Getting Back on One’s Feet

Healthcare providers who treat injured workers with multiple injuries and complex illnesses find the workers’ compensation system and return-to-work (RTW) process “opaque and confusing.” Divergent views on the timing and appropriateness of RTW in these complex cases among healthcare providers and case managers can also give rise to “tension and suspicion.”

These are some of the findings of a two-year, multijurisdictional study that the Institute of Work and Health (IWH) released in December. Focusing on healthcare providers’ experiences with the workers’ compensation system and their roles in the RTW process, the researchers interviewed 97 healthcare providers and 34 case managers in British Columbia, Manitoba, Ontario and Newfoundland and Labrador.

“What we found was that for acute, visible injuries that healed relatively quickly and people went back [to work] quickly, the processes in place seem to work well for healthcare providers. They reported encountering difficulty when they saw patients who had gradual onset and complex conditions, invisible injuries like chronic pain, some musculoskeletal injuries and mental-health conditions,” says study lead author and IWH scientist Dr. Agnieszka Kosny in Toronto.

Many healthcare providers cited the lack of clarity about their roles in RTW as a challenge. Some see their involvement as fairly minimal, while others regard it as essential. While Dr. Kosny thinks that involving healthcare providers in RTW decisions is important, many find it difficult to determine an injured worker’s functional limitations and evaluate the suitability of their job duties, due to a limited understanding of a patient’s job demands.

“Doctors don’t get a lot of training in this area in occupational medicine,” Dr. Kosny says. “Many of them learn about workers’ compensation and return to work as they practise.”

Navigating obstacles

Administrative hurdles and rigidity in the workers’ compensation system have also been cited as roadblocks. For prolonged and complex injury claims, WCB forms are ill-suited for conveying important information needed for decision making and effective RTW planning. In some jurisdictions, “the doctor has to look up a code for a certain system or injury, and that becomes complicated if it is a complex injury,” Dr. Kosny says. The strict requirement for objective evidence of disability or work-relatedness for conditions like depression, anxiety, chronic pain and some musculoskeletal disorders is another challenge.

Healthcare providers who offer input on recovery often have a major impact on the RTW trajectories. Dr. Chris McLeod, an assistant professor at the University of British Columbia in Vancouver who delivered a plenary on RTW outcomes in November, defines RTW as a trajectory consisting of a sequence of events.

“Return to work is not a single event. People who do work in this area with respect to returning injured workers to work after a work-related injury or disease know that it is complex and challenging,” Dr. McLeod says. While the goal of full RTW is to have an injured worker assume the same level of job responsibilities with the same employer, “we certainly know that doesn’t happen in many cases.”

Dr. McLeod’s study found that back strains are associated with early RTW, while fractures have longer RTW trajectories. Age gradient and workers in primary resources like manufacturing, construction and transportation are also associated with longer RTW trajectories.

Given the complexity of RTW, the IWH study recommends that workers’ compensation policy makers, healthcare providers and stakeholders engage in a dialogue to provide clear guidelines on the role of healthcare providers in the RTW process. Possibilities for their role include flagging issues that may complicate recovery and RTW, identifying chronic pain or deterioration in mental health and communicating with WCBs about further treatment needs, such as counselling or occupational therapy. If attempts to involve healthcare providers in the RTW process are unsuccessful, WCBs can then turn to medical consultants, who are hired to help case managers interpret medical evidence and make decisions.

Messaging around the role of healthcare providers and their RTW involvement should also be outlined consistently across materials. Most WCBs have sections on their websites that define the roles of healthcare providers. This section can include information about how the workers’ compensation system operates, its requirements relating to matters such as reporting and who makes the decisions, the study says.

Creating a central portal to house treatment notes, recommendations and decisions of case managers and giving healthcare providers access to these information about their patients will also improve the lines of communication between healthcare providers and WCBs, Dr. Kosny suggests.

Jean Lian is the editor of OHS Canada.