Occupational Health Services Pilot Project Overview

1. Occupational Health Services Pilot ProjectOverview University of Washington, Seattle

2. 100 80 60 40 20 0 0 1 2 3 4 5 6 7 8 9 10 11 12 Changes in Disability Status Over Time among Injured Workers in WA State % of cases on time loss Time loss duration (months) Adapted from Cheadle A et al. Factors influencing the duration of work-related disability: a population-based study of Washington State worker’s compensation. Am J Public Health 1994; 84:190–196.

3. What WA Injured Workers Say • 73% reported that they are very satisfied with the overall quality of medical care received • But…only 36% reported that their doctor talked to them a lot about their job • And...63% of those with time off work reported that their doctor had not talked with their employer about return to work

4. What WA Employers Say • Only 1/3 of employers reported that they received regular updates about their worker’s ability to return to work • Employers report needing: • Estimated time off work • Assessment of the worker’s physical capabilities • Accommodations needed • Instructions on: • recovery • work limits • worker’s capabilities

5. The OHS Challenge Research and experience shows improving occupational health care processes by providers in smaller, limited systems reduces disability. Can we obtain similar results by transferring occupational health knowledge and practice within the broader provider community?

6. Our existing system... • Majority of work claims are seen by practitioners in general practice who treat only a few injured workers each year: Low back conditions: • 38% Family practice doctors • 36% Chiropractic doctors • 18% Emergency rooms

7. OHS Pilot • Not a managed care project • free choice of physician • fee-for-service reimbursement • no physician profiling • Foundation-Up Approach • Community-based effort to expand occupational health expertise • research shows that training works in closed networks • OHS is an evaluation of whether the findings can be translated into an open system • Involving community leaders: • physicians • employers • unions

8. Key Changes • Improved coordination of care • Emphasis on low-tech process changes • things doctors routinely do • Improved funding for: • reimbursement for processes shown to improve outcomes • free CMEs about occupational health best practices and process improvement • care coordination services • More creative and satisfying opportunity to provide health care to injured workers

9. Attending Physicians’ (AP) Role • Workers continue to choose their own doctor • Complete provider application supplement that will outline: • additional reimbursable services • use of basic process improvements • free CMEs on occupational health best practices • Access to additional resources • timely consultations and mentoring • care coordination • outcomes tracking • feedback

10. Process Improvements for AP • Early diagnosis, treatment, and communication • Treatment plan and activity prescription • Communication with employer about plan for return to work or transitional work • Assess impediments to return to work • Identify need for care coordination

11. Process Improvements (cont’d) • Provide timely access to care • Document work relatedness of condition • Attend to condition-specific quality indicators • carpal tunnel syndrome • low back sprain • upper and lower extremity fractures • Provide continuity of care

12. Resource Center’s Role • Center of Occupational Health and Education (COHE) provides: • training and mentoring for physicians • care coordination services • occupational health expertise • facilitation of communication • disability prevention

13. OHS-COHE Organization Dep’t of Labor& Industries UW ResearchTeam Bus/LaborAdvisory. Group COHE PilotCommunity Community Physicians

14. Desirable COHE Qualifications • Substantial capacity to recruit and educate community doctors • Demonstrated leadership and expertise in occupational health, primary care, chiropractic care, and specialty care • Institutional capacity to develop a Center of Occupational Health and Education to serve as a “change agent” in occupational health

15. Desirable COHE Qualifications (cont’d.) • Ability to effectively work with advisory committee of local business and labor leaders • Creative capacity to improve the coordination of occupational health care • Willingness to work with L&I and UW to demonstrate process improvement

16. Why would a Health Care System want to Participate? • Be a leader in innovative health care delivery! • Prevent disability and improve productivity in your community • Better reimbursement and less administrative burden • Strong support from business and labor • Private/public partnership

17. OHS Project is Parallel to Recommendations in IOM (2001) Report: Crossing the Quality Chasm IOM Report OHS Pilot Design more effective Center for Occupational organizational support Health and Education Create infrastructure Free CME, quality to support evidence- indicators based practice More effective use of Tracking software information technology

18. OHS Project is Parallel to Recommendations in IOM (2001) Report: Crossing the Quality Chasm (cont’d) IOM Report OHS Pilot Alignment of payment Provider supplement, incentives to support enhanced fee schedule quality related to quality indicators Improved work force Free CME, mentoring training(providers)

19. Indicators of Quality Specific to Target ConditionsEach of the following indicators of quality received high rankings in the expert focus groups and have substantial validity in empiric data • Carpal Tunnel Syndrome Nerve conduction studies to corroborate presence/absence of CTS if time loss > 2 weeks or surgery being considered. Surgery completed within 4-6 weeks of determination that surgery is indicated

20. Indicators of Quality Specific to Target Conditions (cont’d)Each of the following indicators of quality received high rankings in the expert focus groups and have substantial validity in empiric data • Low Back Injury Exam screens for presence/absence of radiculopathy (using recognized, reliable criteria) at the first visit. Medical history screens for non-neurological red flags at first visit. Need for advanced imaging adequately justified. Decision re: potential value of surgery in workers with documented radiculopathy by 12 weeks—surgery within 4-6 weeks if indicated.

21. Indicators of Quality Specific to Target Conditions (cont’d)Each of the following indicators of quality received high rankings in the expert focus groups and have substantial validity in empiric data • Extremity Fractures Fracture severity graded by documenting key elements at initial visit. Initial exam screens for present/absence of significant vascular or neurologic injury. For open fractures, grade severity of soft tissue injury.

22. Indicators of Quality Specific to Target Conditions (cont’d)Each of the following indicators of quality received high rankings in the expert focus groups and have substantial validity in empiric data • Extremity Fractures Documentation of adequate antibiotic prophylaxis (open fractures, closed fractures requiring internal fixation). Timing and availability of orthopedic consultation documented at initial visit for severe fractures. Radiological follow-up to determine continued adequate reduction by 10 days post-initial reduction.

23. Recommended Quality Indicators:Quality Improvement Quality Indicator Specific Measure Benchmark Timeliness of access % of workers who Year 1: 80% of to care are seen within 3 injured workers days of worker’s seen within 3 1st contact. days’ contact. Year 2: 80% of injured workers seen within 1 day of contact. Probability of work- % of claims for 80% of compen- relatedness ade- which the proba- sable claims quately specified bility of work- contain adequate on ROA relatedness is ade- specification of quately specified work-relatedness on ROA on ROA

24. Recommended Quality Indicators:Quality Improvement (cont’d) Quality Indicator Specific Measure Benchmark Indicators of quality % of claims with 80% of records Specific to target specific conditions should contain conditions for which each all indicators for indicator is docu- each condition mented in medical record

25. Recommended Quality Indicators:Performance Performance Indicator Specific Measure Benchmark Timeliness of submis- % of ROA received 80% of compen- sion of ROA within 2 days of sable claims 1st office visit received within 2 days of 1st office visit Two-way communi- % of claims for 80% of 1st visits cation with employer whom 2-way com- with billing code about return to work munication with reflecting 2-way employer about communication return to work at with employer on 1st visit when time loss claims worker is off or expected to be off work

26. Recommended Quality Indicators:Performance (cont’d) Performance Indicator Specific Measure Benchmark Activity prescription % of workers for 80% of workers on at each health care whom prescription time loss receive visit discussed and activity prescrip- documented at tion at 1st visit each health care and once/month visit when patient for 1st 3 months off work or expected to be off work

27. Recommended Quality Indicators:Performance (cont’d) Performance Indicator Specific Measure Benchmark Referral and assess- % of workers on 90% of workers ment for impediments time loss who receive assess- to return to work have received ment or referral assessment or for assessment by referral for assess- 4 weeks of work ment of impedi- Note: this will ments to return to likely require work (by Centers) Centers to use by 4 weeks of software to track work loss time loss status of each worker on time loss

28. Recommended Quality Indicators:Performance (cont’d) Performance Indicator Specific Measure Benchmark Continuity of care % of workers who 70% of workers have not returned meet continuity to work who have target during the healthcare provider course of their visit every 2 weeks care for 1st 2 months, and at least 1 visit 2-4 weeks following RTW

29. Recommended Quality Indicators:Performance (cont’d) Performance Indicator Specific Measure Benchmark Return to work Time to 1st return No known bench- outcome to work and % of mark workers still work- ing 90 days after 1st return to full or transitional work