New opportunities in the workers’ compensation market.

According to the US Department of Labor, workplace injuries cost US industries $13 to $20 million a year.1 The potential for monetary losses due to lost time, exposure, and costs associated with injury claims can be staggering. Therefore, the objective of work-injury management is to resolve any and all workers’ compensation claims as soon as possible to minimize these losses. Employers and insurance carriers are constantly evaluating the cost and effectiveness of various rehabilitation programs, in an effort to better contain their costs and improve their return-to-work outcomes.

There is a great need for effective and high-quality rehabilitation services in workers’ compensation. However, obtaining a constant referral base is dependent upon the rehabilitation professional’s ability to demonstrate the effective management of the injured worker’s entire rehabilitation process, from acute therapy to return to work.

Opportunities in Work-Injury Management

There are two reasons why the rehabilitation professional should identify new opportunities in the workers’ compensation market: 1) There have been recent changes in workers’ compensation laws in several states. For example, in California’s workers’ compensation reform laws, a cap is now placed on skilled therapy visits; other states are expected to follow suit. In addition, direct-access laws and provisions can influence clinical practice and access to patients. 2) In most states, reimbursement for rehabilitation services under workers’ compensation remains significantly higher when compared to other payor sources such as Medicare and private group insurance. For these reasons, rehabilitation professionals are finding opportunities to provide ergonomics and specialized work-injury-management programs in the workers’ compensation sector. By obtaining specialized training and skills in ergonomics and work-injury-management programs, rehabilitation professionals can contribute and prosper in the workers’ compensation industry.

There are several specialized work-injury-management programs. They include: injury prevention, pre-employment, work-injury containment, and work-integration programs.

Injury-Prevention Programs

Ergonomics committees and safety teams often focus their efforts on identifying high-risk jobs and controlling ergonomic risks to reduce the work injury occurrence rate and the costs associated with these injuries. Injury-prevention programs can be an effective method of injury management in the workplace. These programs can be performed for injured or healthy workers; and their objectives are to identify the ergonomic risk factors, recognize appropriate control measures, and recommend work modifications to prevent new injuries from occurring.

Injury-prevention program components typically include: work task data, ergonomic risk factor identification, control measure identification, overall risk assessment, recommendations, and employee training. An injury-prevention checklist is a useful tool to provide time savings for the rehabilitation professional and consistency to the program.

An injury-prevention program would be indicated if a company’s ergonomics team identifies that shoulder-injury rates have increased on a particular production line compared to the previous year’s incidence rates. The ergonomics team’s efforts would focus on preventing new work-related injuries from occurring on this line. In the injury-prevention program, a rehabilitation professional—as the ergonomics evaluator—would observe the workplace, assess the ergonomic risk factors, identify control measures, and make recommendations to prevent new shoulder injuries from occurring. The rehabilitation professional may identify, for instance, that the conveyor belt and sitting workstation are placed too high. This height forces the workers into awkward shoulder positions when performing repetitive forward and overhead reaching and lifting. In addition, during the last year, the product’s size and shape increased by 25%. As demonstrated by the biomechanical model of lever arms, this new product size increase now produces a significantly higher force on the shoulder tissues during repetitive lifting. Control measures may be to recommend reducing the product’s size and weight, lowering the conveyor belt, and tilting the work surface at the sitting workstations. All of these ergonomic adjustments will reduce shoulder strain and help prevent new injuries. Following the assessment, the rehabilitation professional may also be asked to educate the workforce on safe work practices, ergonomic principles, and stretches.

Pre-Employment Programs

A pre-employment program for injury management is a systematic process of assessing a work applicant’s ability to safely and effectively perform the critical demands of the job. The program’s desired outcome is to assign applicants to jobs that they can safely perform, thus lowering the incidence of work-related injuries that would have been caused by overexertion and inappropriate worker-work pairing. This systematic process involves an appropriate examination and “tryout” of the critical demands of the job in question, to see if the applicant is able to fulfill the requirements.

The components of the pre-employment injury-prevention programs typically include: functional job description, musculoskeletal assessment, safe work practices, and outcome measures.

A company may request a pre-employment program if a particular job has a high injury rate. To make the testing of the critical job requirements accurate and valid, the pre-employment program should simulate the real work environment, using the same work equipment whenever possible. For example, to test a critical requirement—lifting a 50-lb bag of salt from the floor to a conveyor belt at waist height—the functional activities test protocol may call for the candidate to lift a 50-lb box from floor to waist. In this example, lifting the salt bag from floor to waist would be the most accurate simulation of the actual work task. During pre-employment programs, education and adherence to safety is important and plays an additional role in work-injury management.

Work-Injury-Containment Programs

The concept of work-injury containment is based on the premise that if ergonomic risk factors are not addressed when an injured worker returns to work, the current injury and the associated costs will continue to progress and escalate. However, if the ergonomic risk factors associated with the original injury are addressed and reduced, then the injury will heal sufficiently and not progress. The work-related injury is therefore “contained.” The work-injury-containment program is a process that enables the evaluator to identify and control some of the factors that can influence the injury’s progression.

Oftentimes, when a worker is injured due to exposure to ergonomic risk factors, he or she is excused from work temporarily or is put on restricted work duty. Over time, the injury heals either partly or completely, and the injured worker is returned to work at full duty and at full exposure to the ergonomic risk factors that may have caused the original injury to develop. If these ergonomic risk factors are not identified and controlled, they may cause the original injury to progress from a mild, relatively easy-to-treat disorder to a severe, catastrophic injury that may be costly and difficult to manage.

Work-injury-containment programs are divided into the following components: work task data, musculoskeletal assessment, injury characteristics, description of the observed job tasks, ergonomic and injury risk factors, recommendations, and an overall summary.

Program Example

Here’s an example of a work-injury-containment program: A worker has sustained a wrist injury and is diagnosed with wrist strain. The injury has developed due to exposure to the ergonomic risk factors of high repetitions, forceful grasping, and repeated wrist flexion and wrist extension. If the injured worker immediately returns to full work duty, and is exposed fully to these risk factors, the wrist may be weakened and may be more susceptible to further injury if the ergonomic risk factors are not controlled. Over time, the wrist injury may not heal; or a mild wrist strain injury may progress to carpal tunnel syndrome or another inflammatory condition, and may even require carpal tunnel release surgery and extensive rehabilitation. As the injury progresses, the length of time away from work and productive duties increases, and the average cost per injury claim increases. Cost escalation with injury progression is illustrated in the above chart.

On the other hand, if the ergonomic risk factors of high repetitions, forceful grasping, and repeated wrist flexion and extension are reduced during the appropriate stages of tissue healing and return to work, the injury will resolve and heal fully.

Work-Integration Programs

Work-integration programs are a specialized form of return-to-work programs for injured workers. They are performed, at least in part, at the workplace and involve the development of a plan of care that establishes a structured and progressive return to work following a work-related injury.

The program works by evaluating the clinical factors, injury factors, ergonomic risk factors, and work tasks of an injured worker who cannot easily return to his or her pre-injury level of work function. By evaluating the injured worker’s functional deficits, injury characteristics, critical job demands, and ergonomic risk factors, the rehabilitation professional can develop a scheduled progression of work duties that will allow progressive reconditioning and adequate tissue healing, while allowing the worker to remain productive and safe at the workplace. Work-integration programs can be a very effective method of injury management, as they provide prompt return to work, productive work duties, and an opportunity for injury resolution, all of which can significantly influence the overall cost of the injury claim.

The components of the work-integration program include: functional assessment, injury characteristics, work tasks, ergonomic risk factors, and work organization. The program requires the cooperation of not only the injured worker but also the ordering physician, insurance carrier, and employer.

Alternate Example

Let us examine another case in point. A warehouse worker is receiving rehabilitation following a laminectomy he required after he injured his back lifting at work. The worker is 6 weeks postoperative, and the physician has kept the worker completely out of work. The critical job demands include: handling objects weighing between 25 and 100 pounds, driving a forklift, and performing product-logging duties.

At this time, the physician returns the worker to work with lifting restrictions of 50 lbs and a follow-up in 1 month. The employer is concerned about re-injury and lost production, so they contact the rehabilitation professional to develop the work-integration plan of care. A rehabilitation professional evaluates the worker’s functional limitations, which include: maximal lifting of 50 lbs, and limitations in standing, walking, twisting, and forklift driving.

The injury characteristics include a postsurgical condition in the subacute stages of healing, and no prior medical history or postoperative medical complications. The job’s ergonomic risk factors include: whole-body vibration, postural stress, forceful exertions, and repetitive material handling. To facilitate a safe and productive return to work, the rehabilitation professional develops a plan of work duties that include: a short period of forklift driving, followed by a short period of material handling, then a long period of product logging; then repeating the work cycles. The plan also includes continued skilled therapy focused on functional restoration and reconditioning.

This work task schedule is progressed during the next 4 weeks, until the worker next sees the physician. It will be modified as needed and continued for the time following the next physician office visit. The plan is to progressively increase the duration of material handling and forklift driving—the more physically demanding work tasks—while subsequently decreasing the product-logging duties, the least physically demanding work tasks.

This progressive plan of alternating duties and gradually increasing physical work requirements allows for a period of reconditioning. In addition, the rehabilitation professional designs a schedule for 1 month’s time to limit the worker’s lifting to 25 lbs during week 1, 35 lbs during week 2, 45 lbs during week 3, and 50 lbs during week 4. The work-integration program and plan may continue for several weeks or months, until the worker is at full duty with no restrictions.

Marketing Work-Injury-Management Programs

Opportunities to market and provide rehabilitation services in workers’ compensation are abundant. Patient referrals can be obtained by direct communication with the primary referral sources under workers’ compensation. These referral sources typically include the ordering physician, employer, insurance adjuster, case manager, and—indirectly—the patient. In addition, the rehabilitation professional can also act as their own, and best, referral source by representing themselves as specially trained and experienced in work-injury management, and by providing evidence of quality outcomes in worker rehabilitation.

To maximize marketing opportunities, the rehabilitation professional should focus on functional outcome measures. Another key to maximizing marketplace presence is to establish a level of expertise in work-injury management by developing skills and competencies in these specialized programs and services. Continuing education, training, and specialty certifications will identify a rehabilitation professional who has specialized in the issues, objectives, and clinical practice standards within this rehabilitation sector.

Summary

Currently, there are ample opportunities to contribute and prosper as a rehabilitation professional in the workers’ compensation industry. Developing and implementing specialized work-injury management programs provide the rehabilitation professional with programs and services to better manage workers’ compensation patient care and return to work. The key to work-injury management is a strong understanding of ergonomics and how work demands affect human performance and disease development. Core competencies in ergonomics, clinical management of work-related injuries, and ergonomic risk factor  control are essential to successful work-injury management.

Nicole Matoushek, MPH, PT, has more than 11 years’ experience in physical therapy and ergonomics consulting. She practices out of Ergorehab in St Petersburg, Fla, and can be reached at nicole@ergorehabinc.com.

References

1. US Department of Labor, Occupational Safety and Health Administration. “Safety Pays.” Available at: http://www.osha.gov Last accessed February 25, 2005.

2. Kish J, Dobrila V: “Carpal tunnel syndrome in workers’ compensation: frequency, cost and claims characteristics.” National Council on Compensation Insurance Inc. Vol. 3, Issue 3, June 1996.