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Good Morning
9:20:13 AM CDT
Wednesday, April 23, 2014

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Return To Work

Topics Vocational Rehabilitation Forms & Publications Physical Demands-Strength Rating
Return to Work Services Preferred Worker Program WSI SAW/RTW Initiatives Actions and Motions
Transitional Work Job Development Vocational Rehabilitation Brochure  
On-Site Return to Work School Coordinator Preferred Worker Program Brochure  
Medical Case Managers When Work Related Disability is Medical Required MCM Referral Criteria  

Return to Work Services

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.

Why is a Transitional Work Plan so important?

  • 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 Return-to-Work Programs
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

On-Site Return-to-Work Case Managers
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.

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

Vocational Rehabilitation
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.

Preferred Worker Program
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.

Job Developer/Employment Specialist
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.

School Coordinator
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.

**Awareness of how rarely Work-Related Disability is Medically Required
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.


  • 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.

Table 4 – When is a Disability Medically Required, Medically Discretionary, or Medically Unnecessary? *
Medically Required Medically Discretionary Medically Unnecessary

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).

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.

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.

(Source: ACOEM Practice Guidelines, Cornerstones of Disability Prevention and Management)

**Urgency is required because Prolonged Time Away from Work is Harmful
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.
  • 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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