Return to Work: The Best Place to Recover from a Workplace Injury is at Work

Dr. Greaney describes how prompt reporting and immediate care guidance provided by a trusted clinician helps injured employees remain productive. This approach, which focuses on the value of work, has been shown to improve employee health outcomes while reducing associated medical, workers’ compensation and lost-time costs.

Empowering Employees to Take Care of Themselves – Key Points

1. Employees with minor injuries who return to work as soon as possible have a better outcome – both physically and mentally – than those who are taken off work.
2. Best practice models advocate early reporting, immediate attention, and stay at work or return to work soon after injury onset.
3. Many prolonged disabilities begin as common health problems. Poor outcomes are often due to non-medical factors.
4. Helping people stay at work benefits them, their family members, co-workers, their employers and the community.
5. Overtreatment and poor return-to-work decision-making can be avoided with careful monitoring and employee empowerment.

The Scenario

Sergio is repairing equipment at a power station when he feels a twinge of discomfort in his lower back. Per company policy, he informs his supervisor. What happens next is likely to have a critical impact on the outcome for Sergio and his employer.

Let’s assume the supervisor instructs Sergio to stop working and visit a clinic for evaluation. At the clinic, the treating provider does a physical exam, orders some diagnostic tests and writes a prescription for medication to relieve pain and inflammation. Sergio takes the afternoon off and returns to work the next day with restrictions. The encounter is recordable and results in a workers’ compensation claim.

Alternatively, Sergio and his supervisor call or use a smartphone application to contact an injury management triage center. Sergio describes his symptoms to an occupational health nurse or physician who offers reassurance and care guidance. He is given the option of a clinic visit, but with instructions from the clinician voluntarily agrees to self-administer first aid.

After applying a cold pack and taking a non-prescription anti-inflammatory medication approved for use at the worksite, Sergio resumes work and is able to safely finish his shift. A claim is not filed and there is no case to record.

In the first scenario, a routine complaint of low-back discomfort diverges onto a path with the potential for high medical costs, productivity loss, delayed recovery and litigation. In the second scenario, Sergio is given choices that include using work (an “activity prescription”) as therapy during recovery. Sergio is empowered to successfully manage his condition without worrying about making it worse or potentially missing work.

Importance of Empowerment

While practicing occupational medicine in all types of industries, I have observed that the vast majority of work-related injuries are relatively minor and can be effectively managed onsite at the first-aid level. So, why do these types of cases so often end up in a doctor’s office or hospital emergency room? The reasons range from entrenched provider referral patterns, to supervisors’ inexperience with injury management, to employee pain behaviors (such as medicalizing nonmedical issues), to employers’ legal liability concerns.

Environment, health and safety (EH&S) professionals have an opportunity to overcome these barriers and simultaneously improve workforce health outcomes and business results by:

• Promoting healthy habits such as routine exercise, good nutrition and getting enough sleep
• Providing support for the management of chronic conditions such as diabetes or hypertension
• Giving employees the information they need to make informed choices about their own care

Work-related injury rates remind us why it’s important to consider the potential positive impacts of health care consumer education in employed populations when designing workplace injury prevention and management programs.

For example, while injury incident rates have been declining in the U.S., there were still approximately 2.8 million non-fatal workplace injuries and illnesses reported by private industry employers at a rate of 2.8 cases per 100 full-time equivalent workers in 2017, according to the U.S. Bureau of Labor Statistics. On average, 1.5 cases per 100 FTEs resulted in days away from work, job restriction or transfer.

A significant percentage of work-related injuries are musculoskeletal disorders, which cost employers billions of dollars annually and create substantial disability burdens. Overexertion involving outside sources was ranked first among the leading causes of disabling injury in the 2018 Liberty Mutual Workplace Safety Index, with direct annual costs to employers estimated at about $13.7 billion.

In addition, there are lessons to be gleaned from recent studies on provider choice and treatment value. For example:

1. Researchers compared total workers’ compensation case costs in employer-directed states to costs in states that allow employee choice of provider. Costs were higher in states with employer-directed care, at least partly due to increased attorney involvement.¹ This indicates a desire on the part of employees to have more control over their own care.
2. In a multi-year review of cases in 25 states, the Workers Compensation Research Institute found little evidence of differences in average costs per claim between employer-directed and employeechoice states for workers’ compensation care.² However, high-cost back injuries cost even more in choice states. The findings suggest that allowing employees to choose their provider does not necessarily equate to higher costs for employers, and that it may be beneficial to educate managers and frontline workers about factors that drive up costs in certain diagnostic categories.
3. In Washington state a performance measurement tool called the MedInsight Health Waste Calculator was used to evaluate the value of tests, procedures and treatments provided in group health settings. Researchers found 622,000 people received “low value” health care services at an estimated annual cost of $282 million.³ In workers’ compensation cases, similar principles appear to apply.

From an epidemiological standpoint, none of the parties in the workers’ system have found a way to significantly reduce costs and disability associated with work-related injuries. In the U.S., over-treatment is a fundamental problem. Use of narcotics for the management of mildto-moderate musculoskeletal pain, in particular, has contributed to the nation’s opioid addiction epidemic.

Solutions

Preventing injuries is the goal. When injuries occur, medically sound interventions can be used to empower employees to take of themselves, from onset to full recovery.

Prevention

Frontline supervisors and safety professionals who leverage collaboration with occupational health and ergonomics experts are better equipped to detect and manage conditions that increase workers’ injury risk. Such factors include poor physical fitness, obesity, aging, depression, fatigue, substance abuse and chronic disease. Experience shows the sooner these types of conditions are detected and managed, the greater the likelihood of positive results across the board.

Examples of preventive interventions include onsite coaching on the use of proper body mechanics, time of-need training and targeted wellness programs based on population health risk assessments. On the non-occupational side, many group health and self insurance plans offer incentives and disincentives to encourage or discourage certain behaviors.

Giving the workforce a voice in the selection of preferred providers may also pay dividends. Depending on community and workplace culture, employees may express a preference for onsite services, remote telehealth access to clinicians, or use of alternative modalities such as chiropractic care, acupuncture or non-invasive massage techniques. When surveyed, employees often express a need for stress management, mental health, substance use and personal counseling services, as well as physical fitness, weight control and smoking cessation programs.

Injury Management

No matter how minor an injury may be from a medical perspective, it is not trivial to the person who is experiencing it. Employers who respond to injured employees’ expressed needs and have an established care management process tend to fare better than those who do not. Every encounter is a chance for employee education and empowerment.

Astute safety professionals who are responsible for protecting dispersed workforces are learning to take advantage of communications technology that facilitates the use of secure platforms for the confidential exchange of protected health information. That doesn’t mean personal contact with a health care provider does not add value: At times it is essential for an individual to be touched by a caregiver in order to get better and return to full function.

Recommended intervention strategies include:

• Encouraging reporting at injury onset – the sooner the better
• Providing immediate access to qualified medical professionals
• Using “simple” guidance to discourage unnecessary complexity
• Facilitating self-care at the first-aid level, as clinically appropriate
• Managing referrals and monitoring health status during recovery
• Creating pathways for safe return to work, with or without restrictions

Using an early intervention model, an employer should expect 50 to 70 percent of employees with low back strain to elect first aid self-care when presented with options and guidance, along with a return to full duty. Of those requiring an initial clinic evaluation, nearly all should be cleared for return to modified work.

Three interventions, in particular, have been shown to consistently decrease the duration of time lost per work related injury by as much as 45 percent:

1. Temporarily modified duties that match an individual’s clinically and functionally assessed physical capacity.
2. Sympathetic communication with the injured employee.
3. Non-adversarial handling of workers’ compensation claims.

There are certain conditions, including severe intractable pain, that preclude some employees from working, even with accommodations. However, work absence is not medically necessary in the vast majority of cases.

In summary, experience and injury incident data show that most employees with relatively minor injuries are willing to try guided self-care when a trusted source educates them about the nature of their injury and anticipated path of recovery – before a workers’ compensation claim is filed. An optimal strategy for protecting a patient from harm caused by overtreatment, including the use of opioid medications for pain relief, will help prevent the first prescription from ever being issued.

Simple guidance from the outset reduces the likelihood of unnecessary complexity. Regardless of the path a work-related injury case may take, the outlook is always brighter when employees feel empowered.

Did You Know?

The U.S. Agency for Health Care Policy & Research Guidelines Panel did an evidence-based review of studies and developed guidance for the management of low back pain. The panel found significant evidence that over-treatment in the acute phase of low back pain can increase sickness behavior.

This occurs partly through deconditioning of body muscles through excessive rest, and partly through “labeling” and “attention” effects that may make some people overreact to their pain. About nine in 10 adults will experience back pain at some point in their lives. When it occurs, 50 percent of all low back pain will resolve in one week and 90 percent will resolve within three to 12 weeks without any treatment, studies show.

References

1. Is Employer-directed Medical Care Associated with Decreased Workers’ Compensation Claim Costs? Xuguang Grant Tao, M.D., Ph.D., et al.; Journal of Occupational and Environmental Medicine, Vol. 60, Issue 5, May 2018.
2. The Effects of Provider Choice Policies on Workers’ Compensation Costs; David Neumark and Bogdan Savych; April 2017; WC-12-21. 3
3. First, Do No Harm: Calculating Health Care Waste in Washington State; Washington Health Alliance, February 2018.