Managing off-the-job injuries

Communication the key to putting workers back on line

By Karen Gaspers
Associate editor

Your phone rings bright and early Monday morning: Jim injured his foot in a pick-up game of basketball during the weekend. The X-rays show a hairline fracture, and his doctor wants him off his feet for a few weeks. You wonder if his doctor is being overly cautious, but given privacy issues under HIPAA laws, you decide to err on the side of caution. Your hands are tied when it comes to helping Jim get back to being productive any sooner than the doctor ordered.

Then again, maybe you have more control than you realize.

"Often employers will blame the doctor or attorney, saying they won't let us return an employee to work or they're not partnering with us. I believe employers have the most control over return to work, but they need to exercise it and often they don't," said Sara Taylor, president of Structured Health Resources, Inc, a Michigan-based disability-management consulting firm.

Instead, companies need to step up and take control of the situation by establishing return-to-work criteria for different positions within the company, as well as the specific circumstances under which workers may return, said Dr. Richard J. Sagall, an occupational medicine consultant based out of Philadelphia. Such actions ensure the employee will return to work safely. In his experience, Sagall said general practitioners often take a "go back to work and see how it goes" attitude. "You don't want that," he stressed. "It's not in the best interests of the company."

Although companies might shy away from talking to an employee's doctor about an off-the-job injury due to privacy issues, Taylor stressed that employers have the right to communicate with physicians about their place of work, no matter where the injury occurred. The key is in the approach. "Be aware that you only need to ask what impairment or limitations the person has in order to facilitate return to work, not the actual diagnosis," Taylor explained. Taylor used the example of an employee who has cancer and is receiving treatments for which they are missing work Employers can still call the physician to say, "We understand this worker is under your care, we'd like to facilitate this person back to work. What are the restrictions we need to accommodate?"

Of course, it doesn't hurt to get the employee's permission. Mack Turner, safety superintendent with Tucson Electric Power, Tucson, AR, said his company often asks the worker ahead of time if it can talk to the person's doctor. The answer is almost always "yes."

Bottom line savings

The payback for managing off-the-job injuries or illnesses is huge for many reasons, but the cost savings can't be underestimated. According to the 2004 edition of the National Safety Council's "Injury Facts," off-the-job injuries in 2003 cost the nation $156.2 billion and 160 million days of production time. By contrast, companies in 2003 lost 70 million days of production time due to on-the-job injuries.

"Progressive or enlightened employers always treat a disability as a disability," Taylor stressed. "They don't discriminate against the benefit." Taylor added that if one side of the equation is managed while the other is not, i.e., workers' comp claims are watched closely while disability claims are not or vice versa, employees will see that and possibly take advantage. "You just need to manage both, not treat as separate," Taylor argued.

That's a point Kathy Burns advocates. Burns is an insurance specialist with the Montgomery County Risk Management Department in Dayton, OH. She launched a transitional duty program for work-related injuries in 1996, but said the program is not there yet for off-the-job injuries. While some areas are able to accommodate off the job, such as the sheriff's office and some of the courts, no countywide program or service is available. However, Burns continues to push the issue.

"It's the rising medical costs," she said. "As that continues to go up—and I don't see it leveling off, I don't see the cost of drugs going down—we're going to be putting businesses out," she said.

Burns noted that for Montgomery County, bringing employees back to work from off-the-job injuries addresses those rising costs. "To us, it's worth it. We are getting some reimbursement because we are getting work done and we aren't losing the person entirely," she said.

Managing both on and off the job is "a growth process," she said, "but it's exactly where we want to be going."

Create a comfort zone

The biggest stumbling block to return to work, said Burns, is a doctor who is uncomfortable because he or she doesn't understand exactly what the employee's job is, coupled with the fear that the company hasn't clearly established and identified appropriate transitional work.

The way to solve this problem is through communication. Taylor advised companies to let doctors know they are committed to the employee and that they have the tools and resources to effectively facilitate return to work.

Luckily, companies have several options:

Sound like a doctor. Turner suggested having at least one member on staff that has good public relations skills, understands medical terminology, and is acquainted with local labor laws. "If you can talk to doctors and communicate in their language what your company policy is, what labor laws are, you get a lot better buy-in from them," Turner said.

Put it in writing. Create a written return-to-work program that spells out the roles and responsibilities of all stakeholders—the company, the injured employee and the doctor, Taylor said. Communicating those roles reduces confusion among all parties, she said, stressing that this should be about company policy, not about the return to work of a specific individual.

A written policy also engenders consistency. "The bottom line is creating a policy so you can stick with it," Sagall said. "You don't want to make decisions on the fly."

Supply a job demand analysis. A written description of the physical demands of a job helps communicate to a physician the true demands of the job. "Very often when it's a family practitioner, the return to work decision is based on a verbal description of the job given by an employee," Taylor said. How motivated that employee is to return to work may color his or her description of job demands—either downplaying or exaggerating them.

Having a written job analysis helps the doctor determine a person's restrictions and limitations for returning to work. Assess both regular work and the various types of transitional work used to bring people back, Taylor said.

Burns suggested hiring a third party to do the analysis—it needs to be an objective viewpoint, she said. "We can't just have a supervisor go out there and say this is an appropriate job for someone with a shoulder injury," Burns explained. The third party will "actually measure the push and pull, lift and bend, of tasks and then look at the job class and establish exactly what a person can do if have an upper body injury, lower body injury, whatever," Burns said. The data eventually is condensed into a one-page form that can be easily faxed to the doctor's office. "It's key in being able to get the comfort level there with a physician," she noted.

Show willingness to accommodate restrictions. Show that you have an accommodation culture, not a punitive or litigative one, Taylor said. "You have to be committed to value-added work. It's not just meaningless work."

That means counting paperclips is not an option. When a company doesn't provide appropriate work or doesn't monitor the work it does provide, that gets back to the medical community, Taylor said. If a doctor doesn't believe an employer will provide appropriate modified duty, he or she is not going to be willing to return an employee to work. A company must take this part of its reputation seriously, she added.

Make part-time work available. "We've found the idea doctors like best is offering to bring employees back part time, say 4 hours for the first week, maybe 6 hours the second," said Lynn Howe, manager of Employee Health Programs for Blue Cross Blue Shield of Michigan. "It puts the doctor at ease that the person will slowly ease back into work."

Blue Cross Blue Shield of Michigan annually accommodates as many as 400 employees with off-the-job issues ranging from foot surgery to depression, Howe said. She cautioned against allowing part-time work to go on for extended periods. "That just means the person probably isn't ready to come back to work," she said.

Howe added that part-time work also is popular with employees. "We've been doing this enough now that employees are telling their doctor to send them back part-time. They've seen it work for co-workers," she said.

Arrange a conference to clarify details. Once a company has provided the attending physician with job descriptions and any other requested material, Turner suggested offering to sit down with the doctor to go over everything. "That's where you can explain it to them and get them to buy into your company policy—that you are trying to get this employee back to work and being productive," he said.

Schedule plant tours. Invite area doctors to the facility for a luncheon and tour, Taylor suggested. "It has an amazing effect on the physician community," she said. Tours make the doctors "more aware of the company's environment and its commitment, as well as shows integrity."

Plant tours work best in smaller communities where the number of area doctors is small or employees primarily use the same one or two doctors, Taylor added.

Advocate for the employee. Although a company doesn't have as much control when working with an employee's doctor in an off-the-job scenario as in an on-the-job situation, it can still supply input, Howe said. At Blue Cross Blue Shield of Michigan, third-party case managers intervene on behalf of employees to ensure the person is receiving the right care.

"Maybe they've been misdiagnosed. Or maybe they are seeing a podiatrist but should be seeing an orthopedic surgeon," Howe explained. "If an employee is not getting better, we may try to intervene and say, 'this may not be the right care.' There are national guidelines for how long the average person is off for certain injuries or situations. Our case managers use those."

Howe said intervention is one action particularly suited to companies less able to accommodate modified duty. She pointed to the auto industry as an example, where a preponderance of heavy manufacturing positions limits the number of meaningful light duty jobs that are available. "Even in places that can't accommodate everyone with light duty, they can help employees get the right care," she said. "Even if they can only bring back half (of their employees), that's better than none."

Be realistic. In addition to communicating with the doctor, Taylor cautioned employers to be realistic in their expectations. Doctors are "trained to treat and care for medical conditions, not to determine if the patient can return to work," she said. That task lies firmly with the employer.

Sagall also said the employer is responsible for finding appropriate work for the employee. The treating doctor can only "compose restrictions based on the injury," he said. However, companies must also be realistic about their ability to bring every employee back to work. "While someone in an office setting could probably come back to work with a broken leg, a person on an assembly line, a truck driver or janitor couldn't," Sagall argued. "Certain positions are limited in what they can do."

In addition, employers may only have a limited number of alternative or light duty jobs, he added. In Sagall's experience, when jobs are limited companies often want to save those positions for workers' compensation cases.

Choose case management carefully. Most companies use a third-party case management firm to monitor disability. Make sure you choose one that shares a methodology similar to the company's own, Taylor said. "It's important to have a healthy relationship with this firm," she said. "If the company cares about their employees and just want to do the best thing and they hire a case management firm that actually has a more aggressive or punitative approach, your outcomes are not going to be what you desire. They may not be the best partner for the company."