Treating the whole worker in your RTW program

When an employee is injured and has a workers' compensation claim, it's crucial for employers and insurers to look beyond the employee's physical and medical issues to address the injured workers' mental health needs. Failing to do so could result in longer and more costly absences and, ultimately, return-to-work (RTW) failure.

There's a complex array of psychosocial issues that arise with employees out on workers' compensation, points out Sherri Hickey, assistant vice president–Medical Management at Safety National, a provider of alternative risk-funding products such as excess workers' compensation, deductible casualty, loss portfolio transfers, and reinsurance. These include concern over being able to return to work, anxiety about losing their jobs, and fear of pain, whether real or imagined. "This is sometimes referred to as 'catastrophizing' — taking every pain, even if it's minor, and exaggerating it to the point where they believe their life has ended with this injury," she says.

The more prolonged a disability becomes, the more many employees will ruminate on the injury, Hickey adds. "Some employees will begin to treat the claim and the treatment associated with it as a job in itself, making RTW all the more difficult. From a psychological perspective, the injury becomes their life," she says. "In some cases, employees may also have a sense of entitlement — that they are owed everything they can get!"

Insurers and third-party administrators must quickly identify and address any psychological and social issues that may delay treatment or postpone an employee's return to work, stresses Maureen McCarthy, manager, Workers Compensation Field Claims, Liberty Mutual. "Claims managers should look for such issues throughout the claims process. There are sophisticated algorithms that automatically analyze data to identify claims that have such issues. Then medical professionals can become involved to confirm the presence of these issues and help determine how best to address them in order to foster recovery and return to work."

We are what we do

Losing the ability to work, even temporarily, can be a major blow to the way people perceive themselves and the way they believe society and family perceive them. They may have felt like the provider; now they feel like a burden. They may start to feel useless or become dependent on others in their sphere. An overly restrictive approach to injury or illness can cause people to withdraw from their normal activities (including work) and result in isolation.

For so many people, work is a part of their personal identity, points out Mark Walls, vice president, Communications and Strategy Analysis at Safety National. "When you meet a person, usually one of the first questions you ask them is, 'What do you do?' When someone is away from work due to a disability, they lose that part of their personal identity, which can be emotionally challenging. Add to that the financial pressures caused by disability and the societal stigma associated with disability."

By recognizing how the inability to work affects workers mentally and emotionally, you can be sure that caring for the whole worker is an integral part of your RTW plan.

Physical therapist helping young man with yoga ball

Alternative approaches, such as yoga, massage and cognitive behavioral therapy can be more successful than medications in managing pain. (Photo: Shutterstock)

Taking the holistic approach

The holistic approach to health care considers the whole of the patient: body, mind, and emotional state. Going hand-in-hand with looking at the entire person is bringing together conventional and complementary medicine in a coordinated way — also known as an integrative approach.

The use of integrative approaches to health and wellness has grown within care settings across the United States. Researchers are exploring its potential benefits in a variety of situations, including pain management, relief of symptoms in cancer patients and survivors, and programs to promote healthy behaviors. Programs that reduce painrelated fear and encourage a return to activity generally provide a positive response.

"Many integrative therapies have evidence to support their use," says Dr. Teresa Bartlett, SVP Medical Quality, Sedgwick Claims Management Services, Inc., a global provider of technology-enabled risk and benefits solutions. "We often hear from physicians that they would appreciate being able to use acupuncture, yoga, meditation, massage and cognitive behavioral therapy instead of opioids to manage a complex patient."

Recent studies have supported acupuncture, yoga, stretching, walking programs, and the use of acetaminophen and ibuprofen concurrently to address pain instead of turning to opioids, Dr. Bartlett points out. "Many employers will bypass utilization review to pilot targeted programs for specific conditions such as back or neck pain and then measure the program's success to determine whether these therapies are working and beneficial for return to health and work."

Complementary and alternative medicine

If a non-mainstream practice is used together with conventional medicine, it's considered "complementary." However, if a non-mainstream practice is used in place of conventional medicine, it's considered "alternative." Examples of complementary medicine include yoga, chiropractic and osteopathic manipulation, meditation, massage therapy, acupuncture, relaxation techniques (such as breathing exercises, guided imagery, and progressive muscle relaxation), tai chi and qi gong, hypnotherapy, and movement therapies.

Aetna, for one, considers alternative medicine interventions medically necessary if they are supported by adequate evidence of safety and effectiveness in the peer-reviewed published medical literature. The insurer has a comprehensive policy for alternative medicine. The policy, available online, outlines the alternative medicine interventions that Aetna considers medically necessary for properly selected members, subject to applicable benefit plan limitations and exclusions.

The opioid crisis: Can complementary approaches help?

Opioids have been the drugs that doctors and patients use to manage pain, but the social cost has been high. Addiction to prescription painkillers is rapidly becoming an epidemic in the United States. Opioid prescription sales have increased 300% since 1999, and drug overdoses, predominantly from opioid painkillers such as OxyContin and Percocet, now exceed car crashes as the leading cause of unintentional death, notes Ron Skrocki, senior vice president for product management and development at Genex Services, a managed care services provider.

One challenge is finding pain-management practitioners who will work with insurers and employers to ensure that alternative approaches are working. "It's easy to get opioid pain medication approved — however, it's difficult to get alternatives approved," Walls acknowledges. "Many states have limits in their laws on chiropractic treatment and physical therapy, but not limits on opioid medications. This approach is flawed."

It's vital to look at the bigger picture. As Walls points out, a pain-management program may cost $30,000, but if it allows an injured worker to stop taking opioid pain medications costing $10,000 per year, then there is significant savings over the long term. He recalls a case in which a worker was permanently disabled due to a back injury and was receiving high doses of opioid pain medications, which compounded his disability. "His family reported that he slept most of the time, and it was like he was almost dead to them," he says.

However, after Safety National sent the worker to a pain program that taught him coping skills and the importance of exercise, he was able to stop taking pain medications. "He is still disabled from work, but he has a life," Walls points out. "His family has a husband and father back. But to reach that point, it took someone looking beyond just the pain and opioids and being willing to consider the whole person and alternative approaches."

Patients need to understand all the treatment options available. (Photo: iStock)

Challenges to a holistic approach

Challenges include insurance coverage rejections, strict application of evidence-based medicine protocols, insufficient good-quality peer-reviewed studies of whether complementary approaches are medically effective as well as cost-effective; and a need for pain management practitioners — including physicians, psychiatrists, chiropractors, and acupuncturists — who will work with insurers and employers to ensure that unconventional approaches are working.

"Conventional medical approaches such as surgery, drugs, and a variety of therapeutic techniques can often cure, or at least alleviate, pain and disability. However, there are many times when an injured employee's pain and physical limitations become resistant to traditional approaches," acknowledges David Klein, partner, The Klein Law Group, a New York-based firm that specializes in workers' compensation and Social Security disability law.

"Employees need to know that these alternatives are available," Klein says. "The alternatives often work, and they don't have the potential toxicity that medications can have. On the whole, alternative treatments are cost effective. It would be great if more people knew about them and availed themselves of their benefits."

Under certain circumstances, Klein says, an insurance carrier may agree to pay for any form of treatment. Healing treatments that have been authorized in specific cases include massages (if performed by a board-authorized practitioner), as well as biofeedback, acupuncture, chiropractic and swim therapy, he explains.

The personal approach to RTW

The "personal approach" is key for employers to motivate employee RTW and shorten costly claim periods. It starts with communication, the experts agree. "Communication is so important. Keeping the injured worker connected to the workplace can play such an important role in preventing the anxiety associated with disability and return to work," says Safety National's Walls.

Employees who have been away from work due to a workers' compensation claim or disability leave may question whether their employers even want them back, so it is critical for employers to remind employees of their desire to have them return. "When employees are away from work, the employer should continue to remind them of how welcome they are to return, once medically appropriate," says Liberty Mutual's McCarthy.

Such employees lose the "belonging connection" with their work family, which is a huge component of most workers' lives prior to their injuries, points out Bartlett. "It is imperative that the employer find creative ways to stay connected to injured workers either through phone calls, emails, or 'get well soon' cards. It can make a world of difference when a person believes they are missed and needed in the workplace." Employers can also keep employees in the loop by sending them company newsletters, announcements and other work communications they would be receiving if they were on the job.

Of course, employers should also use communication to make sure workers fully understand their benefits. Worrying about finances can be a great stressor and affect recovery. Knowing where they stand can ease uncertainty and alleviate the type of stress that can hamper recovery.

Understanding the family and work dynamics is also important for a holistic approach to RTW, Bartlett says. "For example, an injured worker may be unhappy at work or in the process of being disciplined. It is important to know and address any conflicts in the workplace." And don't overlook your organization's employee assistance program: Encourage the employee and family members to take full advantage of EAP benefits.

Training for supervisors and managers is a key component of mitigating the psychosocial repercussions of workers' comp absences. "Employers should train supervisors on the proper way to communicate with the individuals they manage," McCarthy says. "A study by Liberty Mutual Insurance found that employees who reported to supervisors with an open, honest style of communications were away from work less often and for shorter periods of time.

Keep the RTW goal in mind

The bottom line: Work with the employee and the medical team to develop a personalized RTW plan that has achievable deadlines and goals. "A formal return-to-work program should be a key part of any workers' compensation claim," says McCarthy. "Employees should be returned to light duty if possible. Employers who can't return injured employees to temporary light duty assignments within their operations can still gain the benefits of RTW by having these employees work temporarily at local nonprofit organizations. This benefits the employer, the injured worker and the community."

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