Exploring the Boundaries of Return to Work and Disability Management Practice by Looking Beyond Medical Diagnosis

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Exploring the Boundaries of Return to Work and
Disability Management Practice byLooking Beyond
Medical Diagnosis

• Piotr S. Baranowski M.Rehab., M.Psych., CCRC
• ReSolutions Consulting
• Forward thinking at work!
• Halifax, Nova Scotia, Canada

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Contents

1. A Story of an Absence (from Work)
2. Objective Medical Evidence
3. Disability vs. Impairment
4. Beyond Medical Diagnosis
5. Discussion

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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

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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?

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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

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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

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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

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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, UK
• The Equality Unit - Sheffield City Council,
  Sheffield, UK

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Disability

• Disability may be defined as an alteration of an
  individuals 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 persons 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 Association
• Guides to the Evaluation of Permanent
  Impairment, p.2

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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

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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 Physicians Role in Helping
  Patients Return to Work After and Illness or
  Injury American College of Occ. Env.
  Medicine, April 2002

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• 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.

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• Stress?
• Depression?
• Mental Illness?
• Multiple diagnoses?

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Beyond Diagnosis
Distress
Personality
Beliefs
Coping
Economic
Fears
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Beyond Diagnosis

• Medical issues
• legitimate functional impairments
• Vocational issues
• relationships at work
• job satisfaction, job performance, perspectives
• burnout, disengagement
• Personal issues
• personality (catastrophising)
• relationships with self with others
• secondary gains

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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
  persons 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

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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 quickdecisions
• direct dealings with public
• safety sensitive position

• Functional Abilities/limitations
• regular medication regime balanced diet
• difficulty with night vision
• symptoms aggravated bystress
• side-effects of medicationmay temporarily affect
  judgment
• performance may vary significantly during the day

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Vocational

• Job 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

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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.

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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.

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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

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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

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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

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Beyond Diagnosis - Personal

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

Tate et al., Spine 1999
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Beyond Diagnosis - Personal

• Catastrophising is considered the primary driver
  of health-related absence from work
• Approx. 40 of EU federal funding is now directed
  to early psychological services to decrease the
  negative influence of catastrophising on RTW
  success
• Intl Forum on Disability Mgt, Berlin 2008

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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?

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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

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Piotr S. Baranowski - ReSolutions Consulting
2011 ROSE Conference
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Guiding Principles

• Medical/Treatment component
• address functional limitations (Tx, OT)
• Vocational component
• addressing work environment issues
• Personal component
• offering assistance in managing personal
  matters
• Expected plan outcomes
• reduced anxiety

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MVP
Psych
MD
CM
Client
VR
()
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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., CCRC
• ReSolutions Consulting
• Disability Management Programs Services
  Halifax, Nova Scotia, Canada
• [phone]
  rehabsol_at_telus.net
• DM Program Development Implementation
• Conceptual Framework Service Policy/Protocol
• Benefit Analysis Program Evaluation Metrics
• Seminars Workshops