, Nortin M. Fibromyalgia, Chronic Fatigue,
    and other Iatrogenic Diagnostic Algorithms.
    Postgraduate Medicine. Volume 102.August 1997.
    Pp.161-177.
  • Barsky, Arthur J., M.D., and Jonathon F. Borus,
    M.D. Functional Somatic Syndromes. Annals of
    Internal Medicine. June 1999.Volume 130.
    Pp.910-921.
  • Fibromyalgia, Chronic Fatigue Syndrome and
    Repetitive Strain Injury Current Concepts in
    Diagnosis. Management , Disability and Health
    Economicsby Chalmers, Littlejohn, Salit and
    Wolfe, Editors Haworth Medical Press, 1995
  • Tugman, K. and Palmer, C., The Fear of Return to
    Work A model to enhance return to work
    outcomes. Rehabpro. January 2004.
  • Tugman, K., The Vocational Consultants Guide to
    Psychiatric Rehabilitation. Elliott
    Fitzpatrick. Athens, GA. 2002.
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