Return-To-Work With Complex Injuries
Uncertainty over roles in RTW with complex injuries
Study in four Canadian provinces finds some confusion and areas for potential improvement.
Most health-care professionals, when treating patients with visible, acute physical work-related injuries, find the workers’ compensation system and the return-to-work (RTW) process relatively straightforward.
However, they face challenges when treating workers with multiple injuries, complex or gradual-onset illnesses, chronic pain or mental health conditions, a study by the Institute for Work & Health (IWH) has found. These complex cases are estimated to represent less than 10 per cent of lost-time claims administered by provincial workers’ compensation boards.
In complex cases, health-care providers describe the workers’ compensation system as opaque and confusing. They also report a lack of clarity about their role in contributing to the return-to-work process. In this respect, their views are similar to those of case managers, who are also unclear about the role and degree of involvement of health-care providers in RTW.
“We went into this study with the goal of investigating how health-care providers could be more engaged in workers’ compensation and return to work, which research suggests results in better RTW outcomes,” says IWH Scientist Dr. Agnieszka Kosny, lead researcher on this two-year project. However, it quickly became clear that there’s significant confusion among both health-care providers and workers’ compensation case managers about what the role of health-care providers should be in the management of complex cases.
For this study, Kosny’s team interviewed 97 health-care providers and 34 case managers in British Columbia, Manitoba, Ontario, and Newfoundland and Labrador. The health-care providers were mostly general practitioners in a range of settings, but also included 19 allied health-care providers such as occupational therapists, chiropractors and psychologists, and 19 specialists such as surgeons, physiatrists and rehabilitation specialists.
The study identified the challenges faced by health-care providers and case managers when it came to the role of health-care providers in return to work. These challenges were grouped along
1) Disagreements about timing and appropriateness of return to work: While health-care providers and case managers agreed that return to work has many benefits, they also sometimes disagreed about the timing of RTW. Case managers sometimes felt that health-care providers were delaying return to work because they were following patients’ wishes instead of appreciating the benefits of RTW. On the other hand, health-care providers sometimes felt case managers were predominantly interested in cost-containment and were pushing workers back too soon without understanding their individual circumstances.
2) Lack of understanding of the workers’ compensation system: Both health-care providers and case managers talked about the lack of knowledge that doctors, in particular, had of the workers’ compensation system. Most doctors reported receiving little training in medical school about workers’ compensation, occupational health, work injury management and return to work. Several health-care providers talked about the difficulties they faced when trying to determine patients’ functional limitations or assess workers’ readiness to return to their job. This lack of knowledge led to misunderstandings among both health-care providers and case managers, making collaboration difficult.
3) System rigidity: Health-care providers described instances where workers’ compensation rules and procedures seemed to lack flexibility needed to accommodate the circumstances of workers with complex injuries and conditions. Some said their patients’ conditions did not conform to the recovery guidelines that some workers’ compensation boards applied to assess how long workers should take to recover from a particular illness or injury. They felt that the guidelines failed to consider co-morbid conditions and were sometimes unsuitable for complex injuries arising from multiple causes.
4) Communication: Health-care providers sometimes described difficulties reaching case managers when they had questions or needed information. For their part, case managers also reported difficulty getting information from health-care providers, such as
when they received forms that lacked detail and their phone calls to doctors’ offices were not returned. Several health-care providers said it was common for them to submit an assessment to the workers’ compensation board but never hear about the outcome of the claim. Many also noted that, as a result of communication barriers between health-care providers and case managers, injured workers played the role of the go-between. Some participants pointed out that using injured workers to relay information could result in misunderstandings, delays and incorrect information being conveyed to key decision-makers.
5) Exclusion from the workers’ compensation and RTW process: Health-care providers described instances of feeling alienated from the workers’ compensation system and RTW process, especially when their recommendations were overturned. This feeling of exclusion was made worse for some health-care providers by the use of internal medical consultants by workers’ compensation boards. Although some health-care providers found these consultants helped in the process because they “spoke the same language,” others were concerned about consultants’ independence and the determination of assessments without seeing injured workers in person. Case managers, for their part, said consultants helped them understand medical recommendations and provided a double-check for proposed treatment recommendations.
6) Issues related to the broader health-care system: Both health-care providers and case managers talked about lack of access to the health-care system as a problem in RTW. They noted that many injured workers, especially those in northern and remote communities, did not have family doctors. As a result, these patients depended on walk-in clinics or emergency rooms for their primary care—settings that are not appropriate for dealing with RTW issues. Health-care providers and case managers also spoke about wait times for tests and appointments with specialists, and the challenges these created for patient recovery and RTW. “The challenges
we heard are not going to be easy to solve, but we heard many good ideas for improving the system,” says Kosny. “I’m encouraged by the feedback I’ve heard from different group stakeholders—feedback indicating to me that many share the goal of improving the workers’ compensation and return-to-work experience for injured workers.”
The full study report is available at: www.iwh.on.ca/other-reports. A plenary presentation on this study will be available at: www.iwh.on.ca/plenaries/2017-feb-07.
Source: At Work, Issue 87, Winter 2017: Institute for Work & Health, Toronto.
Potential opportunities for improvement
In the study on health-care professionals, Dr. Agnieszka Kosny and her research team pointed to a number of opportunities for improvement:
1. Health-care providers need greater clarity and more consistent messages about their role in RTW and the workers’ compensation system more broadly. More information about the workers’ compensation system, aimed specifically at health-care providers, could be delivered during medical training, on workers’ compensation websites and through continuing medical education courses. Also, workers’ compensation policy-makers, health-care providers and other stakeholders such as injured workers, employers and unions could engage in a dialogue to identify clear guidelines about the role of health-care providers in the system.
2. Discussion is needed between health-care providers and workers’ compensation decision-makers about the appropriateness of early return to work for certain types of injuries and illnesses, and about strategies for helping patients with complex and prolonged injuries.
3. Case managers could benefit from receiving additional training related to mental health and chronic pain to ensure that workers with these conditions are supported appropriately.
4. Changes could be considered to help health-care providers who treat patients with complex injuries, including revising forms to allow for a greater degree of elaboration when injuries are complex, as well as offering additional services (including mental health counselling) when healing is not progressing as expected.
5 Mechanisms could be put into place to allow health-care providers to easily get additional support with RTW when claims become complicated.
6 Internal medical consultants could be used to better communicate and collaborate with treating health-care providers—not overturn medical recommendations. Treating health-care providers—typically general physicians—are in a good position to understand factors that will complicate recovery and return to work, and their insights should be integrated into return-to-work planning.