“When it all goes wrong”

Review of the barriers to return to work within the healthcare industry

Tony Johnston

Principal Health & Safety Adviser

Queensland Health

Outline

• Defining the problem– No lift– Investment in equipment,

training– BUT, Increasing WC

• Background– Safety model

– Traditional vs systems

– Predicting RTW outcomesFlags models

Questionnaires

• Method– Literature review– Common resources used

within AUS

– Draft tool

• Findings– Statistics

– Complex case review

• Future directions

Patient Handling: Through the ages…

1998 2001 2007 2012

Healthcare Industry… Lost timeFrequency of Claims

Healthcare Industry… Lost timeTotal Cost of Claims

>20 days

RTW70%

>20 days

RTW70%

>45 days

RTW50%

>45 days

RTW50% >70 days

RTW 35%

>70 days

RTW 35%

Objective

• Develop a tool to predict / identify barriers impacting return to work– User:

Injury Management Team (Strategic)

Rehabilitation Coordinator (Operational)– Categories and language to inform decision making– Structured, targeted rehabilitation plans.– Educate decision makers– Organisational improvement

Barriers to RTW… Literature

• 20-30% persistent adverse consequences • Strong predictive factors:

– Catastrophising– Expectations/perceptions– Financial incentives– Physical demands of work– Loss of contact with work

• 5-9% chronic problems regardless of initial injury.• Psychosocial obstacles impede progress, not because

there is more serious injury.– Often unrelated to incident or injury

Barriers to RTW… Literature

• Beliefs:– major underlying pathology.– avoidance of activity will help recovery.– need for passive physical treatments rather than active self-

management.

• Other post-accident factors:– Psychological maintaining variables: depression, anger.– Other adverse events, e.g. further trauma, independent illness,

bereavement, frustrating legal proceedings.

• Quality of care:– Failure to provide positive mobilisation and rehabilitation.– Iatrogenic treatment factors: poorly organised care,

inconsistencies, ambiguities and failure to answer patient's and family's worries

Systems Approach (Swiss cheese)

Individual factorsIndividual factors

Industry Guidelines

• Flags models

• Biopsychosocial factors

• Personal and Environmental risk factors

Flags Models

Red flags

• Medical– Serious pathology– Co-morbidity– Failure of treatment

Black flags

• Context (people, systems, policies)– RTW policy– Threat to financial security– Litigation– Compensation system and

qualification criteria– Lack of contact with

workplace

Flags Models

Yellow flags

• Psychosocial / Individual– Beliefs, thoughts, feelings,

behaviours(pain & injury)

– Coping strategies– Psychological distress– Sick role– Passive role in recovery

Blue flags

• Work Area / Perception– Social support at work– Unpleasant work– Job satisfaction– Excessive demands/low

control– Unhelpful management

style

Biopsychosocial

Body Functions & Structures

Activity Participation

Environmental Factors

Personal Factors

MedicalWork & Non-work

environmentIndividual /

psychological factors

Biopsychosocial

MedicalWork & Non-work

environmentIndividual /

psychological factors

Treatment & Diagnosis

Treatment & Diagnosis

Health Providers

Health Providers

Biological / medical

Biological / medical

Family Family

Attitudes & beliefs

Attitudes & beliefs

Emotions Emotions

Behaviours Behaviours

Compensation issues

Compensation issues

Workplace Workplace

Co-WorkersCo-Workers

RTW processRTW process

Barriers Analysis Tool Purpose

• Psychosocial obstacles impede progress, not because there is more serious injury. (Burton etal 2009)

– May be unrelated to incident or injury

• Identifying flags/barriers complements the diagnosis– Relevance as a contributor to the persistence of the problem– Facilitate problem solving, not prescriptive– Referral to appropriate assessment and intervention

• Used to identify specific obstacles to:– Recovery– Activity– Work

Barrier Analysis Tool (Draft)

DemographicsDOIRTW statusRestrictions

DemographicsDOIRTW statusRestrictions

Individual factors•Severe symptoms/pain•Co-morbidities•Perception of recovery•Perception about RTW•Communication•Unrealistic expectations•Social issues (transport, family)

Individual factors•Severe symptoms/pain•Co-morbidities•Perception of recovery•Perception about RTW•Communication•Unrealistic expectations•Social issues (transport, family)

Medical / Rehab Factors•No TMP•No definitive diagnosis•No timeframe for recovery/RTW•Multiple injuries•Psychological injury/overlay•TMP will not support/participate in RTW•Frequent treatment•Not complying with treatment•Total incapacitated >2 weeks

Medical / Rehab Factors•No TMP•No definitive diagnosis•No timeframe for recovery/RTW•Multiple injuries•Psychological injury/overlay•TMP will not support/participate in RTW•Frequent treatment•Not complying with treatment•Total incapacitated >2 weeks

Workplace Factors•Management support•Contact with worker•SDP limited / unavailable•Management not aware of rehab obligations/benefits•Co-worker support•Demanding job (physically or psychologically•Management responsibility for rehab

Workplace Factors•Management support•Contact with worker•SDP limited / unavailable•Management not aware of rehab obligations/benefits•Co-worker support•Demanding job (physically or psychologically•Management responsibility for rehab

System Factors•Worker does not report injury•Employer does not investigate incident•Rehab delayed•Claim determination delayed•No single person responsible for case•Responsibility not clear•Inadequate plan/goal/timelines•Admin focus rather than person focus•Funding for RTW•Insurer not communicating/coordinating•Insurer reactive, not proactive

System Factors•Worker does not report injury•Employer does not investigate incident•Rehab delayed•Claim determination delayed•No single person responsible for case•Responsibility not clear•Inadequate plan/goal/timelines•Admin focus rather than person focus•Funding for RTW•Insurer not communicating/coordinating•Insurer reactive, not proactive

Barrier Analysis Tool… Method

Complex Case Review•File review complex cases with Rehab Coordinator

– > 2 weeks time lost

•3 sites (metro and regional)•Barriers identified•Action plan documented•Data collated and evaluated

– Local issues– Strategic impact

FINDINGS

Occupational GroupsAverage days lost

AgePercentage of Claims

15.615.6

21.921.9

30.130.1

31.431.4

Body Part effectedPercentage of Claims

24.324.3

86.186.129.429.4

24.924.9

Barrier Analysis ToolComplex Case Review

Barrier Analysis ToolComplex Case Review

Outcome:•Tool practical and easy to use

•Identifies barriers– Point-in-time– Potential future concerns

•Encourages case planning and documentation

•Identifies barriers at individual, work area and organisational level

•Educational tool for Rehab Coordinator, Management– Individual factors Workplace factors & System factors

Barrier Analysis ToolGlobal Issues• Individual factors

– Will not participate in Rehabilitation

– Unrealistic expectations– Will not communicate directly

with employer

• Workplace factors– Management does not

support RTW– Suitable duties

limited/unavailable– Management not aware of

benefits– Co-workers do not support

RTW– Physically demanding job– Management not responsible

for rehab

• Medical/rehab factors– TMO does not support RTW

• System Factors– Rehab delayed– Claims determination delayed

Conclusion / summary

• Education all involved– Line managers

– Rehab coordinators

• Influence– Health providers

– Insurers

• Rehab coordination can have a critical bearing on the outcome– Employment policy

– Social contact

– Nature of work

– Coordination of RTW care

Future Direction

• Ongoing trial

• Review/modify individual elements for barriers specific to local environment

– Utilised by other organisations

• Integrate into Rehab Coordinator training

– Case review and documentation

– Prompt for case planning

• Collation of data to inform organisational needs

– Policy changes

– Education and training: Managers, Rehab Coordinators

– Influence external stakeholder: Insurer, TMO

Bibliography• ACC (NZ). 2006. Return to work and pschosocial issues. Available:

http://www.acc.co.nz/PRD_EXT_CSMP/groups/external_providers/documents/guide/prd_ctrb113170.pdf.

• FOREMAN, P., MURPHY, G. & SWERISSEN, H. 2006. Facilitators and Barriers to Return to Work: A literature review.

• KENDALL, N., LINTON, S. J. & MAIN, C. J. 1997. Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain: Risk Factors for Long-Term Disability and Work Loss. . Available: http://www.kendallburton.com/Library/Resources/Psychosocial_Yellow_Flags.pdf.

• WORKCOVER (NSW). FACTORWEB - Personal and environmental risk factors. Available: http://www.workcover.nsw.gov.au/formspublications/publications/Documents/factorweb_5523[1].pdf.

• WORKCOVER (SA). Considering biopsychosocial factors [Online]. WorkCover South Australia. Available: http://www.workcover.com/site/treat_home/injury_management_by_health_discipline/key_principles_for_all_health_providers/considering_biopsychosocial_factors.aspx [Accessed 2012].

• WORKCOVER (SA). 2007. A guide to assessing and managing red and yellow flags for workers compensation patients. Available: http://www.workcover.com/custom/files/AssessingManagingRedYellowFlags_201004231418832.pdf.