PERSPECTIVES
RETURN-TO-WORK PROGRAMS
Richard K. Schwartz, MS, OTR* Consulting Services 1800 N. E. Loop 410, Suite 416 San Antonio, Texas
RATIONALE FOR RETURN-TO-WORK PROGRAMS To be able to successfully return a worker to employment following injury requires knowledge, skills, and attitudes that both go beyond and run counter to those possessed by most medical rehabilitation providers. First, the nature of the work-
• Richard Schwartz, guest editor for this issue of WORK, is the owner of Consulting Services, a firm specializing in the design and implementation of proactive risk management programs for business, industry, and government. His work includes loss prevention, safety training, ergonomic job analysis/job descriptions, and regulatory compliance programs. Clients include Bausch and Lomb Corporation, K.C.I. (Kinetic Concepts), Sony Microelectronics Corp., Southwestern Bell Telephone Co., the Texas Rehabilitation Commission, U.S.A.A., and the United States Department of Veterans Affairs.
place, including both physical and management environments, and the individual patient'sjob duties must be thoroughly understood. Second, the economic impact of various alternatives on both patients and employers must be appreciated. Third, a knowledge of ergonomics, exercise physiology, and occupational safety and health is required. Fourth, an expertise in labor management and counseling psychology is often required to negotiate and implement return-to-work programs. Finally, attitudes essential to return-towork are those that view the entire work injury management system (i.e., patient, employer, supervisor, workers' compensation manager, and medical providers) as client rather than the clinician's attitude that the patient is the client in work injury rehabilitation! Ogden-Niemeyer and Jacobs (1989) correctly predicted that there would have to eventually be a trend away from clinical work hardening programs as the basis for work rehabilitation programs towards whorkplacebased and employer-sponsored programs. What they failed to foresee was that work hardening services would become peripheral and ancillary, rather than central features of cost-effective, onthe-job work rehabilitation! An unfortunate number of clinic-based work rehabilitation/work hardening programs have
He currently serves on the Low Back Pain Panel, Agency of Health Care Policy and Research, U.S. Public Health Service, the Medical Advisory Board to the Texas Workers' Compensation Commission, and on the Return-to- Work Advisory Board, Texas Rehabilitation Commission. Mr. Schwartz has published extensively and was a corecipient of the 1990 Excellence in Research Writing Award from the Association of Academic Physiatrists. He has conducted many workshops throughout the U.S. and abroad and has lectured widely on work-injury prevention services, work rehabilitation, and medical cost containment measures.
WORK 1993; 3(3):2-8 Copyright © 1993 by Andover Medical
Return-To-Work Programs
come to abuse their authority by routinely prescribing evaluations and treatments that are not appropriate or necessary for most patients. Overutilization of services up to the maximum covered by workers' compensation is not an unusual practice. Numerous therapy clinics and practices are owned by the physicians whose patients are sent there for rehabilitation. The number of such operations in which ownership by referring physicians exceeds the AMA's 20 % maximum guideline is unknown. Work rehabilitation and work hardening are part of a multibillion dollar work injury management industry that, were it to meet its claims to the public, should be well on the way to putting itself out of business. This is not the case. Unfortunately, the product being marketed by such practices is not the product being sold. It is services, both evaluations and treatments, that are the true marketable products not favorable outcomes. The work rehabilitation industry has created providers whose knowledge of allowable CPTs (service codes) per ICD-9 (diagnostic codes) far exceeds their knowledge of effective treatments. Many, ifnot all, of the industry's leading advocates sponsor and/or conduct workshops for medical providers with the express purpose of convincing attendees that work injury management is a growth industry. In spite of any protestations to the contrary on the part of medical providers, it has become increasingly clear that work hardening is usually not an essential service but is nearly always an expensive service. What is worse is that there is no scientific evidence, such as from randomized, controlled clinical trials, to suggest that work hardening services deliver results above and beyond what can be delivered more cheaply, quickly, and simply by conservative medical management and an on-site return-to-work program. Taylor (1989) reviewed 19 articles from 19801986 that reported on rates of return to work following back surgeries. Overall, 77 % of the more than 3,600 patients reported on returned to their previous level of employment with 82 % returning following primary back surgery and 59 % of those with multiple back surgeries returning to their previous employment level. The point that should be made, but is often overlooked, is that most
3
back problems, including the most serious and expensive cases requiring surgery have an excellent prognosis for return to work irrespective of whether work hardening is employed. In Australia, national legislation has led to the government taking an innovative approach to this long neglected area by mandating a system based on the concept of workplace-based rehabilitation. "The underlying principle is that the workplace, and not a medical institution or the home, may be the most effective place to rehabilitate the majority of injured workers." (Workcover, 1987, p. 1) And perhaps the most shocking news is that the law expressly declares "not every injured worker will need rehabilitation." Denying injured workers access to rehabilitation services, regardless of how unnecessary these might be, is an idea that continues to meet with considerable resistance in the U.S. from medical providers, unions, and plaintiffs' attorneys. Expecting doctors and therapists, even those specializing in occupational medicine and rehabilitation, to supervise and direct the resumption of duties by a worker following a lost-time injury is as logical as expecting counterfeiters to serve as investment counselors just because they are experts at making money! Return-to-work programs are not, and should not be, medical rehabilitation programs. They are, and should remain, educational and human resource programs whose clients mayor may not be referred by medical providers. Most return-to-work programs are the creations of disability managers, rehabilitation counselors, insurance loss control experts, and not occupational or rehabilitation medicine specialists. Does medicine have a role to play in returning injured workers to the job? Yes, but it is not the role that medicine would like to play. Return-towork programs hold precious little hope for new profits and sources of revenues to medical providers, to their great dismay. As will be noted below, there are really very few medical services required in most return-to-work programs, and these are always used judiciously and sparingly rather than being required as part of a procrustean "package" of services, such as is common with work hardening programs (Dent, 1990).
4
WORK / SUMMER 1993
Return-to-work programs are far from monolithic. Yet, it is possible to characterize features that appear to be essential to most, if not all, such programs. To understand the truly radical nature and distinctiveness of return-to-work programs requires an appreciation of the goals of such programs and the methods/practices by which these goals are accomplished.
Goals of Return-to-Work Programs The following represents a synopsis of goals commonly advocated by return-to-work programs. Prevent loss of identity as worker. The longer an employee is away from work following injury, the lower the likelihood of returning to work. Taylor (1989) has described the involutional cycle that follows involuntary removal from the work force. The worker may feel blamed by the employer and/or insurance carrier. The role of provider is impaired or ceases completely. There is loss of self-esteem, depression, and a feeling ofloss of control over health and work. Maintaining an identity as a valuable, productive, contributing part of a work force becomes more and more difficult the longer one is told that work is not possible and the longer coworkers continue to function in spite of the absent (lost) coworker. Return-to-work programs are designed to keep the worker in the work force and part of the work milieu even during the period of treatment for injury! Encourage further healing following injury. Part of the mythology of medical treatment of work injuries is the notion that rest is essential to the healing process. Perhaps this comes from the adverse consequences of movement immediately following the initial trauma of injury, perhaps from a lack of understanding of requisite stimuli for healing musculoskeletal tissues such as muscle, tendon, bone, joint capsules, and ligaments. Regardless of the reasons, it has become increasingly clear that mobilization, including both active range of motion exercises and exercises to improve strength, endurance, and cardiovascular fitness are important contributors to physical recovery following injury. There is litde or no evidence that physical agents and/or passive modalities including
stretch, traction, electrical stimulation (other than functional electrical stimulation) affect the outcome status of patients with work-related injuries, and there is considerable evidence that these increase the costs of rehabilitation and may prolong the time spent away from work by the injured party. Prevent secondary deficits. As noted above, it is not only the individual's injury that leads to disability but also the consequences of one's response to injury that result in permanently compromised functional abilities. Rest often contributes more problems than it helps to remedy. Rest does not hasten recovery from musculoskeletal injuries (Taylor, 1988). Nachemson reports that for those who do not recover sufficiently to return to work within 4-6 weeks of initial low-back injury, "a gradual, biomechanically sound return to activity and work is the treatment that will make them symptom-free most rapidly. Patients must be told repeatedly that a gradual return to work will not worsen their condition in the future." (Schwartz, 1992, p. 80) Patients with chronic back pain show demineralization of the axial skeleton due presumably to inactivity. Prevent reinjury. Once injured on the job, the likelihood of reinjury at some future time increases. In fact, with respect to low-back injuries-those most ubiquitous of work-related injuries - successive injuries predict increasing chances of additional injuries. Yet, "back to school" approaches may not always be appropriate. Just because improper body mechanics (especially bending and twisting) can, and often do, contribute to low-back pain syndromes does not mean that an injured worker was not lifting correctly! In fact, when such patients are routinely sent to a classroom or clinic-oriented back school prior to return to work, the assumption is that these risk factors are there being addressed and that reinjury is being prevented. There is little or no evidence to suggest the validity of this assumption! Most physicians' return-to-work recommendations provide a classification of what a worker is or is not permitted to do. These are usually based on U.S. Department of Labor occupational title classification schemes. These classify work as sedentary, light, medium light, and so on, with brief descrip-
Return-To-Work Programs
tions of what is permitted in each classification. First and foremost, it allows a worker to return with a weight limitation without a prescribed frequency limitation! It turns out that a worker who follows these recommendations can exceed the National Institute of Occupational Safety and Health recommendations of such prescriptions (Schwartz, 1991a). Minimize losses to worker and to employer. Return to work programs seek to minimize employer losses as well as employee losses. This is significant in that the loss of a productive worker, the replacement of that worker, the increased burden on coworkers, and the administrative costs to maintain that worker in a disability system apart from the work force may cost as much or more as medical and indemnity costs. When workers are out, everyone loses. Return-towork programs minimize the disruption and costs of injuries. They eliminate the adversarial relationships that lead to tort actions and the add-on costs of such litigation. Return-to-work programs are good for the worker and they are good business.
METHODS/PROCEDU RES FOR ACHIEVING RETURN-TO-WORK GOALS One of the earliest reports on a return-to-work program was that of 3M Company, headquartered in St. Paul, Minnesota. Services des.cribed include case assessment, job analysis, medical coordination, job placement, and follow up (Beaudway, 1986). Dent (1990) added to this list: job modification (light or limited duty), adaptive devices, retraining, coaching, negotiation, role playing, job clubs, and trial employment. Recently, Gottlieb, Vandergoot, and Lutsky (1991) have further extended the list including: other positions in same company, flex time or reduced hours, transitional jobs, out-placement, telecommuting/ home-based work, and commuting/transportation assistance programs. Of the full range of services proposed, only a very few would seem to be within the domain of medical providers. Detailed descriptions of these program components can be found in the literature and will not be provided
5
here. The manner in which each contributes to overall success of programs deserves some comment. For present purposes, these have been rearranged to reflect the chronological sequence in which they often occur. Job analysis. Systematic evaluation of the worker's duties, physical environment, requisite knowledge, skills, and abilities provide information essential for planning return to work. Ideally, all positions within an organization would have been analyzed prior to implementation of the program. Although this has rarely been the case in the past, the Americans with Disabilities Act has resulted in a significant group of employers who have conducted job analyses as part of their response to regulatory requirements and EEOC guidelines. Case assessment. Evaluation of medical history, current injury assessments and treatments, educational background, family situation, motivation for return to work, and functional capacities provide information needed prior to determining the best course of action for an individual client. Medical coordination. Consultations among treating physician and therapists, the injured worker, and the employer's representative are useful in determining any medical concerns related to return to work and the need, if any, for on-the-job work hardening to be included in the program with or without medical supervision. Role playing. The return-to-work counselor may be able to deal with worker's fears, hostility, guilt, dependency, and/or lack of assertiveness through structured role playing to simulate the emotional/social environment. By teaching more effective social and communicative skills, failures of return-to-work program are minimized, and worker confidence and esteem are enhanced. Negotiation. There is often need for ongoing advocacy by the disability manager and/or rehabilitation/vocational counselor on behalf of the injured worker. Because return to work requires an expertise beyond that of the typical supervisor or manager, the counselor must perform liaison and educational services for the client.
6
WORK / SUMMER 1993
Job placement. One of the most critical stages in the entire process is the determination of whether the employee will return to the same position held when injured and if so, how and when the resumption of duties will occur. Job modification (light or limited duty). One of the most commonly utilized, albeit poorly understood options is the provision of temporary duties during a predefined period of work hardening' conditioning, or recovery that will prevent secondary deficits, maintain worker identity and commitment, and decrease injury costs. Adaptive devices. Often one of the most cost-effective investments in returning an injured worker to employment is to provide clever, simple, inexpensive devices to accommodate the known limitations of the worker or to minimize the chances of reinjury. Although such devices can be expensive (such as electronics and powered devices), the average intervention of this type costs under $100 with many other $10 per case. Trial employment. As an alternative either to terminating an employee who mayor may not be able to return to work or being forced to provide ongoing compensation if the employee is unable to perform a previousjob, a period of trial employment, most often in another department of the same organization, may permit the employee to elect to seek other work, be terminated for nonperformance, or returned to some other position. Alternatively the employee may be out-placed or fully reaccepted into the workplace. Flex time or reduced hours. What serves as a reasonable accommodation for an otherwise qualified worker with a bona fide disability is also an excellent option either as a transitional measure or as a permanent compromise between the needs of the employer and those of the injured worker. Commuting/transportation assistance programs. Some companies with return-to-work programs have found that providing transportation for workers who might otherwise be able to perform job duties is a cost-effective and simple solution. Telecommutinglhome-based work. Especially for those employees whose work is knowledge-based or requires extensive computing and/ or telecommunications functions (using phones,
modems, faxes, etc.), permitting the employee to work from home on a temporary or permanent basis may be an important option to consider. Retraining. Although some retraining is almost always required for employees returning to work following injury, retraining for other positions within the same organization may also minimize company losses and promote loyalty of both injured and noninjured employees. Job clubs. Small group sessions with employees who are in need of placement services within or outside the company can serve to systematically explore individual qualifications including both strengths and weaknesses. Likewise the requirements for and availability of alternative employment can be effectively explored in this group context. Other positions in same company. Suffice it to say that this option avoids numerous costs to the company from unemployment to training of replacements, and minimizes the disruption of the worker's career whenever return to a previous position is not feasible. Coaching. An emerging recognition of the efficacy of coaching of workers, as opposed to "bossing," suggests that ongoing support and advocacy on behalf of the person immediately following placement after injury can favorably influence outcomes. Feedback, correction of errors, dealing with conflicts, and resocialization of the worker all improve the chances of success. Out-placement. Next to returning to work at one's previous employer, the ability to organize and successfully complete the placement of the worker in a suitable position with another company is one of the most cost-effective and moralebuilding activities that a company can offer. Follow up. Probably the number one reason for failures in return-to-work programs is the lack of consistent, timely, and appropriate follow up. The ability to remove a worker from a situation where failure is imminent and to explore other placements is critical to long-term cost containment. Although specific program elements are important, there are also considerations that transcend the specific methods used, but are nonetheless critical for success. Return-to-work programs
Return-To-Work Programs
should should be on the job whenever possible. The problems with clinical work rehabilitation and "back school" programs have been detailed elsewhere (Schwartz, 1991b). In brief, there is little likelihood that skills taught in a clinic or classroom will generalize to work, and it appears important that such instruction be given on the job in the employee's own environment/work station. This has been so widely accepted in Australia that the Workers Compensation Act (1987) requires that the employer shall establish a rehabilitation program in consultation with workers and unions (where applicable), that all parties must be committed to programs, that absenteeism from work is to be avoided whenever possible, and rehabilitation is to be provided at the worksite. By law, each employer must have a rehabilitation coordinator designated! Participation by individual employees is voluntary but benefits are reduced for those who do not participate. Jobs available for early-return-to-work placements must be identified early from those usually filled by temporary and/or part-time workers so that they can be made readily available for those experiencing a medical need for less stressful jobs. Early-return-to-work programs are not always uniformly systematic or effective (Taylor, 1988)! A 1989 study by Ohio Bureau of Workers' Compensation showed that the more often employees were contacted by their employer to discuss health, medical care, or the workers' compensation file, the more likely that they would return to work (Smith, 1991). Those involved in work rehabilitation, and especially early return to work, need to understand the nature of work and understand risks and hazards of specific jobs. Doctors and therapists, who are traditionally responsible for return-to-work decisions almost never make visits to the workplace to assess environmental and/or ergonomic factors contributing to injury. Industrial managers and immediate supervisors are therefore at the mercy of professionals who cannot possibly understand the full implications of what they are recommending. It should be clear that line supervisors cannot fully understand and appreciate issues related to return to work unless they are included in the educational processes that characterize virtually every aspect of return-to-work program-
7
mingo Immediate supervisors are all too often ignorant of environmental hazards, inappropriate tool use, and the contribution of work schedules and production demands to injury. With the best of intentions, medical practitioners predicate their return-to-work prescriptions upon an understanding of the work based on an interview with the worker or a visit at some remote past time to the work site. This lack of work site assessment and modification, when needed, is a direct contribution to failure. What is often poorly appreciated is that the event of returning to work is far less important than the conditions under which the worker returns. Just as medical providers contribute to failures in return to work of those injured, so can those who supervise the injured worker contribute to failure upon return to the workplace. The immediate supervisors of injured workers often have little or no knowledge whatsoever concerning injuries, workplace assessment, or biomechanics. Even when the return-to-work recommendations are appropriate, accurate, complete, and complemented by work site assessment, the entire return-to-work process can be impeded or destroyed by a supervisorwho fails to understand, accept, and/or comply with medical advice. Instruction in early warning signs of new or recurring problems should be provided so that appropriate medical evaluation of any new or recurring symptoms will not be deferred or delayed. Finally, periodic medical reevaluation and follow up should be a routine part of the return-to-work orders. With this awareness should be offered the caveat that an additional and primary responsibility of persons supervising a return-to-work program is to assure that the immediate supervisor understands and will comply with what is requested (Schwartz, 1991a, 1992). Good working relationships with employers and a commitment to educate them are a sine qua non of successful, long-term, return-to-work programs.
CONTROVERSIES INHERENT IN RETU RN- TO-WORK PROGRAMS Brief analyses, such as this, whose intention it is to simplify and provide an overview of complex
8
WORK / SUMMER 1993
processes can be misleading. Return-to-work programs are not all equally well designed or effective. Somewhere, much to my personal dismay, there will be the reader who will use this analysis to create a slick marketing package and start selling tum-key return-to-work programs. Perhaps there are those who are already entering this "market." These programs will be expensive, popular, and undoubtedly ignore many of the important considerations and caveats listed above. Complexities, difficulties, frustrations, and conflicts are the rule not the exception in the return-to-work process. For example, labor relations often playa major role in determining return to work. Issues that confound process include seniority, light duty pay, and a 100% minimum effort or else attitude (Smith, 1991). Unions have their own agendas that must be addressed and considered at the point of formation of return-to-work programs. Their collective nature can make or doom a program. Taylor (1988) notes, Some issues and problems that can develop during the post-injury phase include: loss ofidentity and self-esteem, changes in family and social roles, and loss of control. These factors contribute to poor outcome, especially when workers feel unjustly blamed for the injury, that they have been treated unfairly by the employer or insurance carrier or that they no longer have control over employment, treatment or other outcomes.
Basic to allegations of unfairness on the part of both management and labor are often economic considerations dictated by common law, workers' compensation systems, employment laws, and local, state, national and global economies. Failure to deal with such issues has been the rule not the exception prior to formal return-to-work programs. Properly conducted and with full commitment of all parties, return-to-work controversies and stumbling blocks can be resolved.
SUMMARY Return to work is fundamentally an educational, not a medical process. Psychological, administrative, and economic barriers do more to keep workers away from work than physical limitations or disabilities. Workers are part of a social system, not just cogs in a machine. A working body does not make a person a worker! Long-range changes in outcomes following injury will require that rehabilitation of the injured worker be taken from the clinic back to the workplace, that employers, not medical providers, assume responsibility for service provision, and that such services address the educational, environmental, social, and economic issues that have long been ignored by medical rehabilitation providers.
REFERENCES Beaudway, D. L. (1986). 3M: A disability management approach.] Appl Rehabil Counsel, 17;20-22. Dent, G. L. (1990). Return to work by design. Stockton, CA: Martin-Dennison Press. Gottlieb, A., Vandergoot, D., and Lutsky, L. (1991). The role of the rehabilitation professional in corporate disability management. ] Rehabil (Spring), 23-28. Nachemson, A. (1983). Work for all: For those with low back pain as well. Clin Orthop Rei Res, 179, 77-85.
Ogden-Niemeyer, L. 0., and Jacobs, K. (1989). Work hardening-State of the Art. Thorofare, NJ: Slack, Incorporated. Schwartz, R. K. (1992). Preventing occupational in-
jury: safety training and return-to-work prescriptions. Workplace Safe Health 5, 3-4. Schwartz, R. K. (1991a). Return to work prescriptions: Are the ignorant leading the blind? Work, 1, 84-88. Schwartz, R. K. (1991b). Transfer oftraining: Which programs work best. Work Programs Newsl, 5, 2-3. Smith S. L. (1991). Returning to health: Getting injured workers back on thejob. OccupHazards(February), 37-40. Taylor, M. E. (1989). Return to work following back surgery: A review. Am] Indust Med, 16, 79-88. Workcover: The Occupational Health, Safety, and Rehabilitation Board of New South Wales. (1987). Guidelines for workplace-based occupational rehabilitation programmes. Darlinghurst, NSW, Australia: Work-
cover.