Beyond Work Hardening 101 Connie Doherty, MBA, OYRIl Bethesda Work Capacity Centers Cincinnati, Ohio
HISTORY Work hardening is a relatively new, fastgrowing area of rehabilitation. This is evidenced by the fact that the first public presentation given on a national level was in 1979. Entitled "The Evaluation of Work Capacity of Injured Employees," it was given by Leonard Matheson, Ph.D., to the American Occupational Medicine Association. 1 The first national publication on the subject was entitled "Work Hardening: Occupational Therapy in Industrial Rehabilitation" by Matheson, Ogden, Viollett, and Schultz in The American Journal of Occupational Therapy (AJar), published in 1985. 2 Work hardening appears to be the new buzzword in rehabilitation. This is due to a number of factors, including the onset of the diagnostic related group (DRG) ruling (which has put a tighter financial grip on other areas of rehabilitation), soaring Workers' Compensation costs, and outcries from Workers' Compensation officials and employers to meet the needs of the injured worker. Another significant factor evident in the development and understanding of work hardening is the limited number of graduate, postgraduate, and continuing-education opportunities available in the field. There are courses to give definitions and the nuts and bolts for setting up and running a work-hardening program such as "Work Hardening," "Functional
Capacity Evaluation," "Marketing," "Symptom Magnification," "Startup." But what is work hardening? There are several schools of thought with differences of opinion. The followers of Blankenship have a philosophy geared toward musculoskeletal dysfunction and the programs are primarily focused on physical therapy. 3 On the other hand, the followers of Matheson are geared toward the vocational model and are primarily occupational therapy and/or vocationally based. 4 If you use Matheson's Stage Model for Industrial Rehabilitation, you will find programs ranging in all spectrums from Level 2 through 8, focusing in the following areas, with any and all combinations in between. 5 Level 2: Level 3: Level 4: Level 5: Level 6: Level 7: Level 8:
Impairment Functional limitation Disability Feasibility Employability Vocational Handicap Earning capacity
In response to the outcry in the field for some consistency of purpose, the Commission on Accreditation of Rehabilitation Facilities (CARF) decided to develop standards for work hardening. A National Advisory Committee was convened in March 1988 to draft the standards. This committee was composed of leaders in work hardening from across the country. 6 The standards were sent out for field review in June 1988 and published in January 1989. The standards went into effect in July 1989 with the Bethesda Work Capacity Centers
Beyond Work Hardening 10 1
being the first in the nation to be surveyed and accredited and other programs following closely behind. The standards address what work hardening is, what makes up a comprehensive program, and how to ensure a workhardening program will provide quality care on a consistent basis. Now what? We have the nuts and bolts for setting up a program. We have standards to help assure quality of care. While each facility is at a different stage of development, each has experienced the growing pains of development. Concerns that must be addressed after the initial start-up phase include: 1. Determining what the program is capable of doing. 2. Determining what disciplines should be involved. 3. Determining the role and function of each discipline. 4. Developing individual programs to meet the needs of the client. 5. Dealing with the difficult client (including areas of symptom magnification and noncompliance). 6. Handling difficult situations. 7. Determining program effectiveness. 8. Meeting the needs of the multiple consumers involved. 9. Determining program weaknesses. 10. Determining and prioritizing solutions to problem areas. 11. Making the program work in the constraints of the complex Workers' Compensation system. This article will address these concerns, which are integral parts of developing and maintaining a quality program on a consistent basis.
THE MISSION The first task any center must undergo is to determine what it does or would like to do. This is called developing a mission. In order to do this, the center must critically analyze what needs are going unmet and what problems are
63
associated with returning individuals to work. These problems include the very obvious areas of decreased strength, decreased endurance/ work tolerance, and decreased ability to perform the physical demand required on the individual's job. Problems include length of time off work (which could affect overall feasibility) as well as decreased conditioning. They also include the more difficult areas ofIack of motivation, chronic pain, lack of vocational planning or goals, job satisfaction, employer relations, feelings of entitlement, poor physician! attorney education (which leads to enabling), fear of reinjury, and anxiety regarding transition to work.
DEVELOPMENT OF PROGRAM GOALS After defining the problems associated with returning someone to work, the next decision is to determine what you need to provide, what you want to provide, and what you can realistically provide. It is important for a program to realize that it cannot do all things for all people. Since a program can only do a finite number of things, it is important to develop the overall goals for the program. In keeping with the definition of work hardening from CARF, the goals should include: 1. Improving ability to safely perform work task, 2. Improving physical-demand characteristic! physical tolerances related to the specific job, 3. Improving musculoskeletal dysfunction, 4. Improving issues of productivity, and 5. Improving work behaviors, among others. It is critical for the program to determine the program goals in the context of the demands for competitive employment. For example, it might be determined that hamstring flexibility is one of the physical requirements necessary to be able to lift objects from the floor. However, if the goal is only addressed as hamstring flexibility and not hamstring flexibility related to a
64
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specific task, then the goal is not specifically designed to maximize the individual's ability to return to work, only to increase hamstring flexibility to some arbitrary measure. In the same light, a program may have a goal to increase pain tolerance. However, you need to determine what is acceptable in the workplace in order to develop the measurement criteria for this goal. It is important to take each of the program goals and determine how it is related to maximizing the individual's ability to return to work.
THE APPROACH: INTERDISCIPLINARY VERSUS MULTIDISCIPLINARY Now we have the constraints of the program. The next step is to determine what disciplines should be involved and to develop role delineations to ensure that all processes will be met. This can be done by a number of methods. However, this author would like to suggest one that, while not radical in concept, is radical in practice. This is the interdisciplinary-treatment concept. To understand why this is radical in practice, let us discuss the definitions of both interdisciplinary and multidisciplinary. Interdisciplinary is defined as "characterized by participation or cooperation of two or more disciplines or fields of study; drawing on or contributing to two or more disciplines." Multidisciplinary is defined as "combining several specialized disciplines for a common purpose." Most facilities in all types of rehabilitation, while calling their approach interdisciplinary, practice the multidisciplinary approach. In the multidisciplinary approach, each discipline works on a specific task in relation to a common purpose but essentially does not have to interact with anyone else in order to get the job done. For example, on an inpatient rehabilitation unit, while each discipline is essentially working on improving an individual's function to return home, the goals tend to be very serviceoriented. For example, physical therapy might work to maximize ambulation and mobility, while occupational therapy will maximize the
skills involved in the daily living activities of bathing and dressing. The goals and subsequent outcomes are not related to an overall functional goal, but to the individual service goal. The interdisciplinary approach, on the other hand, requires each discipline to work together to achieve one overall functional goal. In work hardening there is a golden opportunity to have an interdisciplinary approach. All of the goals should be related directly to overall function. And each discipline must have input in order for the goals to be achieved. For example, the goal is to increase the physical capacity of lifting required by the individual's job. The physical therapist may use his or her expertise in the musculoskeletal-function area. The occupational therapist may use his or her expertise in activity analysis and job modification, and the vocational specialist may use his or her expertise in understanding the workplace for the transition to work. Hence, people from each discipline are required to work together on the specific goal by providing expertise in order to achieve goal attainment. Too often we take the easy way out by delineating specific functions in work hardening. For example, the physical therapist concentrates only on exercise and conditioning. The occupational therapist concentrates on the job simulation, and the vocational specialist concentrates on vocational testing and placement and transition to work. While appearing efficient, the segmentation does not allow the program to look at the interrelationships in the total picture. With only the physical therapist concentrating on exercise and conditioning, the behavioral and vocational aspects that occur duri~g the exercise or conditioning program are not addressed by the individuals who have the most expertise. On the other hand, if job simulation is addressed only by the occupational therapist, the musculoskeletal expertise of the physical therapist is lost. If the program can be delineated by goal instead of function, then each discipline in the interdisciplinary approach can provide its expertise for the achievement of that particular goal. In this approach you must interact or attainment of
Beyond Work Hardening 10 1
the goal will be compromised. In order to have optimal goal attainment, the program should review all of the goals that have been established and determine which discipline's expertise is required. The next step would be to select the discipline that would maximize achieving the goal.
THE GOAL PROCESS IN THE DEVELOPMENT OF INDIVIDUAL PROGRAM PLANS Thus far, total program needs, determining goals to meet those needs, determining who needs to be involved in the process, and establishing their role and function have been addressed. The next step is to look at the individual client and develop a plan that meets his or her needs to return to work within the context of the program. Information can be obtained from evaluation results, while will provide areas that need to be addressed in returning the client to work. In addition, the client will provide insight into his or her needs and wants. With these program goals, a plan can be constructed. A case example should help illustrate this point. You have recendy evaluated a 52-year-old female with a diagnosis of lumbosacral strain. Her job as a full-time office clerk includes lifting packages of checks, putting checks in trays, carrying the trays, pushing a wheeled cart, lifting bags from the floor, and processing the checks on an encoder. The job also requires bending, walking, standing, and twisting. The maximal lifting weight is 25 pounds. This client has been off work for approximately six months and has received other types of acute treatment that have not enabled her to return to work. The assessment of the client is as follows: 1. Physical capacities that are below the level that would allow her to return to her former occupation. 2. Pain in the low-back musculature. 3. Poor posture and body mechanics. 4. Decreased endurance for an eight-hour workday.
65
5. Decreased tolerance to activity. 6. Postural deficits in the thoracic and cervical spine region. 7. Limited trunk motion in side bending and rotation with complaints of pain on the right. 8. Deficits in lower-extremity flexibility. 9. Deficits in trunk strength. 10. Image of an extremely debilitated individual with poor self-concept and worker concept. 11. Poor pain-coping mechanisms. 12. Self-limiting behavior. 13. Fear of reinjury. 14. Tendency toward symptom magnification. The client's input included the following five goals: 1. To be able to return to work at her bank job, which included sitting for long periods of time. 2. Walking without pain. 3. Learning to live with the pain. 4. Improving her quality of work. 5. Getting along with others. It is important to note that during the client's initial interview, she was unable to envision herself returning to her job and could see no options or alternatives for the future. Her only goal, at that time, was to be able to do things without back and leg pain. We now need to integrate this information with our program goals to develop the individual's program plan. The first goal should include increasing the client's ability to safely perform and sustain workplace activities required of her bank job. These activities include those oudined in the job description. This goal also would include the physical-demand level of that particular job. The second goal should address improving the client's musculoskeletal dysfunction so that the client can properly and safely carry out the work activities. The goal would address the deficits in posture, trunk range of motion, and trunk strength.
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The third goal should address improving the client's pain-coping mechanisms so that the work can be sustained. This goal area addresses both pain tolerance or tolerance to activity due to increased pain, and pain behaviors that address the overfocus on pain and other overt pain behaviors. This goal should address alternative coping mechanisms to deal with decreasing pain behaviors and increasing tolerance to activity. The fourth goal should address improving the client's work productivity so that the quantity/quality of work required can be maintained. There is no evidence from evaluation or previous work history that this client had difficulty in attendance, timeliness, or quality or quantity of work prior to injury. However, it is important that the client expressed concern and desire to improve the quality of work that she produced. Additionally, the client has been out of work for approximately six months and is likely to have some deficits in her ability to perform the quantity and quality of work required by her position. The fifth goal should address the client's cognitive functioning so that job activities can be adequately carried out. This goal could include memory, concentration, instructibility, and problem-solving capabilities. For this particular client, the problem-solving capabilities would be the particular area of focus. She had identified, in her initial interview, poor potential for positive outcome, as well as inability to formulate options or alternatives if she is unable to return to her former position. The sixth goal should address adherence to workplace safety. This could include body mechanics, use of protective behaviors, problem solving in relation to safety, and pacing activities in order to sustain work over a period of time. The seventh goal should address the client's interpersonal skills as related to job feasibility. Components of this goal would include acceptance of supervision, response to fellow workers, and response to change. There is little evidence from evaluation or past history that would indicate the client would have difficulty with supervision. The client expressed a specific
concern to enhance her ability to get along with others. Additionally, the client lacked insight into possible alternatives for her future, which would indicate that change may become an obstacle to treatment. The final goal would address the client's selfimage of being a worker. The components of this goal include general worker attitude, facilitation of the client's transition to work, behavioral issues that are detrimental to work, past issues with employers, and motivational issues. This is an important goal in the total picture, since the client exhibited poor self-concept and worker concept during the evaluation, as well as self-limiting behavior, fear of reinjury, symptom-magnification tendencies, and limited ability to formulate options. Each of the goals is a necessary portion of the total plan to improve the client's overall feasibility to return to work. It is the program's responsibility to maximize all aspects required to return an individual to work. If any of the goals are deleted, then an important component of the overall picture is missing, thus limiting the potential for maximal outcome. Additionally, formulating goals in all of the component areas will assist in dealing with the difficult client and difficult situation. If goals are only formulated to address physical problems, there is no context to address behavioral and attitudinal issues, which often become the primary focus of treatment and prove to be the most limiting factors in returning an individual to work. After each goal has been formulated for the individual, it is important to determine the measurement criteria for the specific goals, keeping in mind the goal's relationship to enhancing the individual's ability to return to work. For example, trunk range of motion should be addressed in the context of what is required for competitive employment, not what is required to have normal trunk range of motion. If the question of what specifically is required to enable the individual to return to work can be answered, then the chances for optimal goal attainment will increase.
Beyond Work Hardening 101
PROGRAM EVALUATION-THE KEY TO CONTINUOUS QUALITY ENHANCEMENT The final questions for discussion include (1) How do we determine the effectiveness of the overall program? (2) Is the program meeting the needs of the clients and referral sources? (3) What portions of the program require modifications to improve outcome and enhance quality of care? A system needs to be devised to critically analyze all ofthe components of the program and their interrelationships. This will assist in identifYing problems and possible solutions. Setting up a program-evaluation system appears to be a complex task. However, by following a few simple steps, a system can be developed and maintained that will analyze the program components and yield positive results. The first step needs to include developing an understanding of the purpose of program evaluation. The purpose of an overall program evaluation is to look at the overall program results, to appraise their effectiveness, and to identifY areas that are less than optimal. Program evaluation should not be constructed or seen as a mechanism only for collecting statistics. It needs to be viewed as a dynamic system that will assist in ensuring quality care on an ongoing basis. The second step in developing a program evaluation is deciding what you need to know. This is probably the most important and most difficult step. The program needs to take a step back and decide what information the program designers would like to know, let's say, a year from now, and in what combinations the program designers would like to look at the results. One method of doing this is to hypothesize the factors that will influence outcome. Then, the system needs to be developed to encompass those factors. In a work-hardening program, the most obvious information is what percentage of clients are returning to work. However, that is only a part of what needs to be analyzed. Other factors to be analyzed could include the percent-
67
age of people who complete or do not complete the program, the reasons for completion or noncompletion, other referral action taken with those individuals who completed or did not complete the program, goal attainment in the individual goal areas, as well as other classifications that will be helpful in analyzing data. These might include age, physician of record, chiropractic involvement, attorney involvement or active litigation, diagnostic categories, occupation categories, surgical intervention, time off work since injury, and job target. Also included may be behavioral or job-satisfaction issues that affect outcome. Other factors to be included are the length of the program and the absenteeism rate. This will allow the program to sort the individuals, for instance, who completed the program and returned to work versus those who completed the program and did not return to work. By developing a coding system, the program can then determine, for example, specific reasons why individuals did not return to work. This may provide valuable information. It may also be interesting to look at those individuals who did not complete the program and the reasons for noncompletion. This may pinpoint areas for program addition and/or enhancement to improve results. By breaking down the statistics in specific categories, the program can determine other influences that effect overall outcome. The data need to be compiled and analyzed on a periodic basis. The next important step of the program-evaluation system is to use the data and make appropriate changes in the program based on the results. For example, if a program has a high noncompletion rate for medical reasons, the program may want to enhance its medical-screening or admission criteria to help provide more appropriate care for the client. Or a program that has a high noncompletion rate for nonfeasibility or pain reasons may want to increase the vocational and psychological components of the program to enhance the completion rate. It is important to review the program changes and the results of the program-evaluation system to determine if the changes made were
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effective. The program-evaluation system will allow you to systematically analyze the program in this fashion. The long-term effect will lead to continuous program improvement.
SUMMARY Many facilities have enthusiastically entered the work-hardening market, have understood the basic concepts, and have gone through the initial start-up phases. However, then each program is faced with the more difficult decisions of how to handle clients on an ongoing basis and how to provide high-quality, consistent services. This article was intended to provide the reader with knowledge about work hardening beyond the fundamentals of establishing programs. It was also the intent to provide a
conceptual framework to improve existing rehabilitation programs, and subsequently, their outcomes. Three important components are required for this framework. 1. Developing and understanding the mission and goal process 2. Establishing an interdisciplinary team process 3. Developing and utilizing a programevaluation system to monitor program effectiveness
With these additional tools to provide a framework, a facility can move beyond the basic understanding of work hardening and deal with the complex issues related to this field of practice.
REFERENCES 1. Matheson LN: Inte{ffated Work Hardening in Vocational Rehabilitation: An Emerging Model. Personal Communication, 1988. 2. Matheson L, Ogden L, Viollett K, and
Schultz K: Occupational therapy in industrial rehabilitation. Am] Occup Ther 1985; 5:314-323. 3. K Blankenship, PT: President, American Therapeutics, Inc., Macon GA. 4. LN Matheson, PhD: Director of Research,
Physical Assessment and Reactivation Center, Irvine Medical Center, Irvine CA 5. Matheson LN, Ogden L, Niemeyer 0: Work Capacity Evaluation: Systematic Approach to Industrial Rehabilitation. Einployment and Rehabilitation Institute of California, 1986.
6. Commission on Accreditation of Rehabilitation Facilities: Standards Manual for Organiwtions Serving Persons with Disabilities. Tucson AZ, CARF, 1989.
HISTORY Work hardening is a relatively new, fastgrowing area of rehabilitation. This is evidenced by the fact that the first public presentation given on a national level was in 1979. Entitled "The Evaluation of Work Capacity of Injured Employees," it was given by Leonard Matheson, Ph.D., to the American Occupational Medicine Association. 1 The first national publication on the subject was entitled "Work Hardening: Occupational Therapy in Industrial Rehabilitation" by Matheson, Ogden, Viollett, and Schultz in The American Journal of Occupational Therapy (AJar), published in 1985. 2 Work hardening appears to be the new buzzword in rehabilitation. This is due to a number of factors, including the onset of the diagnostic related group (DRG) ruling (which has put a tighter financial grip on other areas of rehabilitation), soaring Workers' Compensation costs, and outcries from Workers' Compensation officials and employers to meet the needs of the injured worker. Another significant factor evident in the development and understanding of work hardening is the limited number of graduate, postgraduate, and continuing-education opportunities available in the field. There are courses to give definitions and the nuts and bolts for setting up and running a work-hardening program such as "Work Hardening," "Functional
Capacity Evaluation," "Marketing," "Symptom Magnification," "Startup." But what is work hardening? There are several schools of thought with differences of opinion. The followers of Blankenship have a philosophy geared toward musculoskeletal dysfunction and the programs are primarily focused on physical therapy. 3 On the other hand, the followers of Matheson are geared toward the vocational model and are primarily occupational therapy and/or vocationally based. 4 If you use Matheson's Stage Model for Industrial Rehabilitation, you will find programs ranging in all spectrums from Level 2 through 8, focusing in the following areas, with any and all combinations in between. 5 Level 2: Level 3: Level 4: Level 5: Level 6: Level 7: Level 8:
Impairment Functional limitation Disability Feasibility Employability Vocational Handicap Earning capacity
In response to the outcry in the field for some consistency of purpose, the Commission on Accreditation of Rehabilitation Facilities (CARF) decided to develop standards for work hardening. A National Advisory Committee was convened in March 1988 to draft the standards. This committee was composed of leaders in work hardening from across the country. 6 The standards were sent out for field review in June 1988 and published in January 1989. The standards went into effect in July 1989 with the Bethesda Work Capacity Centers
Beyond Work Hardening 10 1
being the first in the nation to be surveyed and accredited and other programs following closely behind. The standards address what work hardening is, what makes up a comprehensive program, and how to ensure a workhardening program will provide quality care on a consistent basis. Now what? We have the nuts and bolts for setting up a program. We have standards to help assure quality of care. While each facility is at a different stage of development, each has experienced the growing pains of development. Concerns that must be addressed after the initial start-up phase include: 1. Determining what the program is capable of doing. 2. Determining what disciplines should be involved. 3. Determining the role and function of each discipline. 4. Developing individual programs to meet the needs of the client. 5. Dealing with the difficult client (including areas of symptom magnification and noncompliance). 6. Handling difficult situations. 7. Determining program effectiveness. 8. Meeting the needs of the multiple consumers involved. 9. Determining program weaknesses. 10. Determining and prioritizing solutions to problem areas. 11. Making the program work in the constraints of the complex Workers' Compensation system. This article will address these concerns, which are integral parts of developing and maintaining a quality program on a consistent basis.
THE MISSION The first task any center must undergo is to determine what it does or would like to do. This is called developing a mission. In order to do this, the center must critically analyze what needs are going unmet and what problems are
63
associated with returning individuals to work. These problems include the very obvious areas of decreased strength, decreased endurance/ work tolerance, and decreased ability to perform the physical demand required on the individual's job. Problems include length of time off work (which could affect overall feasibility) as well as decreased conditioning. They also include the more difficult areas ofIack of motivation, chronic pain, lack of vocational planning or goals, job satisfaction, employer relations, feelings of entitlement, poor physician! attorney education (which leads to enabling), fear of reinjury, and anxiety regarding transition to work.
DEVELOPMENT OF PROGRAM GOALS After defining the problems associated with returning someone to work, the next decision is to determine what you need to provide, what you want to provide, and what you can realistically provide. It is important for a program to realize that it cannot do all things for all people. Since a program can only do a finite number of things, it is important to develop the overall goals for the program. In keeping with the definition of work hardening from CARF, the goals should include: 1. Improving ability to safely perform work task, 2. Improving physical-demand characteristic! physical tolerances related to the specific job, 3. Improving musculoskeletal dysfunction, 4. Improving issues of productivity, and 5. Improving work behaviors, among others. It is critical for the program to determine the program goals in the context of the demands for competitive employment. For example, it might be determined that hamstring flexibility is one of the physical requirements necessary to be able to lift objects from the floor. However, if the goal is only addressed as hamstring flexibility and not hamstring flexibility related to a
64
W 0 R K / FALL 1990
specific task, then the goal is not specifically designed to maximize the individual's ability to return to work, only to increase hamstring flexibility to some arbitrary measure. In the same light, a program may have a goal to increase pain tolerance. However, you need to determine what is acceptable in the workplace in order to develop the measurement criteria for this goal. It is important to take each of the program goals and determine how it is related to maximizing the individual's ability to return to work.
THE APPROACH: INTERDISCIPLINARY VERSUS MULTIDISCIPLINARY Now we have the constraints of the program. The next step is to determine what disciplines should be involved and to develop role delineations to ensure that all processes will be met. This can be done by a number of methods. However, this author would like to suggest one that, while not radical in concept, is radical in practice. This is the interdisciplinary-treatment concept. To understand why this is radical in practice, let us discuss the definitions of both interdisciplinary and multidisciplinary. Interdisciplinary is defined as "characterized by participation or cooperation of two or more disciplines or fields of study; drawing on or contributing to two or more disciplines." Multidisciplinary is defined as "combining several specialized disciplines for a common purpose." Most facilities in all types of rehabilitation, while calling their approach interdisciplinary, practice the multidisciplinary approach. In the multidisciplinary approach, each discipline works on a specific task in relation to a common purpose but essentially does not have to interact with anyone else in order to get the job done. For example, on an inpatient rehabilitation unit, while each discipline is essentially working on improving an individual's function to return home, the goals tend to be very serviceoriented. For example, physical therapy might work to maximize ambulation and mobility, while occupational therapy will maximize the
skills involved in the daily living activities of bathing and dressing. The goals and subsequent outcomes are not related to an overall functional goal, but to the individual service goal. The interdisciplinary approach, on the other hand, requires each discipline to work together to achieve one overall functional goal. In work hardening there is a golden opportunity to have an interdisciplinary approach. All of the goals should be related directly to overall function. And each discipline must have input in order for the goals to be achieved. For example, the goal is to increase the physical capacity of lifting required by the individual's job. The physical therapist may use his or her expertise in the musculoskeletal-function area. The occupational therapist may use his or her expertise in activity analysis and job modification, and the vocational specialist may use his or her expertise in understanding the workplace for the transition to work. Hence, people from each discipline are required to work together on the specific goal by providing expertise in order to achieve goal attainment. Too often we take the easy way out by delineating specific functions in work hardening. For example, the physical therapist concentrates only on exercise and conditioning. The occupational therapist concentrates on the job simulation, and the vocational specialist concentrates on vocational testing and placement and transition to work. While appearing efficient, the segmentation does not allow the program to look at the interrelationships in the total picture. With only the physical therapist concentrating on exercise and conditioning, the behavioral and vocational aspects that occur duri~g the exercise or conditioning program are not addressed by the individuals who have the most expertise. On the other hand, if job simulation is addressed only by the occupational therapist, the musculoskeletal expertise of the physical therapist is lost. If the program can be delineated by goal instead of function, then each discipline in the interdisciplinary approach can provide its expertise for the achievement of that particular goal. In this approach you must interact or attainment of
Beyond Work Hardening 10 1
the goal will be compromised. In order to have optimal goal attainment, the program should review all of the goals that have been established and determine which discipline's expertise is required. The next step would be to select the discipline that would maximize achieving the goal.
THE GOAL PROCESS IN THE DEVELOPMENT OF INDIVIDUAL PROGRAM PLANS Thus far, total program needs, determining goals to meet those needs, determining who needs to be involved in the process, and establishing their role and function have been addressed. The next step is to look at the individual client and develop a plan that meets his or her needs to return to work within the context of the program. Information can be obtained from evaluation results, while will provide areas that need to be addressed in returning the client to work. In addition, the client will provide insight into his or her needs and wants. With these program goals, a plan can be constructed. A case example should help illustrate this point. You have recendy evaluated a 52-year-old female with a diagnosis of lumbosacral strain. Her job as a full-time office clerk includes lifting packages of checks, putting checks in trays, carrying the trays, pushing a wheeled cart, lifting bags from the floor, and processing the checks on an encoder. The job also requires bending, walking, standing, and twisting. The maximal lifting weight is 25 pounds. This client has been off work for approximately six months and has received other types of acute treatment that have not enabled her to return to work. The assessment of the client is as follows: 1. Physical capacities that are below the level that would allow her to return to her former occupation. 2. Pain in the low-back musculature. 3. Poor posture and body mechanics. 4. Decreased endurance for an eight-hour workday.
65
5. Decreased tolerance to activity. 6. Postural deficits in the thoracic and cervical spine region. 7. Limited trunk motion in side bending and rotation with complaints of pain on the right. 8. Deficits in lower-extremity flexibility. 9. Deficits in trunk strength. 10. Image of an extremely debilitated individual with poor self-concept and worker concept. 11. Poor pain-coping mechanisms. 12. Self-limiting behavior. 13. Fear of reinjury. 14. Tendency toward symptom magnification. The client's input included the following five goals: 1. To be able to return to work at her bank job, which included sitting for long periods of time. 2. Walking without pain. 3. Learning to live with the pain. 4. Improving her quality of work. 5. Getting along with others. It is important to note that during the client's initial interview, she was unable to envision herself returning to her job and could see no options or alternatives for the future. Her only goal, at that time, was to be able to do things without back and leg pain. We now need to integrate this information with our program goals to develop the individual's program plan. The first goal should include increasing the client's ability to safely perform and sustain workplace activities required of her bank job. These activities include those oudined in the job description. This goal also would include the physical-demand level of that particular job. The second goal should address improving the client's musculoskeletal dysfunction so that the client can properly and safely carry out the work activities. The goal would address the deficits in posture, trunk range of motion, and trunk strength.
66
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The third goal should address improving the client's pain-coping mechanisms so that the work can be sustained. This goal area addresses both pain tolerance or tolerance to activity due to increased pain, and pain behaviors that address the overfocus on pain and other overt pain behaviors. This goal should address alternative coping mechanisms to deal with decreasing pain behaviors and increasing tolerance to activity. The fourth goal should address improving the client's work productivity so that the quantity/quality of work required can be maintained. There is no evidence from evaluation or previous work history that this client had difficulty in attendance, timeliness, or quality or quantity of work prior to injury. However, it is important that the client expressed concern and desire to improve the quality of work that she produced. Additionally, the client has been out of work for approximately six months and is likely to have some deficits in her ability to perform the quantity and quality of work required by her position. The fifth goal should address the client's cognitive functioning so that job activities can be adequately carried out. This goal could include memory, concentration, instructibility, and problem-solving capabilities. For this particular client, the problem-solving capabilities would be the particular area of focus. She had identified, in her initial interview, poor potential for positive outcome, as well as inability to formulate options or alternatives if she is unable to return to her former position. The sixth goal should address adherence to workplace safety. This could include body mechanics, use of protective behaviors, problem solving in relation to safety, and pacing activities in order to sustain work over a period of time. The seventh goal should address the client's interpersonal skills as related to job feasibility. Components of this goal would include acceptance of supervision, response to fellow workers, and response to change. There is little evidence from evaluation or past history that would indicate the client would have difficulty with supervision. The client expressed a specific
concern to enhance her ability to get along with others. Additionally, the client lacked insight into possible alternatives for her future, which would indicate that change may become an obstacle to treatment. The final goal would address the client's selfimage of being a worker. The components of this goal include general worker attitude, facilitation of the client's transition to work, behavioral issues that are detrimental to work, past issues with employers, and motivational issues. This is an important goal in the total picture, since the client exhibited poor self-concept and worker concept during the evaluation, as well as self-limiting behavior, fear of reinjury, symptom-magnification tendencies, and limited ability to formulate options. Each of the goals is a necessary portion of the total plan to improve the client's overall feasibility to return to work. It is the program's responsibility to maximize all aspects required to return an individual to work. If any of the goals are deleted, then an important component of the overall picture is missing, thus limiting the potential for maximal outcome. Additionally, formulating goals in all of the component areas will assist in dealing with the difficult client and difficult situation. If goals are only formulated to address physical problems, there is no context to address behavioral and attitudinal issues, which often become the primary focus of treatment and prove to be the most limiting factors in returning an individual to work. After each goal has been formulated for the individual, it is important to determine the measurement criteria for the specific goals, keeping in mind the goal's relationship to enhancing the individual's ability to return to work. For example, trunk range of motion should be addressed in the context of what is required for competitive employment, not what is required to have normal trunk range of motion. If the question of what specifically is required to enable the individual to return to work can be answered, then the chances for optimal goal attainment will increase.
Beyond Work Hardening 101
PROGRAM EVALUATION-THE KEY TO CONTINUOUS QUALITY ENHANCEMENT The final questions for discussion include (1) How do we determine the effectiveness of the overall program? (2) Is the program meeting the needs of the clients and referral sources? (3) What portions of the program require modifications to improve outcome and enhance quality of care? A system needs to be devised to critically analyze all ofthe components of the program and their interrelationships. This will assist in identifYing problems and possible solutions. Setting up a program-evaluation system appears to be a complex task. However, by following a few simple steps, a system can be developed and maintained that will analyze the program components and yield positive results. The first step needs to include developing an understanding of the purpose of program evaluation. The purpose of an overall program evaluation is to look at the overall program results, to appraise their effectiveness, and to identifY areas that are less than optimal. Program evaluation should not be constructed or seen as a mechanism only for collecting statistics. It needs to be viewed as a dynamic system that will assist in ensuring quality care on an ongoing basis. The second step in developing a program evaluation is deciding what you need to know. This is probably the most important and most difficult step. The program needs to take a step back and decide what information the program designers would like to know, let's say, a year from now, and in what combinations the program designers would like to look at the results. One method of doing this is to hypothesize the factors that will influence outcome. Then, the system needs to be developed to encompass those factors. In a work-hardening program, the most obvious information is what percentage of clients are returning to work. However, that is only a part of what needs to be analyzed. Other factors to be analyzed could include the percent-
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age of people who complete or do not complete the program, the reasons for completion or noncompletion, other referral action taken with those individuals who completed or did not complete the program, goal attainment in the individual goal areas, as well as other classifications that will be helpful in analyzing data. These might include age, physician of record, chiropractic involvement, attorney involvement or active litigation, diagnostic categories, occupation categories, surgical intervention, time off work since injury, and job target. Also included may be behavioral or job-satisfaction issues that affect outcome. Other factors to be included are the length of the program and the absenteeism rate. This will allow the program to sort the individuals, for instance, who completed the program and returned to work versus those who completed the program and did not return to work. By developing a coding system, the program can then determine, for example, specific reasons why individuals did not return to work. This may provide valuable information. It may also be interesting to look at those individuals who did not complete the program and the reasons for noncompletion. This may pinpoint areas for program addition and/or enhancement to improve results. By breaking down the statistics in specific categories, the program can determine other influences that effect overall outcome. The data need to be compiled and analyzed on a periodic basis. The next important step of the program-evaluation system is to use the data and make appropriate changes in the program based on the results. For example, if a program has a high noncompletion rate for medical reasons, the program may want to enhance its medical-screening or admission criteria to help provide more appropriate care for the client. Or a program that has a high noncompletion rate for nonfeasibility or pain reasons may want to increase the vocational and psychological components of the program to enhance the completion rate. It is important to review the program changes and the results of the program-evaluation system to determine if the changes made were
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effective. The program-evaluation system will allow you to systematically analyze the program in this fashion. The long-term effect will lead to continuous program improvement.
SUMMARY Many facilities have enthusiastically entered the work-hardening market, have understood the basic concepts, and have gone through the initial start-up phases. However, then each program is faced with the more difficult decisions of how to handle clients on an ongoing basis and how to provide high-quality, consistent services. This article was intended to provide the reader with knowledge about work hardening beyond the fundamentals of establishing programs. It was also the intent to provide a
conceptual framework to improve existing rehabilitation programs, and subsequently, their outcomes. Three important components are required for this framework. 1. Developing and understanding the mission and goal process 2. Establishing an interdisciplinary team process 3. Developing and utilizing a programevaluation system to monitor program effectiveness
With these additional tools to provide a framework, a facility can move beyond the basic understanding of work hardening and deal with the complex issues related to this field of practice.
REFERENCES 1. Matheson LN: Inte{ffated Work Hardening in Vocational Rehabilitation: An Emerging Model. Personal Communication, 1988. 2. Matheson L, Ogden L, Viollett K, and
Schultz K: Occupational therapy in industrial rehabilitation. Am] Occup Ther 1985; 5:314-323. 3. K Blankenship, PT: President, American Therapeutics, Inc., Macon GA. 4. LN Matheson, PhD: Director of Research,
Physical Assessment and Reactivation Center, Irvine Medical Center, Irvine CA 5. Matheson LN, Ogden L, Niemeyer 0: Work Capacity Evaluation: Systematic Approach to Industrial Rehabilitation. Einployment and Rehabilitation Institute of California, 1986.
6. Commission on Accreditation of Rehabilitation Facilities: Standards Manual for Organiwtions Serving Persons with Disabilities. Tucson AZ, CARF, 1989.
