Piotr S. Baranowski M.Rehab., M.Psych., CCRC ReSolutions Consulting Forward thinking at work!

1. Exploring the Boundaries of Return to Work and Disability Management Practice byLooking Beyond Medical Diagnosis Piotr S. BaranowskiM.Rehab., M.Psych., CCRC ReSolutions Consulting Forward thinking at work! Halifax, Nova Scotia, Canada

2. Contents • A Story of an Absence (from Work) • Objective Medical Evidence • Disability vs. Impairment • Beyond Medical Diagnosis • Discussion

3. Traditional/Diagnostic Looking for only medical reasons • Trigger: a life event • Action: visit a doctor to ask for help • Method: search for medical reasons • Outcome: discovering medical answers (professional bias) Roles and Attitudes • Employee:efforts to prove disability • Employer:efforts to disprove disability • Doctor:patient advocate • Insurer/Employer:sponsor of the disagreement Parties’ needs are not met • gradual decrease in cooperative behaviour Mutual Losses • Employer attempts to control the perceived abuse • Erosion/Loss of Relationship • Employee – symptoms magnification & extension of absence • Increased cost

4. Systemic issues On average a MD visit is less than 8 minutes. • Symptoms history, physical examination, diagnosis, order lab tests, write prescriptions & treatment, arrange referrals or follow up and perhaps discuss secondary health issues (smoking cessation, stress, family, etc.) When is CM/DM or RTW supposed to be discussed?

5. Patient Bias “(…) doctors do not care about the employer or insurer – their only customer is their patient.” OMA Committee on Medical Care and Practice O.M.A. November 1994

6. Patient Bias • “(…) Most physicians rely on their patientsfor information about the conditions in the workplace and on his or her ability to do the original job.” • “(…) Ultimately, the patient makes the decision that they are too ill to work and then asks their physician to agree.” OMA Committee on Medical Care and Practice O.M.A. November 1994

7. System - Patient Bias • Medical support for a partially disabled employee during a prolonged absence from work is often driven by policies which require disabled workers to claim total disability in order to maintain their income benefits. • Some recovering patients, willing and able to do modified work, find their employer unable to provide it, and their disability insurer unwilling to continue partial benefits for limited impairments. • Family physicians often feel they must certify their patients as totally disabled to prevent loss of disability benefits OMA Committee on Medical Care and Practice O.M.A. November 1994

8. Impairment vs. Disability • Impairment: an injury, illness, or congenital condition that causes or is likely to cause a loss or difference of physiological or psychological function. • Disability:the loss or limitation of opportunities to take part in society on an equal level with others due to social and environmental barriers. “Disabilities Studies Manual” - Leeds University, Leeds, UK The Equality Unit - Sheffield City Council, Sheffield, UK

9. Disability Disability may be defined as an alteration of an individual’s capacity to meet personal, social or occupational demands, or statutory or regulatory requirements, because of impairment. A disability arises out of the interaction between impairment and external requirements, especially those of a person’s occupation. Disability may be thought of as the gap between what a person cando and what the person needsor wantsto do. American Medical Association Guides to the Evaluation of Permanent Impairment, p.2

10. Impairmentis a medical term usually defined by a set of relatively objective and measureable parameters (e.g. diagnostic tests) determining the extent of pathological changes. Disability:is a legal and social term defined by social/cultural context, contractual definitions, personality/attitude, economic conditions, etc. Loss of Hearing – Ability to Communicate Disability vs. Impairment

11. Disability vs. Impairment Physicians are educated to determine impairment not necessarily disability • Position Statement on Early return to work After Illness or Injury – Alberta Medical Association, February 1994 • Position in Support of Timely Return to Work program and the Role of the Primary Care Physician – Ontario Medical Association, March 1994 • The Attending Physician’s Role in Helping Patients Return to Work After and Illness or Injury – American College of Occ. & Env. Medicine, April 2002

12. Medical In the clinical model the treatment is matched to a diagnosis, which is derived from a specific pathology. Appendicitis, diabetes, a bone fracture, etc. We can usually agree on the cause, the medical findings, the recommended treatment and the recovery timeline.

13. Medical Stress? Depression? Mental Illness? Multiple diagnoses?

14. Beyond Diagnosis Medical Distress Personality Beliefs Coping Economic Fears

15. Medical Issues Vocational Issues Personal Issues Choice

16. Beyond Diagnosis • Medical issues • legitimate functional impairments • Vocational issues • relationships at work • job satisfaction, job performance, perspectives • burnout, disengagement • Personal issues • personality (catastrophising) • relationships with self & with others • secondary gains

17. Medical • Medical Status Evaluation (MSE)Identifies diagnosis, current status, medication, clears individual to participate in activities: FCE, Tx or RTW • Independent Medical Evaluation (IME)Answers specific questions re: impairment, treatment, medication • Functional Capacity Evaluation (FCE)Identifies functional abilities, gains some insight to person’s beliefs • File ReviewOffers chronological perspective on documented medical history, helps to draw conclusions and plans • Psychological EvaluationGain in-depth inside to personal beliefs, motivation, coping strategies, support systems, family dynamics

18. Medical to Functional Job demands: • irregular work hours • may need to work O/T • must be able to drive shortand long distances • fast paced environment • ability to make quickdecisions • direct dealings with public • safety sensitive position Functional Abilities/limitations: • regular medication regime & balanced diet • difficulty with night vision • symptoms aggravated bystress • side-effects of medicationmay temporarily affect judgment • performance may vary significantly during the day

19. Vocational Job demands: JDA Category:Degree of self-Supervision required JDA Definition: The extent of self-supervision required in the course of duties. JDA Ranking Scale: • No self-supervision required (fully supervised) • Occasional self-supervision required (supervisor frequently provides work direction) • Frequent self-supervision required (supervisor occasionally provides work direction) • Predominantly self-supervised throughout the shift (may contact supervisor to obtain work direction as needed) Functional Abilities/limitations: FAE equivalent:Ability to self-supervise FAE Definition: The ability to work effectively without supervision. FAE Ranking scale: • Cannot self-supervise, requires constant work supervision • Requires frequent supervision • Can tolerate infrequent supervision • Able to carry out work tasks in a self-supervised manner

20. Work Environment Positive relationship with the supervisor and work environment is considered one of the primary determinants of work success. Interpersonal aspect of supervision and communication with co-workers are considered as equally important for the successful outcome, as the physical job accommodation.

21. Practice Job Accommodationmeans changing the way job expectations are met. Empathy and Compassion are good healing strategies and introduction to a relationship yet not always sufficient for building a long term business relationship. Equality and Productivity form a much stronger foundation for sustainable employment.

22. Beyond Diagnosis - Personal “It is always more important to know what type of person has a disease, than it is to know what type of disease a person has” Hippocrates

23. Beyond Diagnosis - Personal Patients’ beliefs about their pain and ability to work warrant as much attention as the anatomical and pathological aspects of their condition. V. Wilk, MD

24. Beyond Diagnosis - Personal • “People experience what they expect to experience” • “If you can only do 1 thing in a return to work support program, sit down with the person and explain to them what to expect health- and symptom-wise during their disability event, then what is and what is not indicative of a health risk (…)”. Dr. Presley Reed

25. % Injuries with time loss Disability score at time of Injury Beyond Diagnosis - Personal Perception of disability within two days of injury predicts likelihood of time loss Tate et al., Spine 1999

26. Beyond Diagnosis - Personal • Catastrophising is considered the primary driver of health-related absence from work • Approx. 40% of EU federal funding is now directed to early psychological services to decrease the negative influence of catastrophising on RTW success Int’l Forum on Disability Mgt, Berlin 2008

27. Personal - Relationships Relationship with self and the Universe: Questions in the “first half” of life: • What does the universe expect of me? • How can I get there? Questions in the “second half” of life: • What do I expect of myself? • What is the meaning of my existence? • How can retain this feeling and this connection?

28. Personal – Secondary Gains Secondary gains: • Justifiable: • caring for sick child • caring for ill elder • an addiction • Non-Justifiable: • avoiding dealing with performance concerns • magnifying loss for a benefit (MVA, WCB) • holding another job simultaneously

29. Piotr S. Baranowski - ReSolutions Consulting– 2011 ROSE Conference

30. Guiding Principles • Medical/Treatment component • address functional limitations (Tx, OT) • Vocational component • addressing work environment issues • Personal component • offering assistance in managing personal matters Expected plan outcomes: • reduced anxiety

31. MVP Psych MD CM Client (…) VR

32. Guiding Behaviour Strategies: • Medical issues -----give control • Vocational issues -----take control • Personal issues -----give support Outcomes: • Clearer options for employee &employer • More informed choices • Greater individual responsibility for results

33. ng Piotr S. Baranowski M.Rehab., M.Psych., CCRC ReSolutions Consulting Disability Management Programs & Services Halifax, Nova Scotia, Canada (902) 476-2131 rehabsol@telus.net ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ • DM Program Development & Implementation • Conceptual Framework * Service Policy/Protocol • Benefit Analysis * Program Evaluation * Metrics • Seminars & Workshops