Mind-set is Key to Quick Recovery
Psychosocial barriers “account for 30 percent of variance in the magnitude of disability,” said Ruth Estrich, chief strategy officer at MedRisk and the moderator of “Overcoming Psychosocial Barriers to Recovery” a session presented at the 2014 National Workers’ Compensation and Disability Management Conference & Expo in Las Vegas.
There are four major psychosocial barriers that impact workers’ compensation cases, according to the experts on the panel, which also included Sherri Burrell, head of operations, Briotix Inc., and Carrie Freeland, manager, integrated leave department, Costco Wholesale.
The first is “catastrophizing,” or assuming that the worst will happen. The second is perceived injustice, or believing “I don’t deserve what is happening to me.” The third barrier is fear/avoidance, or believing that physical activity will aggravate an injury, leading a worker to disengage from daily life activities. The fourth barrier is negative beliefs about disability.
“What you believe about your disability has a huge impact on how you handle it and what your outcome will be,” Estrich said. “If expectations are negative, your reality will be negative.”
Progressive Goal Attainment Programs (PGAP) are an effective way to get at-risk injured employees back to work, and have a 77 percent enrollment success rate and 60 percent return to work result, according to the panel.
PGAP pairs a worker with a certified consultant once a week for up to 10 weeks. The consultant, who often has a background in occupational or physical therapy, provides the worker with a daily schedule of structured activity and clear goals, which promotes re-engagement with daily life and combats depressive symptoms.
Burrell, whose company provides trained PGAP clinicians, noted that not every success story results in a return to work; someone who can perform everyday tasks and re-engages with life is considered a success.
Once a PGAP-eligible case is identified, employers reach out to an injured worker’s treating physician for a referral.
While most physicians are on board, others aren’t so keen. Attorneys of workers, adjusters “entrenched in their own procedures,” or the employees themselves can refuse to participate, Freeland said.
Those who do enter the program often improve vastly. Costco, one of a few major employers to implement PGAP, has run two pilot programs, Freeland said. One employee had been out of work for over a year with a cervical sprain. She was told not to lift more than five pounds.
Costco had been ready to cut her off and litigate, but decided to offer the PGAP program as a last-ditch effort. At the end of the 10-week period, her functional capacity had increased to 40 pounds and she was back on the job.
“This was someone who had been written off completely,” Freeland said.
Costco now plans to expand their program and incorporate non-occupational disabilities.
When a Claim Runs Off the Tracks
Mike is a 54-year-old construction worker. One day, he strains himself picking up a piece of lumber and goes home with shoulder pain. He reports his injury and five weeks later is taking Vicodin, an opioid, and Naproxen, an anti-inflammatory, and given an occupational therapy regimen.
That was the scene set for a crowded roomful of attendees at “Risk Scenarios Live! Navigating the Challenging Claim” session, presented at the 2014 National Workers’ Compensation and Disability Management Conference & Expo in Las Vegas.
Mike begins taking more Vicodin per day than he’s prescribed, and performing duties at work that do not allow his injury to heal.
Eventually, he sees an orthopedic surgeon. She suggests Mike may have a rotator cuff tear, which would require surgery and an extensive recovery period that would keep Mike out of work for six months, at least. She orders an MRI to determine if there is a tear.
Even at this early stage of treatment, there are several red flags on Mike’s case, said experts on the panel that included Dr. Kurt Hegmann, associate professor at the Rocky Mountain Center for Occupational & Environmental Health; Dr. Robert Goldberg, chief medical officer at Healthesystems; and Tracey Davanport, director-national managed care, Argonaut Insurance Co.
Using an anti-inflammatory medication alone, without an opioid, often yields better outcomes and avoids the risk of addiction that comes with opioids, said Hegmann.
In Mike’s case, Vicodin was not medically necessary. His condition was not improving, and he was commuting to and from work and performing his job under the influence of an opioid, said Goldberg.
What should have been done to get this claim back on track? Every party involved – worker, employer, claims organization and prescribing physician – should have been communicating directly. That would have helped catch early abuse of painkillers and ensured that the physician is adhering to evidence-based guidelines.
Assignment of a nurse case manager may have also been necessary.
MRIs should be administered with caution, experts said. Such tests often turn up problems unrelated to the original injury, opening up a can of worms in terms of appropriate treatment and compensability.
“You have to treat the entire patient, not just the injury that brought him in,” Goldberg said, such as taking pre-existing conditions into account. Mike’s age, for example, significantly increased his risk for a slow recovery.
The MRI scan revealed a full-thickness tear of the rotator cuff. After surgery, Mike was prescribed Oxycontin to manage post-op pain. He then sat at home, gaining weight and drinking while taking his pain medication and neglecting to perform the at-home exercises his orthopedic surgeon advised.
When he went in for a check-up, the doctor decided to switch him back to Vicodin, although Mike still had a refill left on his Oxycontin. He envisioned doubling up the medications to achieve a new high.
At this point in the case, someone needed to step in to track Mike’s refills and limit his dosage.
“The patient can’t be the one to control the prescription pad,” Goldberg said.
Employers should also try to have workers return to modified-duty positions as soon as possible, which helps to maintain social connections and motivates the employee to get back to their pre-injury capacity.
“The patient needs to be engaged and motivated to get better,” Hegmann said. “If they choose not to do the work, then there’s nothing else a doctor can do for them.”
Mike was not motivated. He did not adhere to the restrictions placed on him in a light-duty position; he failed to dedicate himself to physical therapy and stay active; and he abused the opioids prescribed to him.
A year after his injury, he was 20 pounds heavier, had not progressed in strengthening his shoulder, and his employer’s workers’ comp claims organization was looking at a six-figure settlement for permanent disability.
A Strategy of Total Health
Dr. L. Casey Chosewood, senior medical officer and director of the Office for Total Worker Health Coordination and Research at the National Institute for Occupational Safety and Health (NIOSH), opened his morning keynote with the statement, “I’m from the government, and I’m here to help.”
Speaking at the 2014 National Workers’ Compensation and Disability Management Conference & Expo in Las Vegas, Chosewood’s quip drew laughter, but his message is relevant to every size employer in every industry: the intersection of the workplace and personal health matters.
“Health is your currency to do anything in life that you want to do,” he said.
Regardless of where workers health issues originate, they straddle the line between home and work. Whether it’s stress, joint pain, or poor sleep, an employee’s productivity at work will be effected.
Therefore, Chosewood said, it doesn’t make sense to isolate a worker’s health needs on the job from his needs at home or in other areas of life.
Thus, the creation of Total Worker Health: “a strategy integrating occupational safety and health protection with health promotion to prevent worker injury and illness and to advance health and well-being.”
In other words, it advocates taking care of the employee as a whole person in order to reduce risk of injury and illness.
In 1970, there were 14,000 fatal workplace injuries. In 2010, with a workforce twice as large, there were 4,547 fatalities, but still 3.7 million serious injuries. Workplace illness and injuries that year resulted in $128 billion to $155 billion in direct and indirect costs.
The deadliest threats workers face today include obesity stemming from too many calories and too much sitting. Those who sit for 12 hours a day have a mortality risk 40 percent higher over the following two years than those who sit for 9 hours a day.
Smoking, still the leading cause of preventable death, presents another danger.
These threats often increase propensity for chronic conditions like diabetes, joint pain and depression. Fifty percent of the American population currently has some form of chronic illness, Chosewood said.
In combination with an aging workforce, such conditions are driving up injury risk, lengthening recovery time, and increasing claim costs. One study showed that chronic disease increases acute injury risk by 25 percent.
However, employers can’t expect individuals to change their behavior when the “social, cultural and physical environments around them conspire against them,” he said.
Companies must create cultures and environments that send employees home healthier at the end of the day than when they came in.
The CDC’s Atlanta campus, for example, purposefully built a new parking facility a 15-minute walk away, which provoked some initial grumbling. After the lot was built, though, no new employee ever complained about the walk.
“Be brave enough to take short-term heat,” when changes ultimately benefit the health of your workforce, Chosewood said.
Allowing flexible work arrangements is another way organizations can help employees improve health by managing stress. A survey from 2010 showed that 44 percent of people say work is often or always stressful, while 50 percent say work interferes with their time and duties at home.
Flexible work arrangements have been shown to increase employee retention, job satisfaction, and overall employee health.
With 65 percent of the U.S. adult population on the job, workplaces are effective venues for addressing health and promoting behaviors that could change the landscape of U.S. healthcare.
“Getting health care spending right in this country is an economic necessity,” Chosewood said. “Companies that build a culture of health have a healthier bottom line.”