DISABILITY MANAGEMENT
The Obligation Of The Treating Phycisian

It is estimated that at any given time, approximately 8 million American workers are at home, not working, because of illness or injury. The median days away from work designates the point at which half the cases involved more days and half involved fewer days. The median days away from work for all cases was 6 days in 2001, with over one fourth of the cases resulting in 21 days or more away from work. For the past 10 years, more than 40% of injuries and illnesses resulting in time off work were sprains, most often involving the back. In a Workers’ Compensation claim almost half of the cost of the claim is disability payment. Return to work is a collaborative effort involving the Employer, Injured Worker and the Treating Physician.

One primary difference of caring for patients with Workers’ Compensation injuries, and caring for patients with non work related injuries is the obligation for the treating physician in the former sitution to perform disability management. Disability management should focus on the early yet safe return of the Injured Worker to some type of productive work activity. Clear advantages of early return to either modified or full duty for the injured worker include: minimizing the extent of physical deconditioning due to altered activities; psychologic benefit of lessening the loss of self esteem and the feeling of regaining control of one’s life; minimizing the loss of professional and personal relationships and lastly, minimizing the loss of income.

Disability management extends beyond writing a “return to work slip”. Proper disability management encompasses first gaining a clear understanding of what the patient actually does at his normal job task. One must probe beyond the job title and get from the patient a physical capacity description of his or her job duties. It is important to document this in the initial report to the claims administrator to be sure that the information that is being given to you is indeed accurate and appropriate. If you are in doubt or feel that you need further information to be able to grasp the physical requirements of the job, contact the Case Management Nurse or the Claims Examiner and request a job description. If the Claims Examiner, upon reading your initial report, feels that the job description rendered by the injured worker is incorrect, it is his/her responsibility to contact you and forward to you an appropriate job description. A good idea is to have a section in your initial report titled “occupational history” which should include the job description given to you by the patient as well as perhaps previous work history if you feel that it has bearing on either this injury or present complaints.

The availability of a modified duty program is at the discretion of the employer. The new Senate Bill 899 provides for funding to small employers to establish a return to work program by making workplace modifications to facilitate the return of injured workers to some type of employment. Modified duty has been a highly successful mechanism by which to transition the injured worker back into the work force. As the injured worker clinically improves, restrictions should become less intense until the patient is able to perform his /her normal work activities. Often by taking an adequate history of what the current work status of the patient is at the time of your initial visit you will be able to identify whether or not modified duty is available. Whether or not the injured worker tells you that the employer does or does not have modified duty, you should still complete the return to work slip noting the activity limitations and capacities that he/she can do. Often there are changes in the availability of modified duty at employers and the type of physical restrictions that the patient has may well dictate whether or not a modified duty will be available in the future.

In addressing written work restrictions, it is important to document specifically what activity and to what extent the injured worker is limited from the activity. There is a significant difference between “no bending or stooping” and “no repetitive bending or stooping”. If a patient is going to have some limitation imposed regarding keyboard activity, it would be important to specifically note the amount of time that the patient is able to be on the keyboard per hour, per half day or per day, depending on the situation. Similarly, when imposing a restriction on lifting, note the amount of weight that the patient can lift. The disability status of the patient at the conclusion of the examination or consult must be clearly stated. In addition, as described above, if appropriate, specific activity restrictions should be outlined and the date that the patient is able to return to this work if indeed it is made available.

However, perhaps the most important part of disability management is a discussion with the patient regarding the appropriateness of his/her return to work. The benefits to the injured worker of return to work should be discussed as outlined above, as well as the reassurance given to the patient that as his/her physician you are secure that he/she should be able to tolerate work within the restrictions that you have outlined. Often times, the injured worker has concerns that his employer will not adhere to the work restrictions that are imposed, and will demand that the patient perform work beyond these limitations. It is important for you as the treating physician to acknowledge this concern: the patient should be assured that the restrictions are in writing, not verbal, and if there are any questions at the onset of return to work about the specific restrictions, the employer should contact your office. In addition, if the injured worker feels that he/she is required to exceed these restrictions once returning to work, he/she should be advised to contact his/her Claims Examiner and you should offer to the patient at the time of your examination the name and telephone number of the Claims Examiner should the need arise for dialogue about this issue.

Lastly, the patient must be given a return appointment for follow up and again, reassured that his/her tolerance to the modified or full duty work will be monitored by you, the treating physician. Releasing the patient to work with restriction but with no follow up appointment will typically result in a great deal of apprehension on the part of the patient as he/she might feel that he will not have access to medical care if he/she encounters a problem once returning to work.

Again, it is a true collaboration between you as the treating physician to facilitate the return to work, the employer to cooperate with the process and make available a modified work program if necessary and the injured worker to partake in this process in good faith. The Claims Examiner or Case Management Nurse should serve as the liaison between the three parties to facilitate the process.