Return To Work
The goal of return-to-work (RTW) services is to return
the injured worker to substantial gainful employment with a
minimum of retraining as soon as possible after an injury occurs.
The emphasis is placed on substantial employment with the
pre-injury employer in the injured worker’s pre-injury or
regular capacity through transitional work. Transitional
work is work that allows the injured worker to remain safely
on the job, but in a modified or alternate position.
Two types of work are outlined in a transitional work plan:
- Modified work is the injured worker’s
pre-injury or regular job that is modified to
accommodate restrictions outlined by the medical provider.
- Alternate work is a temporary work
assignment when the injured worker is unable
to perform his or her pre-injury duties or
regular job as a result of the injury.
- Allows the injured worker to “transition” back into the work environment after sustaining a work-related injury
- Encourages a safe and early return to work, taking into account the injured worker’s abilities and injury
- Injured worker benefits by being productive and receiving a salary
- Employer benefits by having an experienced and productive worker back at the job
Ideally, a company (employer) representative is able to accompany the
injured worker to the medical appointment and acquire information from
the medical provider regarding diagnosis, prognosis, and physical abilities.
The physical ability information should be specific regarding activities
such as sitting, standing, walking, lifting pushing, pulling, and carrying.
Frequency of tasks should also be addressed. Terms generally used to
describe frequency are as follows:
- Occasionally (1/3 of the time)
- Frequently (1/3-2/3 of the time)
- Constantly (2/3 or more of the time)
It is important to keep all parties involved during recovery and
provide an understanding of expectations. RTW services can be an
important tool for medical providers in coordinating the care and return-to-work options.
WSI’s RTW service department offers the following services:
- On-Site Return-to-Work Case Manager
- Medical Case Manager
- Vocational Rehabilitation
- Preferred Worker Program
- Job Developer/Employment Specialist
- School Coordinator
WSI has teamed up with six of the larger medical facilities in
North Dakota to have registered nurses on site to assist injured
workers seeking medical attention at their facilities. RTW case
managers will open case management services when their initial evaluation indicates:
- A wage-loss claim has occurred (time loss from work for five or more consecutive calendar days)
- Work restrictions prevent the injured worker from returning to the pre-injury position
- Claims adjuster requests assistance
- Extended medical treatment is anticipated
The RTW case managers assist in coordinating care and
evaluate proposed medical treatment for appropriateness
and medical necessity. They also assist with transitional
work and work restrictions, act as a liaison between the
injured worker, employer, medical provider and WSI claims
adjuster, and provide recommendations for care. They do
not make decisions on compensability of claims.
The RTW case manager will continue to follow the care until:
- The injured worker has returned to work in their pre-injury position
or a modified position (the injured worker’s pre-injury job that is
modified to accommodate restrictions imposed by the physician) and
further impact by the case manager is not expected
- Employer will not be returning injured worker to work
- Employer or adjuster do not feel RTW case manager is necessary (Some employers have detailed RTW programs)
- Adjuster feels comfortable following the RTW process
For injured workers treating in facilities who do not
have an On-Site RTW case manager, the claims adjuster,
employer or medical provider can request assistance from
WSI medical case managers.
WSI has registered nurses on staff to assist with the return-to-work
process. Medical case managers are located in Minot, Bismarck, Fargo,
and Grand Forks. Medical case managers work with the claims adjuster,
injured worker, employer, and medical provider to assess, plan,
coordinate, and implement the options and services needed to support
the injured worker in the recovery process and help them return-to-work.
Medical case managers will be assigned to cases where:
- Catastrophic Injury
- Medically complex
- Chronic pain
- Appropriate referral from claims adjuster, employer or medical provider
- Common Referral Criteria for Medical Case Management is appropriate
The Medical case managers assist in coordinating care, evaluate
the proposed medical care for appropriateness and medical necessity,
and play a role as a facilitator and communicator when multiple
providers may be involved in the care of the injured worker. They
assist with transitional work and work restrictions, act as a
liaison between the injured worker, employer, medical provider, and
the WSI claims adjuster and provide recommendations for care. They
do not make decisions on compensability of claims.
Medical case managers attend appointments with injured workers
to assist with questions and treatment plans. Some of the cases
referred involve severe burns, amputations, multiple traumas, head
injuries, and spinal cord injuries. The MCM will continue to follow
care until:
- Medical stability is reached
- Lack of cooperation from injured worker
- No further impact on medical issues can be made
If early intervention is not successful in returning the injured
worker with the employer of injury,
vocational rehabilitation services
will be assigned. This service is provided by a contracted company,
currently CorVel. Vocational consultants and staff are located in
Bismarck, Fargo, Minot, Marion, Watford City, and Grand Forks, with
a national network to provide vocational rehabilitation for out-of-state
injured workers.
Vocational rehabilitation utilizes workers’ functional
capabilities, education, employment history, experience,
and transferable skills to develop a return-to-work plan.
To identify the appropriate rehabilitation option the
injured worker may be required to complete vocational or
capabilities testing.
The vocational rehabilitation consultant will assist
the injured worker in understanding the process, share
information relating to the injured worker’s medical and
vocational status, and attend medical appointments as
necessary to review medical status. They are available
to the injured worker to answer questions, explain job
goals, transferable skills, assist with job readiness
skills, and explain test results of any required testing
i.e. Functional Capacity Assessment (FCA), or Test of
Adult Basic Education (TABE).
The injured worker and the vocational rehabilitation
consultant review the rehabilitation options in the following order:
- Return to same position (same employer)
- Return to same occupation (any employer)
- Return to modified position (same employer)
- Return to modified or alternate occupation (any employer)
The vocational rehabilitation consultant will submit a
vocational consultant’s report (VCR) to WSI for approval.
While some injured workers will never be able to return to
their former occupation, the
Preferred Worker Program is
designed to encourage the re-employment of North Dakota’s
injured workers by offering cost-saving incentives to employers
participating in the program. Benefits include:
- Premium exemption on the preferred worker for up to three years
- Wage reimbursement for a portion of the preferred worker’s wage
- Reimbursement will be up to 50 percent of wages for the
first six months (not to exceed 50 percent of the state’s current average weekly wage)
- Claim costs exemption if the preferred worker sustains an on-the-job injury during the premium exemption period
- Reimbursement for worksite modification
- On site job analysis
- Hiring an experienced worker
To be eligible for the program, employers must have and maintain
an account providing workers’ compensation coverage and be in good
standing. The employer of injury is not eligible for the program
with their own injured employee.
For an injured worker to be eligible for the program they
must have sustained a compensable work injury in North Dakota,
resulting in an obstacle in their ability to return to work.
The injured worker cannot have been released to return to “regular”
work and they cannot have refused an offer of appropriate
employment with the employer of injury.
Benefits for the injured worker include:
- Preferred worker can easily match their work abilities to the list of employment opportunities
- Aides preferred workers with finding employment, taking into consideration their work abilities
At the time the injured worker is approved for the program, they
will receive an Identification Card. This will be the first of two
cards issued to the preferred worker. The worker should carry the
ID card with them as they look for work. At the time they are hired
under the Preferred Worker Program, the ID card will be completed
by the employer and returned to WSI. Once approved and the agreement
has been signed by the employer and the preferred worker, the
benefits are activated. Once the Preferred Worker Agreement is in
effect, WSI will issue the preferred worker a second card, which
is an Eligibility Card. If the worker changes jobs or obtains an
additional job, the preferred worker may present this card to
inform the employer of the remaining premium exemption period.
This position works with the vocational consultants and the
Preferred Worker Program in preparing and presenting job
seeking skills workshops and job search coaching. They also
assist in matching injured workers to jobs by assessing their
knowledge, skills, and capabilities. The job developer is
responsible for actively engaging employers throughout North
Dakota to identify positions for injured workers. This
includes cold calling, visits to local businesses, networking,
and relationship building.
The school coordinator assists injured workers who have been
awarded a retraining program with school preparation, class
scheduling, tutoring needs and any associated requirements of
their retraining programs. They verify the injured worker’s
enrollment and attendance of classes at the end of each semester
or quarter.
Only a small fraction of medically excused days off work are
medically required – meaning work of any kind is medically
contraindicated. The remaining days off work result from a
variety of non-medical factors such as:
- Administrative delays of treatment and specialty referral
- Lack of transitional work
- Ineffective communications and lax management
- Logistical problems
These days off are based on non-medical decisions and
are either discretionary or clearly unnecessary. Absence
from work is “excused” and benefits are generally awarded
based on a physician’s decision confirming that a medical
condition exists. This implies that a diagnosis creates
disability.
However, from a strictly medical point of view, people
can generally work at something productive as soon as there
is no specific medical condition to keep them from working
(see Table 4 below). The key question is what kind of work?
Many obstacles that appear to be medical are really situation-specific.
For example, an employee with a cast on the right foot cannot
drive a forklift, but can perform other tasks until the cast
is removed. A person recovering from surgery may not be able
to work a full day in the office, but could work half days.
In fact, people often sit home collecting benefits because
their employers don’t take advantage of their available
work capacity. Today, these decisions generally are
misclassified as “medical,” and as such are not examined.
Recommendation:
- Stop assuming that absence from work is medically
required and that only correct medical diagnosis and
treatment can reduce disability.
- Pay attention to the non-medical causes that underlie
discretionary and unnecessary disability.
- Reduce discretionary disability by increasing the
likelihood that employers will provide on-the-job recovery.
- Instruct all participants about the nature and
extent of preventable disability.
- Educate employers about their powerful role in
determining Stay-A-Work/Return-to-Work (SAW/RTW) results.
Current Initiatives/Best Practices: Clinicians,
employers, and insurers can now use the following criteria
(see Table 4) to determine whether a disability is medically
required, discretionary, or unnecessary. If all parties use
these definitions, clearer communication and better decision
making will result. In particular, physicians will no longer
have to make employment decisions, and employers will stop
misclassifying business decisions as medical decisions.
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Table 4 – When is a Disability Medically Required, Medically Discretionary, or Medically Unnecessary? *
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Medically Required
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Medically Discretionary
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Medically Unnecessary
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Absence is medically required when:
- Attendance is required at a place of care (hospital,
physician’s office, physical therapy).
- Recovery (or quarantine) requires confinement to bed or home.
- Being in the workplace or traveling to work is medically
contra-indicated (poses a specific hazard to the public,
coworkers, or to the worker personally, i.e., risks damage to tissues or delays healing).
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Medically discretionary disability is time away from
work at the discretion of a patient or employer that is:
- Associated with a diagnosable medical condition that
may have created some functional impairment but left
other functional abilities still intact.
- Most commonly due to a patient’s or employer’s
decision not to make the extra effort required to
find a way for the patient to stay at work during
illness or recovery.
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Medically unnecessary disability occurs whenever a
person stays away from work because of non-medical issues such as:
- The perception that a diagnosis alone (without
demonstrable functional impairment) justifies work absence.
- Other problems that masquerade as medical issues,
e.g., job dissatisfaction, anger, fear, or other psychosocial factors.
- Poor information flow or inadequate communications.
- Administrative or procedural delay.
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(Source: ACOEM Practice Guidelines, Cornerstones of Disability Prevention and Management)
Unnecessary prolonged work absence work can cause needless, but
significant harm to a person’s well-being. While on extended
disability many patients lose social relationships with co-workers,
self-respect that comes from earning a living, and their major
identity component – what they do for a living. Many key players
in the SAW/RTW process do not fully realize the potential harm
that prolonged medically excused time away from work can cause.
Many think that being away from work reduces stress or allows
healing and do not consider that the worker’s daily life has been
disrupted. With these attitudes system-induced disability becomes
a significant risk. Early intervention is the key to preventing
disability. Research confirms:
- People who never lose time from work have better outcomes than people who lose some time from work.
- The odds for return to full employment drop to 50-50 after six months of absence.
- Even less encouraging is the finding that the odds of a worker ever returning to work drop 50 percent by just the 12th week.
Recommendation:
- Shift the focus from “managing” disability to “preventing” it and shorten the response time.
- Revamp disability benefit systems to reflect the reality that resolving disability episodes
is an urgent matter, given the short window of opportunity to re-normalize life.
- Emphasize prevention or immediately ending unnecessary time away from work,
thus preventing development of the disabled mindset, and disseminate an educational campaign supporting this position.
- Whenever possible, incorporate mechanisms into the SAW/RTW process that prevent or minimize withdrawal from work.
- On the individual level, the health care team should keep patients’
lives as normal as possible during illness and recovery while
establishing treatments that allow for the fastest possible
return to function and resumption of the fullest possible participation in life.
Current Initiatives/Best Practices: Many employers and some insurers now begin return-to-work efforts on the first day
** information taken from ACOEM’s Preventing Needless Disability Guideline.
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