1. HM10 Reducing Re-injury Through Early Intervention Functional Restoration September 19, 2012 10:15 a.m. – 11:30 a.m. September 18-21, 2012

2. Functional Restoration and Delayed Recovery Dr. Doug Benner, Chief Medical Officer, EK Health Anita Weir, Director, Medical & Disability Management, Safeway Inc.

3. Reduction of frequency, however… “Severity” continues to rise. Incentives drive behavior. Disparity of Medical Care

4. Delayed Recovery – The Hidden Epidemic An estimated 10% of CA WC cases consume 75% of the resources. Predictors have been identified. Largely preventable.

5. Characteristics Functional decline Drug dependency Depression and anxiety Chronic pain Disability is out of proportion to impairment Transfer of “locus of control” to others

6. A Revealing Study “The relationship of adult health status to childhood abuse and household dysfunction.” Felitti, Anda, Nordenberg, et al. American Journal of Preventive Medicine, 1998

7. The Evidence Base …supports the contention that there is a demonstrable and significant relationship between adverse childhood experience and adult medical disease, psychiatric disorders, sexual behavior and resource utilization across clinical settings.

8. The Size of the Problem 2010 CDC Survey (26,000 adults): 60% reported childhood familial problems 15% experienced physical abuse >12% had been sexually abused 9% had at least five “adverse childhood experiences” (ACE)

9. An Increased Incidence “There is a relationship between traumatic stress in childhood and the leading causes of morbidity, mortality, and disability in the United States....” Vincent J. Felitti, MD

10. Clinical Findings of Delayed Recovery Catastrophizing Somatization Distress, depression, anxiety Excessive pain/disability behaviors

11. Dynamics of Delayed Recovery Medical diagnosis is verification of distress A medical diagnostic/treatment process permits sublimation of psychosocial issues MD advocate accepts “locus of control” Willing overutilization of medical services

12. “MEDICALIZATION” The increasingly acceptable inclination and process of explaining real and imagined complaints or problems in medical terms, as disease, requiring medical scrutiny Examples include: aging, cellulite, menopause, childbirth, “fibromyalgia,” “systemic yeast infection,” “reactive hypoglycemia,” etc.

13. Dynamics of Delayed Recovery, cont. Polypharmacy permits self-medication for ACE- related issues, and opportunity for drug abuse and diversion Complicated by physician ignorance, misconceptions, disincentives, time constraints and limited resources Disability becomes a lifestyle (Chronic Pain)

14. Functional Restoration “…The process by which the individual acquires the skills, knowledge and behavioral change necessary to assume or re-assume primary responsibility (‘locus of control’) for his/her physical and emotional well-being post injury.” Melvin Belsky MD

15. Principles of Functional Restoration Timely/accurate diagnosis Maintenance of social connections Maintenance of “locus of control” Identify, acknowledge, address psychosocial realities Manage expectations Mutually agreed, functionally oriented goal setting Multidisciplinary problem-solving Education/Prevention Independent self-management

16. Approaches Patients identified into risk levels for delayed recovery at first or second visit (by short questionnaires, identified co- morbidities, or presenting attitude) No increase risk Moderate increase risk High increase risk Treatment “Bundles” at each risk level with a team focus on functional improvement (prior authorization established) Case conferences Treatment plan issues Return to work issues Awareness of patient’s triggers – behavior, work place, medical

17. Getting Physicians On Board Recognition: Treating physicians struggle managing patients who have difficulty with pain control and failure to improve functionally Physicians welcome a team approach to help them manage these difficult cases It takes collaboration with all providers, claims adjuster and employer to optimize recovery

18. Today’s Physicians Many have limited exposure to principles of medical rehabilitation and delayed recovery Limited access to high quality, multidisciplinary resources Incentivized to utilize symptom-focused care and have a bias to remove all patient’s discomfort regardless of functional improvement Use counter-productive, directive clinical style Over utilize opiates and pharmacy solutions

19. Today’s Best Providers Remind patients that they are responsible for their own improvement and recovery Understand the limitations of the biomedical model Understand the powerful effects of psychosocial factors Understand the salutary effects of work Understand the power of multidisciplinary treatment

20. View From the Payers Desk

21. Early Intervention (EI) Early-as-possible form of Functional Restoration Identification of those at risk Behavioral intervention as needed Focus on function improvement and not just pain control

22. Essential Elements of FR: Early Assessment with an evidence-based treatment plan Addressing psychosocial barriers in a timely manner Functional goal sitting Early and sustained patient education Ongoing assessment of participation, compliance and progress towards functional recovery

23. Safeway /Kaiser EI Pilot No chronic pain cases No lawyers All employees returned to work timely Mod Duty and TTD reduced markedly

24. Safeway /Kaiser EI Pilot <5% Back Injuries Tested at RISK Returned To Work - 100% 3% Surgery - All RTW 6 mo. Transfer Of Care - 1 Case TTD Average - 8 days MOD Duty Average - 28 days Duration Average - 65 days

25. Claims Management Options Head in the sand orActive planning Hope or Expectation to RTW Deny or Support Early Treat only body or Change Behaviors Reserve high orIntervene early Incentives in WC need to change

26. Claims Management Actions Partnership with physicians Treatment plan and contract – expectation setting Communication on regular basis Keep timeline for progression for everyone Partnership with employees. Functional focus Frequent contact and encouragement Full RTW progressive program

27. Essential Elements of FR: Early Assessment with an evidence-based treatment plan Addressing psychosocial barriers in a timely manner Functional goal sitting Early and sustained patient education Ongoing assessment of participation, compliance and progress towards functional recovery

28. Points to Remember Delayed Recovery is identifiable and manageable Delayed Recovery impacts the cost of claim Physicians know intuitively recovery will delay Physicians need tools and experience with care Employees need encouragement to self recovery Treatment authorization early is cost effective We are all in this together!

29. Functional Restoration programs……… Reduce needless disability by maximizing employee’s strengths Reduce medical and indemnity costs Require multi-discipline program access

30. Conclusion Functional Restoration teaches the injured worker how to “THRIVE”

31. Q&AQ&A Questions … Answers … Comments …