National Workers Compensation & Disability Program

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Michigan Self-Insurers' Association - www.michselfinsurers.orgMSIA 2011 Spring Conference PresentationNational Workers Compensation & Disability ProgramRay Gagne Presentationwww.Fit2wrk.com

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An Integrated Approach«
It is no mystery that there are significant costs and loss time associated with soft tissue injuries in the workplace. Sprains and strains account for 41 percent of all workplace injuries and illnesses requiring days away from work. The musculoskeletal disorders or MSD¶s as they are called in the Industry, are difficult to assess and ultimately are handled differently by providers across the country. With little standardization and consistency of care delivery, the outcomes are varied from one provider to the next. The solution is the development of an integrated approach that manages and reduces risk throughout the continuum of care.

Statistics
1. Employees out of work for more than 12 weeks with a work-related injury have less than a 50 percent chance of returning to work. (Hartford Study) 2. Musculoskeletal disorders (MSDs) cost the U.S. economy between $13 and $15 billion annually ending in a total cost of employee disability which adds up to 6.3% of total United States payroll (Watson Wyatt Worldwide and the Washington Business Group on Health, 2001). 3. An employee who files a Workers¶ Compensation(WC) claim for lost time is twice as likely to file another WC within 3 years 4. 26% of employees with a prior WC claim who remained employed with the same employer are more likely to file another claim with employer 5. The 2nd claim filed for this employee has more than a 50% chance of being a back injury 6. Over the past three years, workers' compensation costs have increased an average of 50 percent and currently account for $.67 of every dollar spent on casualty insurance. Average Industry wide costs per type of injury are as follows;
Upper Extremity: The average days lost for an upper extremity injury is 61 with an average cost of $14,700 Back: The average days lost to a back injury is 32 with a cost for one of between $18,900 and $24,900

The High Risk Job«
Every Industry has a job that is simply a difficult one that has historically run an increased rate of injury occurrence. These jobs for the most part have been reviewed from an ergonomic hazard standpoint, but they cannot be easily changed. This leaves the question, how do we be proactive and go about reducing risk of injury in this type of environment. Quality care after injury is certainly important, but are there other areas where we can minimize exposure going forward. These injuries, and these high risk jobs make up for the majority of the premium costs and need to be looked at from all aspects. A general review of past injuries and claim duration will help to direct you to the High Risk Jobs in question.

Ergonomic Assessments
Ergonomics is the scientific study of people at work. The goal of ergonomics is to reduce stress and eliminate injuries and disorders associated with the overuse of muscles, bad posture, and repeated tasks. This is accomplished by designing tasks, work spaces, controls, displays, tools, lighting, and equipment to fit the employee´s physical capabilities and limitations. ³The easier it is to do a job, the more likely it is to see gains in productivity due to greater efficiency. Analogously, the safer it is to do a job, the more likely it is to see gains in productivity due to reduced time off for injury. Ergonomics addresses both of these issues by maximizing the workspace and equipment needed to do a job.´

The Job Demands Analysis
All programs for employee care begin with the details of the job demands. If job demands are not clearly stated then in the course of evaluation, individuals may be over or under tested, rehab will be misdirected and there will always be a potential for re-injury upon return to the workforce. The first place to start in the development of an integrated program for reducing risk is to update and/or redo existing job demands, specifically for the high risk jobs. They need to properly reflect essential and high risk duties of the work environment. In accordance with the ADA and EEOC, the Uniform Guidelines on Employee Selection Procedures states that a thorough job analysis is needed for supporting a selection procedure.

JDA / PDA
A Physical or Job Demands Analysis is a systematic procedure to quantify, and evaluate all of the physical and environmental demand components of all essential and non-essential tasks of a job. JDA or PDA is a process of establishing what a job is in it¶s entirety, in a way that complies with the law. For the purpose of employee rehabilitation and return to work, a JDA/PDA is the ³cornerstone´ of the analytical process used to determine compatibility between a worker and a specific job. Without a properly constructed, recently reviewed JDA/PDA; the rehabilitation professional has difficultly in the preparation of a worker for return to work, the Physician has limited ability to determine work restrictions, the Functional Capacity Evaluation service is rendered ineffective and the Post offer Pre Employment Screen is deemed non-compliant in relation to the ADA and EEOC. Needless to say, the first direction of any company in overall injury reduction is to tie down their job descriptions.

The Continuum of Care«
³No one service will suffice in the continuum of care, instead you need to be prepared to handle all situations that may arise with both the employees in the High Risk Job and those coming in to it. Furthermore, you need to ensure all aspects of testing and treatment are in tune with existing legislation and that your approach is legally and ethically sound.´

Where do I start«
One of the most common practices to reduce risk of injury is to review the work environment for areas that may be causing increased strain on the employees. Start with reviewing the type of injuries found in that particular job detail and then begin a thorough review of equipment, tools and processes that may increase risk through perhaps repetition, force, sustained posture or unique tasks such as twists or turns. This is essentially the foundation for a more formal ergonomic hazards analysis. If the environment cannot be changed then move on to the next phase of management.

New Hires
New Hires can be effectively managed with the incorporation of a post offer pre employment screening protocol. If not previously incorporated into your risk management model, then a formal validation study needs to be completed and you need to ensure both ADA and EEOC compliance. This evaluation qualifies any pre-existing conditions that may hinder his/her ability level and also provides a solid baseline of abilities to compare with if a future injury occurs. Several factors affect employers' existing and future health and safety. As we are aware job applicants today are increasingly heavier, more out of shape, and we are dealing with an aging workforce. As the total number of qualified job applicants is reduced, hiring and retaining qualified and physically ³able´ workers is one of the greatest challenges that employers face.

Post Offer Pre Employment Testing
This is an evaluation that is conducted following an offer of employment. Post-offer/Preemployment Evaluations usually involve medical examinations. Physical agility testing and drug screening are not considered medical evaluations; however, they may be components of the Post-offer/Pre-employment Evaluation. Post offer screening is a valid and reliable tool for identifying applicants' physical capabilities. The physical capabilities of the applicant are then compared to the essential physical demands of the job. Legally, these tests must be applied consistently to all applicants and applicants must be offered the job, prior to testing, on the condition that they meet the physical requirements of the job (ADA, 1990). A comprehensive post offer screen includes the following components: Accurate Physical Job Demands Analysis (JDA/PDA), Clear acceptable criteria, Physical screen, Standardized objective test, Occupational and job specific test. Benefits 1) The Evaluation identifies individuals that are a direct threat to their own health or safety, or to the health or safety of others at the work site. 2) Identifies potential health or safety risks lowers the rate of medical and injury claims. 3) Decreased medical and injury claims mean decreased costs.

Validation and Legal Rights
Validation Studies Aside from legal considerations, a properly-conducted validation study can help an employer determine to what extent the information obtained from testing job applicants is predictive of future job performance, and accordingly what weight should be given to the results of such tests. Griggs vs. Duke Power. The Court's opinion stated "«703 (h) authorizes the use of any professionally developed ability test, provided that it is not designed, intended, or used to discriminate." "The Act does not preclude the use of testing or measuring procedures, but it does prescribe giving them controlling force unless [401 U.S. 424, 425] they are demonstrably a reasonable measure of job performance. Pp. 433-436."

Rehabilitation
Understanding that you most likely already have a relationship with a qualified Occupation Health Group or Urgent care Delivery Model, the Physical Therapy component needs to be seen as a separate entity. It is well established that combining the two components in the same entity results in increased rehabilitation referrals and subsequently higher costs and loss work time. Once defined as a provider of choice, the Physical Therapy program for handling your employees MSD¶s needs to be driven by the job demands analysis. Start with functional restoration and then focus on simulated essential work demands as are dictated by the job demands analysis. This combined work simulation model helps to build endurance for activities considered to be high risk and subsequently allows for an expedited return to a sustained and safe work environment.

Baseline, Progress and Return to Work Evaluations
Rehabilitation Baseline Evaluations will display actual injury loss and help to direct treatment while ongoing progress evaluations will display range of motion and strength changes of the employee. This method provides immediate real time data to determine changes in treatment direction or for that matter an assessment of when the employee has reached Maximal Medical Improvement (MMI) or a return to work target (full duties and or transitional/modified duties). Return to Work and or Fit for Duty evaluations need to be directed to a match with existing full duty requirements or transitional/modified duties as is directed by the employer. The purpose of this evaluation is to ensure a safe and sustained return to duties. There are two very important considerations in this evaluation; first it needs to be relational to both the essential job demands and any previously designed post offer pre employment screen protocol and secondly the protocol needs to be medically legally sound and designed in such a way as to not over or under test the employee.

Modified or Transitional Duties
These programs can be developed to allow for early re-entry into the work environment. It is well documented that time on the job provides an expedited return to full function and also that the more time off from the job the less chance the employee will return back.

Modified duty Modified duty allows an injured worker to return to work or remain at work performing physically appropriate modified duties in relationship to his or her functional capabilities. When considering modified duty the employer will need to work with the physician of record and the rehabilitation specialist to determine the best possible solution for each individual worker. This may include: Comparing the employee¶s functional capabilities to the job requirement listed in the analysis; Deciding to what extent the job can be modified; Identifying other modified-duty opportunities on a limited or full-time basis. Transitional work Transitional work is a progressive, individualized, time-limited program focused on returning the worker with physical restrictions to the original employment site. Transitional work allows the injured worker to perform productive work at the workplace under the direction of rehabilitation professionals. The program may include progressive conditioning, on-site work activities, education for safe work practices, work re-adjustment and Job Modification.

Job Modification and/or Gradual Return to Duties
Job Modification Job modification is the removal or alteration of physical barriers that may prohibit an injured worker from performing the essential functions of the job. Successful job modifications are the result of a cooperative effort involving these people: Rehabilitation case manager; Employer; Injured worker; Physician of record; Other professionals as appropriate. Job modifications are developed and implemented keeping in mind the injured worker¶s limitations, restrictions, functional capacity and physical capabilities. An example of a job modification might be the purchase and installation of a power lift table for a mechanic with a back injury no longer able to lift. Gradual Return to Duties Gradual return to work is a program that allows an injured worker to return to work on a graduated basis building up from no less than four (4) hours per day to a full-time work status within a 13-week period. The employer pays the worker for the hours worked and living maintenance is paid for the hours not worked (or) the employer pays the full salary and is reimbursed for the hours not worked.

Job Transfers
Job Transfers are a significant risk if an employee is moving from a low risk (low weight, low repetition) job environment to that of a higher risk job. This has become increasingly apparent with employees with seniority wanting extended overtime hours that workers in other departments are getting. Going from a white collar to a blue collar environment is a concern due to de-conditioning and change in function. Of course individuals cannot be fired, but a transfer can be stopped if it poses a risk of injury to themselves or their fellow co-workers.

Preventative Maintenance
One of our primary concerns is that of the aging workforce already involved in the high risk job. With the existing workforce an evaluation qualified as a ³Preventative Maintenance´ evaluation can be developed and implemented. It is essentially designed to prevent injury and maintain the worker on the job. The purpose is to monitor patterns of degradation for both range of motion and strength of the employee in comparison to themselves versus the job. Example: Meat packer with extensive historical hand/wrist injuries: Test the wrist range of motion and hand/pinch grip strength every three monthsto review any significant changes in function.

What else can we do?
Strengthening and exercise can be a positive factor either on site at the employer or off site after hours at a local clinical facility. As we are aware more and more employers are embracing the Industrial Athlete concept and are incorporating programs during and after the work day to assist the employees on high risk lines in keeping Fit for Duty. Like an athlete they are involved in training their body to be able to effectively and safely manage their required tasks. Education of the employee base in topics ranging from tool handling and lifting to nutrition assist the employer in keeping the wellness directive on track. Wellness coaching as part of this model provides increased interest on the employee¶s part to participate.

Communication is the Key
Throughout the entire process it is important to maintain and increase communication with all parties involved. From the Treating Physician to the Occupational Health Team and the Physical Therapist, communication is the key to early re-entry into the workforce and ultimately positive interaction with the injured employee. The primary goal with any risk management program is to minimize loss work days and to reduce overall direct and indirect medical costs. By incorporating a program such as the one above, versus individual services, we ensure all aspects from ³Hiring to Retiring´ are accounted for in the continuum of care for the employee.

Additional Resources:

http://www.osha.gov/

http://www.cdc.gov/

http://www.cdc.gov/niosh/injury/

http://www.disabilitydurations.com/

http://www.workerscompensation.com/

http://www.dol.gov/dol/topic/workcomp/

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