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Early Intervention in high risk individuals injured at work

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1 Early Intervention in high risk individuals injured at work
Concord Repatriation General Hospital Sydney

2 Concord Repatriation General Hospital
2,500 FTE employees (now has 4,500 FTE) Part of Sydney South West Area Health Service which has 17,500 FTE employees

3 Who are we? We are not a consultant firm.
We are not academics or professional researchers I am a F/T medical staff specialist. Andrew McGarity is a F/T Rehabilitation Coordinator

4 Staff Health “One Stop Shop” Workers Compensation
Occupational Health and Safety Medical management of workers (GP’s 80%) Compensation injuries Vaccinations Needle stick injuries and mucosal splashes Health monitoring e.g. noise, cytotoxic agents, etc Pre-employment assessments

5 Soft tissue injuries to shoulder, upper limb, wrist and hand 36
Audit of 100 consecutive workers compensation patients through the unit showed the following case-mix: Soft tissue injuries to shoulder, upper limb, wrist and hand Soft tissue injuries to back, lower back, knee, foot and ankle 37 Soft tissue neck injuries Hernias Fractures Head injuries Motor vehicle accidents Assaults Miscellaneous (bruising, needle stick) 6

6 Self Insurer – Treasury Managed Fund Sub-contract to an insurer (EML)
NSW Health Self Insurer – Treasury Managed Fund Sub-contract to an insurer (EML)

7 Necessity is often the mother of invention
we had a huge number of open claims ~ 300 We felt we were failing our injured workers because we were not meeting their needs despite good medical management and good case management. Something needed to change! Spate of very difficult cases who went on to have chronic pain syndromes There was no “road map” to tell us what to do! The following is about 5 years to this presentation. Huge number of open claims ~ 300 with one rehabilitation coordinator We did not feel that we were meeting the needs of the small but significant percentage of those injured workers who cost us the most As a specialist physician in musculoskeletal injuries I had been working in Staff Health for about four years up to that point and did not feel that I was improving things as much as I thought I should have even though I knew what the guidelines were for various conditions and I was confident. Cognitive behavioural approaches did not seem to work in this high risk group. We had had a spate of difficult cases that went onto chronic pain syndromes We knew that for most of the cases we were doing a reasonable job but in the 20% of cases that we did not feel that we were doing the best job, they cost the most. There was nothing in the research to tell us what to do We felt disheartened!

8 What we did first Change in Rehabilitation Policy to require worker to attend Staff Health for initial assessment (unless medically contraindicated). Database developed to track workers from notification to finalisation. Development of suitable duties lists for a majority of depts. Increased role of managers in the rehabilitation process. Meetings with managers of major depts. with monthly meetings to review claims and provide comparative data. Regular monthly meetings with the physiotherapists who regularly saw our patients. Despite these changes our results did not improve significantly

9 Where to go from here? We decided that the first 4 weeks was the answer, – after that you start to lose control! We did not need to do anything that is not normally done, only we needed to do it earlier (mainly for the high risk individuals). We needed to find these high risk individuals in the first week. We needed to see people face to face within 48 hours of the injury. We needed expert help in the two areas that were most influential in a person’s recovery – the psychological area and the medical area (to assist the GP). We needed to ensure that the GP was in control of the whole process through consultation and approval. We also did not have the power to do it!. We decided that we had less than four weeks to intervene in these high risk cases, after that we had great difficulty in keeping control or had “lost control”. However most of the Soft Tissue WorkCover Guidelines will tell you not to do much before 6 weeks. We decided that we would include all consecutive claims and only not include people who could not speak English, or had “red flag” conditions such as cancer, tumors or neurological conditions needing urgent treatment.. We decided that we needed to see everyone and if that meant bringing them in we would pay for them to come to the hospital unless there was a good medical reason why they couldn’t. We decided that we needed to act within 48 hours of an injury so that the interventions could be done between weeks 2 – 4. We decided that the GP’s needed help in these difficult cases and often did not have the early confidence to send these people back to work especially if the patients did not want to go back. We decided that if we were doing the correct thing by the patients then our costs would come down so we decided that we were only going to be interested in the total cost of the claim at the end of the claim and did not measure anything in between. Cost of the claim would be done independently by the insurer once the case was finalised by a final medical certificate. We needed to ensure that we followed an evidence-based research structure for management of the condition. We needed a psychologist who was independent, time and outcome focused. We decided that we did not have the man-power to handle the potential workload that came with doing this work as most of these individuals were not only high risk but also high maintenance. We decided that we had to convince the hospital and insurer to put money up front to save money down the track. We decided that we would not do anything that is currently not done later in the course of injury management but do it earlier. We developed a strategy and a research plan.

10 What else did we decide? We decided to just use TOTAL COST OF THE CLAIM as the main indicator of success or not (time lost, treatments by all health professions, legals etc) We needed an evidence-based intervention. We needed to spend a significant amount of money upfront. We needed to consult and convince stakeholders. We needed the process to be “portable” so it was not just something that could only be done at Concord Hospital or by a particular medical specialty who had a particular expertise in MSK injuries GP’s remained the main doctor involved and the main NTD. We decided that we had less than four weeks to intervene in these high risk cases, after that we had great difficulty in keeping control or had “lost control”. However most of the Soft Tissue WorkCover Guidelines will tell you not to do much before 6 weeks. We decided that we would include all consecutive claims and only not include people who could not speak English, or had “red flag” conditions such as cancer, tumors or neurological conditions needing urgent treatment.. We decided that we needed to see everyone and if that meant bringing them in we would pay for them to come to the hospital unless there was a good medical reason why they couldn’t. We decided that we needed to act within 48 hours of an injury so that the interventions could be done between weeks 2 – 4. We decided that the GP’s needed help in these difficult cases and often did not have the early confidence to send these people back to work especially if the patients did not want to go back. We decided that if we were doing the correct thing by the patients then our costs would come down so we decided that we were only going to be interested in the total cost of the claim at the end of the claim and did not measure anything in between. If a person was off work it would have a higher cost. Cost of the claim would be done independently by the insurer once the case was finalised by a final medical certificate. We needed to ensure that we followed an evidence-based research structure for management of the condition. We needed a psychologist who was independent, time and outcome focused. We decided that we did not have the man-power to handle the potential workload that came with doing this work as most of these individuals were not only high risk but also high maintenance. We decided that we had to convince the hospital and insurer to put money up front to save money down the track. We decided that we would not do anything that is currently not done later in the course of injury management but do it earlier. We developed a strategy and a research plan.

11 How to do it? Literature search – confirmed our understanding about psychosocial issues as the best predictor of a person’s outcome following a W/C injury OMPQ: 4 – 6 weeks NSW WorkCover “Special sort of Psychologist” Use the IMC Program that NSW WorkCover has in place. Use WorkCover accredited rehab providers for all high risk people We did literature search and found that psychosocial issues were the best predictor of long term disability. But there was nothing to help us to know what to do in terms of early intervention. So we had to decide for ourselves. The OMPQ (Orebro) designed and tested by Stephen Linton from Orebro University in Sweden was used by WorkCover NSW at 6 weeks to help case managers with difficult cases. We decided to use this as a basis to work from. We felt we needed skilled help around psychosocial issues or “yellow flag” issues. We needed to help the GP’s who saw 80% of injured clients especially those at high risk with high psychosocial needs and were the most influential in the early management of high risk individuals. For all high risk injured workers we had an independent medical consultant see the person within the first three weeks of an injury. In NSW IMC’s have to ring the NTD (nominated treating doctor) to discuss the case after they have seen the person. This ensured that we had two doctors looking at the person, one the NTD and one who was expert in injury management. We only used selected Occupational Physicians. We found a very good psychologist who had worked in the army and was used to treating anxiety, depression, PTSD and related psychological conditions and was independent of the hospital. We decided that he would see all the medium and high risk injured workers. We used an independent physiotherapist to see all high risk injured workers who were spending longer than 6 weeks at one on one physiotherapy rather than being shown a home program to continue their management. There are conditions that need longer than 6 weeks but we wanted an independent physiotherapist to make that decision with the treating physiotherapist. All high risk individuals of long-term disability would be referred to an independent NSW WorkCover accredited provider for injury case management and assessment of the workplace. I would review all cases that were off work for more than four weeks.

12 Yellow Flags Depression Anxiety/ Fear avoidance behaviour Stress
Poor pain coping strategies Expectations of recovery Perception of health change Perceived psychological demands at work Perceived confidence in management Perceived high job demands

13 BUT before we could do the intervention we had to:
We needed to change the current OMPQ (Orebro) 26 questionnaire which as designed to be done at 4 – 6 weeks to one that was one page and could be done soon after an injury and in around 10 minutes. We needed to trial the new form to see if it did what we wanted. We needed to categorise people into low, medium and high risk according to the new modified questionnaire We needed to involve and get agreement with all stakeholders. We needed to change the current OMPQ (Orebro) 26 questionnaire which as designed to be done at 4 – 6 weeks to one that was one page and could be done soon after an injury and in around 10 minutes. We needed to trial it and needed to categorise people into low, medium and high risk according to the new modified questionnaire We needed to involve and get agreement with the general manager of the hospital, the supervisors in order to ensure systems were in place to get people to see us within the time period, the insurers, the unions. Up front costs for each high risk individual would be of the order of $5 –

14 Research Pilot: 30 consecutive injured workers – asked if they would fill out the modified questionnaire and followed them through until they returned to work with a final certificate. Reviewed the costs and categorised the groups into high, medium and low. Took a year and a half. Control Group: We then followed a cohort of 80 injured workers where they received “usual care” (no special intervention). In our institution, they still got seen within 48 hours of notification of the injury, put in a injury notification, received physiotherapy within a few days of the injury and often that occurred before we received a medical workers compensation certificate. Trial Group: We then followed a cohort of 80 consecutive injured workers with soft tissue injuries and instituted the intervention program. Took three years to complete the main part of the study

15 Örebro Musculoskeletal Pain Screening Questionnaire (Modified)(Linton & Hallden, 1998)
Please tick the box that reflects you current age How many days of work have you missed because of this injury? How long have you had your current pain problem? Is your work heavy or monotonous? How would you rate the pain that you have had during the past week? How tense or anxious have you felt in the past week? How much have you been bothered by feeling depressed in the past week? In your view, how large is the risk that your current pain may become persistent? Physical activity makes my pain worse. An increase in pain is an indication that I should stop what I’m doing until the pain decreases. I should not do my normal work with my present pain. How long have you been employed at Concord Hospital In your estimation, what are the chances you will be working your normal duties in 3 months Örebro Musculoskeletal Pain Screening Questionnaire (Modified)(Linton & Hallden, 1998) < [2] [4] [6] years [8] years [10] Please tick the box that reflects you current age 0 days [2] 1-2 days [4] 3-7 days [6] days [8] days [10] How many days of work have you missed because of this injury? Tick (√ ) one. 0-1 weeks [1] 1-2 weeks [2] 3-4 weeks [3] 4-5 weeks [4] 6-8 weeks [5] How long have you had your current pain problem? Tick (√) one. 9-11 weeks [6] months [7] 6-9 months [8] months [9] over 1 year [10] Is your work heavy or monotonous? Circle the best alternative. Not at all Extremely [ ] How would you rate the pain that you have had during the past week? Circle one. No pain Pain as bad as it could be 6. How tense or anxious have you felt in the past week? Circle one. Absolutely calm and relaxed As tense and anxious as I’ve ever felt How much have you been bothered by feeling depressed in the past week? Circle one. 8. In your view, how large is the risk that your current pain may become persistent? Circle one. Not at all Extremely Here are some of the things which other people have told us about their pain. For each statement please circle 1 number from 0-10 to say how much physical activities, such as bending & lifting, affect your pain. No risk Very large risk 9. Physical activity makes my pain worse. Completely disagree Completely agree An increase in pain is an indication that I should stop what I’m doing until the pain decreases. I should not do my normal work with my present pain. 0-5 years [10] years [8] years [6] years [4] > 20 years [2] How long have you been employed at Concord Hospital 13. In your estimation, what are the chances you will be working your normal duties in 3 months No chance Very Large Chance

16 Results of the Control Group
RISK GROUP NUMBER (%) ($) COST/CLIENT LOW (<69) 36 (47%) $ 4,878 MEDIUM (70 – 84) 24(31%) $ 6,240 HIGH (> 85) 17(22%) $ 17,178

17 Intervention strategy
High Risk (>85) Independent Rehabilitation Provider within 2 weeks Independent psychological assessment and treatment within 2 weeks at Staff Health Independent Medical Consultation within 2 – 4 weeks Independent Physiotherapy Assessment after 6 weeks. File review by Medical Director if not returned to work within 4 weeks. Medium risk (70 – 84) Psychologist assessment and treatment within 2 weeks of injury plus “usual care”. Independent Medical Consultation within 1 month Low risk (<69) “Usual care”

18 Results of the control and intervention arms
CONTROL GROUP INTERVENT GROUP INTERVENT GROUP RISK CATEGORY Number (%) $ COST LOW 36 (47%) 40 (51%) 4878 4898 MEDIUM 24 (31%) 23 (29%) 6240 6752 HIGH 17 (22%) 15 (19%) 17178 $617394 12847 Difference $ 4331 or 25% $531081

19 Key Findings “Yellow flags” can predict the cost of a workers compensation claim within 48 hours and independently of what or where the injury is. The provision of an early assessment and intervention process can reduce costs in high risk claims. That there is a significant difference between the 20% in the “high risk” category and the other 80% who manage pretty well with “usual care”. There is no further reason to separate low and medium risk patients.

20 But – what about the longer term – how much difference does it make?

21 Days lost per employee June 2009

22 SSWAHS Experience Premium Movement from 2007/08 to 2008/09

23 Number of claims in fund year

24 Cost/employee 2006/2007

25 Cost/employee 2007/2008

26 Cost/employee 2008/2009

27 Number of open claims

28 What do we do now? All W/C injuries are screened at 48 hours
High risk clients are referred to an independent psychologist within 3 weeks and seen at Staff Health. All high risk clients are seen by IMC within 4 weeks of the injury Use IPC’s and independent professionals for all treatment areas including massage, chiropractors. Accredited External Providers are used if people are not back on normal duties within 6 weeks or there are special reasons to use them upfront or injured workers request them.

29 Could you do this? Yes but!
There are no short-term solutions and you need a longer-term plan You need consistent staff and good leadership If you are geographically diverse, you need to re- think how you do workers compensation Consider centralising your most experienced W/C staff Chose carefully your referral base You need to think carefully about a psychologist You need to have Executive/CEO support and advocacy You need to consult with all stakeholders

30 Where to from here? WorkCover NSW and SSWAHS are looking at funding a larger trial over two Area Health Services with one being a “Control” with no change in current practice but doing the early screening and one Area Health Service being an “Intervention” using similar approach.

31 Garry Pearce, Medical Director Consultant Rehabilitation Medicine Physician Injury Research Management Unit Staff Health and OH&S Risk Management Unit Concord Hospital Steven J. Linton PhD Professor of Clinical Psychology Department of Behavioral, Social and Legal Sciences Örebro University Sweden Andrew McGarity, Rehabilitation Coordinator Professor Jennifer K Peat Statistician and Research Consultant Sydney Michael K Nicholas PhD Assoc Prof. & Director, ADAPT Pain Management Programme Pain Management & Research Centre University of Sydney at Royal North Shore Hospital St Leonards NSW 2065  Australia Daren Wilson BA (Soc Sc) MA (Psych) MAPS Psychologist Clearview Psychology Services Pty Ltd


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