Overview

1. The Physician’s Role in Recovery and Return to WorkIAIABC WOKERS’ COMPENSATION COLLEGE 2009DR J.W. MELENCHUK, CHIEF MEDICAL OFFICER, SASKATCHEWAN WCB

2. Overview • ACOEM position 2008 • MD role in RTW • MD role in assessment, monitoring and diagnosis • Key messages from MD to IW during recovery and RTW • The 10% and Disability Management

3. ACOEM POSITION • The role of the personal physician is to diagnose, treat, and prevent illnesses and injuries, prevent additional injury, offer advice and support to the patient, and provide appropriate factual medical information to the patient, the employer, and the benefits payer. • Fulfilling these responsibilities requires that the personal physician understand the important role that work plays in allowing a patient to experience a fully satisfying life.

4. ACOEM (cont’d) • The consensus document addresses the role of the personal physician in assisting the patient to minimize life and work disruption. This assistance entails keeping the patient’s daily routine as normal as possible, and for the employed patient, includes helping him or her stay at or return to work as soon as it is medically feasible and safe to do so. Remaining active and being productively engaged in life benefits both the patient and his or her family. It not only enhances recovery, but reduces personal, household, social, and economic problems, and also prevents needless work disability and job loss.

5. ACOEM (cont’d) • The personal physician should also be aware of the important contributions that can be made by other parties, especially those familiar with the patient’s work life, in the stay-at-work and return-to-work process, and should work cooperatively with these other parties to help the patient minimize the impact of health conditions and maintain the fullest possible participation in life. Whenever possible, all parties should endeavor to prevent needless work disability by helping the working patient stay employed.

6. ACOEM Recognizes That: • a fundamental purpose of medical care is to restore health, optimize functional capability, and minimize the destructive impact of injury or illness on the patient’s life; • medically related withdrawal from normal social roles, including work, is destabilizing and may be detrimental to a patient’s mental, physical, and social well-being;

7. ACOEM Recognizes That: • maintaining or returning a patient to all possible relevant life activities as soon as is safely possible has many beneficial psychosocial and physical effects; • the physician can positively affect the likelihood and rapidity of healing by setting clear expectations for recovery with the patient and by providing useful and appropriate guidance to the patient and his or her employer;

8. And Finally ACOEM Recognizes That: • ….with patient consent or when legal requirements are met regarding disclosure of personal health information, the physician can collaborate effectively with other involved parties in the stay-at-work and return-to-work process.

9. MD Role in RTW • Expectations may be different for parties involved and from jurisdiction to jurisdiction • Always a work in progress • Workers’ Compensation Insurer should always look for the best method to facilitate communication between health care provider, injured worker and employer on RTW

10. THE ROLE OF THE MD IN RTW: In addition to the normal assessment and treatment physicians provide their patients, the treatment plan for an injured worker mustinclude a return to work component. The extra responsibility this places on physicians is balanced by the assistance available from the worker’s compensation insurer (WCI) and employer.

11. The physician has a responsibility to maintain communication with the worker and the WCB about the extent of the worker’s injury and the expected recovery timeline. The physician also has a responsibility to provide to the WCI and to the employer (via the worker or directly with consent) information about any restrictions the worker may have because of the injury, and to update any restrictions as the worker’s condition progresses.

12. In almost all circumstances, restrictions should be provided unless the worker is hospitalized or house bound. The list of restrictions allows the employer to identify if appropriate work is available for the worker while they are recovering. The onus is on the employer to match work to the restrictions the physician has outlined.

13. Example of Medical Professional POLICY Support for RTW guidelines and timely reporting: College of Physicians and Surgeons of Saskatchewan policy: Role of the Physician in Certifying Illness and/or Assessing Capacity for Work ACOEM 2008 position paper Other examples for timely reporting of injury and restrictions: CMA, AMA and the CMPA (Sept, 2008 Newsletter)

14. What does the medical literature show is best for the Injured Worker? Recovery can best be achieved by active treatment at the primary level integrated with a return to work as soon as appropriate, and timely access to secondary and tertiary services, where required.

15. MD Role in Assessment and Diagnosis

16. It is important to identify workers at the initial visit. The WCI may recommend that the Clinic/Outpatient Department post a sign in their waiting room asking injured workers to identify themselves to the receptionist or admitting clerk as having a work injury on initial and return visits.

17. We recommend that physicians carefully document the worker’s condition at the first visit and throughout recovery and fill out all WCI report forms completely. This information is valuable to the WCI, other health care professionals, and to the worker. Prompt reporting allows timely WCI decisions and prompt payment of benefits.

18. Extra care is needed at the initial visit(s) to ensure that the injured worker has an accurate perception of the prognosis for recovery. An imagined catastrophic prognosis can become aself-fulfilling prophecy!!!!!!!

19. 1.MD should explain the Benefits of Functional Rehabilitation and Early Return to Work

20. During an injured worker’s initial visit(s), the physician can forestall many worries the worker has about their condition by: • stressing the importance of being as active as possible within any restrictions the worker may have; and • reassuring the worker that discomfort from recommended activity is a normal part of the recovery process.

21. 2. MD Must Evaluate Any Risks Involved in Return to Work

22. In most cases, return to accommodated work has a positive impact on the worker’s recovery. However, sometimes a worker’s injury or illness or the effects of medication prescribed for the injury or illness may impair their judgment and balance and pose a safety risk to the worker or others. Physicians should consider such impairment when giving restrictions.

23. Medical Associations have stated: “If the medical condition of the patient and the nature of the work related tasks performed are likely to endanger the safety of others, the physician must place the public interest before that of the individual patient.” CMA Policy Statement and ACOEM position

24. 3.MD must communicate Restrictions

25. In addition to the normal information about the recommended course of treatment and the expected recovery time, physicians need to advise injured workers about their restrictions/capabilities. With few exceptions, if a worker is not in hospital or house bound they could return to work if their restrictions can be accommodated. Rather than authorizing absence from work, the physicians should provide the injured worker with a list of restrictions resulting from the injury to be shared with the employer.

26. Once the worker shares the list of restrictions with them, the employer (RTW support) can determine, in consultation with the worker, and union (if any), if the worker’s duties can be modified or other accommodations can be made to allow for a safe return to work

27. Physicians should always assume that the employer with the assistance of their RTW planning support can and will accommodate, even if workers think otherwise. If the employer cannot accommodate the worker’s restrictions, then an absence from work may be required. Physician monitoring is essential to update or modify restrictions as the recovery progresses to ensure optimal timing on RTW.

28. The advantage of this approach for both the worker and employer is that it encourages both to keep the dialogue open regarding accommodation. Continuing communication between the worker and employer is a vital part of successful recovery and return to work.

29. 4. The Physician should always prepare a list of work restrictions and/or acceptable activities If the worker’s employer has a Return to Work program in place, the worker may bring a copy of a Return to Work form to be filled out. If the worker does not provide a form, the physician should list any restrictions the worker has on the WCI provided form or physician letterhead and give the list to the worker with instructions that it be given to the employer.

30. The list of restrictions should be based, as much as possible, on objective findings. The list should include: • the period for which accommodated duties will be required; and • when possible, specify the worker’s range of activity. If unsure of the range, the physician should prohibit the questionable activity and refer the injured worker to a physiotherapist or other Biomechanical Practioners for functional testing.

31. At each visit, this list of restrictions should be reviewed, and, as the worker’s condition changes, updates forwarded to the employer via the worker. Be aware that Health Information Privacy Law in many jurisdictions has caused Medical Professional Associations to caution their members about direct contact with an employer. Providing the restrictions (health information) directly to the worker to provide to the employer provides consent and is usually the quickest in implementing the RTW. Many WCIs have RTW facilitators that can liaise with the employer and MD in setting RTW expectations.

32. 5. Report to the WCI Every work injury that needs medical attention must be reported to the WCI.

33. To simplify the reporting process, physicians may attach a copy of their clinic notes to the WCI form or submit clinic notes electronically if in a paperless office, provided the notes: • include all of the information requested on the form; and • are limited to the work injury only.

34. 6. Request Advanced Assessment & Treatment If Needed

35. Physicians should advise the treatment team of: • health-related issues; • the worker’s progress; • the direction health and disability management is taking; and • any interventions required regarding non-health related issues.

36. 6a. Expedited Appointments When the physician determines specialist and diagnostic services are required, WCI can assist. Where a waiting list exists for a service required by a worker, the WCI can help arrange an expedited service in many cases (i.e. MRI, CT scan or other diagnostic; day surgery; and appropriate specialist appointments.)

37. Requests for expedited services can be made either on a WCI report form or by contacting the Worker’s Compensation Insurer directly. WCI staff will forward requisitions for referral letters to the attending MD to be completed. An early response is encouraged and required to maximize treatment and RTW.

38. 6b. Referrals Most referrals from the attending MD to other consultants/services can be expedited via the WCI. WCIs may not require a specialist referral to arrange expedited MRIs, CT scans and other diagnostic tests. A tick box may be provided on the Physician Initial and/or Progress Report.

39. 6c. Special Requests Requests for unusual devices, treatment or diagnostic tests by any physician may require discussion with a WCI Medical Officer or WCI arranged Medical Consultant

40. 6d. Advanced Assessment and Treatment If the injured worker’s recovery does not proceed as expected, the physician should contact the WCI to arrange for a multidisciplinary (team) assessment. Many WCIs will have the regulatory ability to require the worker to present for an assessment when recovery/RTW is delayed from expected recovery timelines.

41. The Key Messages and Process in Monitoring RTW

42. As the worker’s condition improves, the physician should: • revise the worker’s restrictions and convey this information to the employer via the worker and to the WCI via progress reports. • reassure the injured worker that some increase in discomfort is normal and expected during return to work (unless there are symptoms to suggest danger or signs to suggest injury progression.) • *** MD should be aware that failure to progress in recovery and RTW will require further timely assessment...often multidisciplinary with added psychosocial/pain management

43. discuss modifications to the return to work plan with other involved health care professionals. • make modifications to return to work plans, but do not stop return to work unless continuing presents a clear danger to the injured worker. A rest from return to work rarely leads to improvement. (Exception: The immediate days after acute injuries.)

44. Example of Literature Support for WCI Process in Low Back Injury • Conservative treatment of adults with occupational nonspecific low back pain includes analgesics and NSAIDs, massage and supervised and home exercises. • Adults with NSLBP should return to work, which might need to be modified on a short term basis; a multidisciplinary rehab program is recommended for those unable to resume work after 4 to 12 weeks. • American Family Physician Review Article Nov. 15, 2007.

45. What Comes Next? • About 10% of work injuries (not progressing with usual care/RTW) will require proactive/intensive disability management. • This would include extra diagnostics, assessments and treatments including pain and psychosocial interventions in addition to an active RTW plan/implementation. • A portion of these will require vocational rehab/retraining

46. Summary • Most injuries are managed with usual care and employer accommodation in a RTW. • WCIs can assist employers, health care providers and IWs through both the recovery and RTW process. • Insurers, professional associations and employers appear to be finally moving in the same direction in recovery, RTW and information exchange!!!!!!!