Return-to-work programs slash workers’ comp costs
Employee health services positioned to generate savings
(Editor’s note: In our December 1996 issue, Hospital Employee Health presented practical methods of reducing musculoskeletal injuries among health care workers. In this second installment of our two-part series on preventing and managing those injuries, we look at how modified-duty return-to-work programs can significantly reduce workers’ compensation costs and help workers remain productive.)
Many employee health managers are seeking ways to show that they can save money for their hospitals. Experts say implementing return-to-work programs for injured workers not only results in significant cost savings, but also allows workers to remain productive.
According to the 1996 Hospital Employee Health reader survey, 78% of respondents administer a modified-duty program. Guy Fragala, PhD, PE, CSP, director of environmental health and safety and faculty member at the University of Massachusetts Medical Center’s occupational health program in Worcester, says return-to-work programs offer "tremendous opportunities" for cost savings.
"Cost savings are definitely a consideration in health care. Occupational injuries include direct costs, such as compensation paid and medical costs. But return-to-work programs also can save money associated with indirect costs, such as administrative time, reduction in morale, and the effect on patient care. These often can be greater than the direct costs," says Fragala, who also is the author of Ergonomics: How to Contain On-the-Job Injuries in Health Care (Joint Commission on Accreditation of Healthcare Organizations; Chicago, 1996).
Fragala says a new philosophy is necessary for return-to-work programs to succeed.
"Many times, when we evaluate injured workers, we look at how they’re limited, but a better way is to focus on their capabilities what they are capable of doing, not what they cannot do. As a result of that, we can more easily place people," he says.
For example, Fragala says post-injury evaluations sometimes result in workers who have incurred musculoskeletal injuries being given modified-duty jobs that require sitting all day, but this often is not the best choice. In fact, such assignments can aggravate certain types of back injuries, he says. Instead, workers often will benefit from job assignments that allow a combination of sitting, standing, and moving, such as posting them near hospital entrances to greet and direct visitors. In such a job, an employee could sit behind a desk, yet get up and walk short distances periodically.
Employees still feel valued
Although a job might vary from an employee’s usual work, it still provides a necessary service, Fragala notes. Because many hospitals are short-staffed, any number of jobs go begging for personnel to perform them. An injured nurse who is unable to care for patients, for example, could take on much-needed quality assurance duties in a return-to-work program that still makes use of her expertise. That way, not only does the hospital retain a skilled worker and get a job done, but the employee feels valued and needed, providing a psychological boost to rehabilitation and recovery.
"Many times, workers who are injured and stay off work suffer psychosocial problems due to isolation and a lost feeling of value and worth," he says. "The longer people are out from work, the more difficult it is to get them back. It’s to everyone’s advantage [to get them back to work]. If [workers] are doing a job they feel good about and that makes them feel useful, they are going to be happier, healthier people, and a healthy, satisfied work force improves the quality of patient care."
Fragala emphasizes that hospital administrators should look to their employee health services to manage workers’ compensation by evaluating injured workers for return-to-work programs.
"We need to look at employee health services within our health care facilities and make sure they’re given the appropriate attention in terms of resources," he says. "Many times, the employee health service in a health care facility is overlooked, but we should make sure the physician director has a good understanding of occupational medicine, and we should also use nurse practitioners and trained occupational health nurses to evaluate injured workers for return-to-work."
Many employee health practitioners have come to appreciate the value of returning injured workers to modified-duty jobs where they are carefully monitored, with the goal of being able to resume their full former work capacity. EHPs interviewed for this article also have realized significant cost savings for their institutions.
Sandra Billing, RN, MS, manager of employee health for the 1,300-employee Kennebec Health System in Augusta, ME, has been operating an aggressive return-to-work program for injured workers since 1991.
With workers’ compensation costs around the $1.6 million mark annually the previous year, "administrators became very much aware how important it was at that point in time that we return people to work," she says. "Once they saw the figures, they were the ones who said we will have a modified-duty program. It came from the top down."
Although cost savings were not the only motivation for returning injured employees to the workplace, it was an important factor. Now, five years into the program, annual workers’ comp costs have been slashed by more than half, to about $770,000, says Billing, who adds that safety evaluations and awareness no doubt contributed to the reduction, as well.
Promotes focus on safety
Modified duty also benefits workers by allowing them to continue to feel productive and to earn their full salaries. Workers on modified duty are paid by their departments. Billing says this usually motivates managers to find modified-duty jobs for injured workers, as well as to focus more on safety issues to prevent future injuries.
At first, managers were reluctant to find jobs for injured workers, preferring to use only the completely able-bodied in their departments. Billing says intensive education on the benefits of return-to-work programs helped dispel that attitude.
"There is so much work to be done in health care that an extra pair of hands is better than one less pair of hands," she notes. "Taking an employee off the floor and being short one person doesn’t help us. But having them do some other [job tasks] certainly does help."
Billing began the program by following up on every accident and getting in touch with every doctor to explain the modified-duty program.
"We said we want employees back to work as soon as it’s medically safe for them, and that we would accommodate their needs. Once we started that, they were willing to say, for example, that employees could come back if they could work only four hours the first week or if they didn’t have to lift greater than 10 or 20 pounds. When employee health evaluates workers who might have a minor injury such as a sprain, we put them right on modified duty," Billing explains.
Finding jobs for nursing personnel is not difficult, she adds. For example, a certified nurse assistant on modified duty can perform a myriad of tasks that don’t require lifting, such as taking vital signs, washing non-combative patients’ faces and hands, doing intakes and outputs, completing paperwork, and even answering patients’ bells to find out what they want, which often is nothing more than a glass of water.
Modified-duty jobs for housekeepers can be somewhat harder to find. "Most jobs require a lot of twisting and bending, so we might not be able to find enough for them to do," Billing says. "They might work four hours doing some tasks in housekeeping and the other four hours in the billing office, but we make a real effort to keep them in their own department."
Limit time on modified duty
Employee health follows up weekly with modified-duty workers to check their progress and help them move forward with increased hours or job tasks. They also receive medical attention weekly if needed.
Billing advises EHPs to establish time limits on modified-duty work. At Kennebec, workers can remain on modified duty for a maximum of four months without improvement in their condition. Injured employees who do show improvement are accommodated for up to one year. At the end of both time limits, workers who cannot return to their pre-injury jobs can apply for another position within the company. However, if a position for which they are qualified does not exist, "unfortunately they are out of work, but we will continue to look for another job to open up," says Billing. Only once in the program’s history has she been unable to accommodate an injured worker with a modified-duty job due to the severity of the injury, and 95% of workers who go on modified duty make progress. Most workers can return to their original jobs.
The "transitional duty" program at Massachusetts General Hospital (MGH) in Boston began with a six-month pilot program in 1995, says Gael A. Uhl, MS, RN, CS, COHN, CCM, workers’ compensation coordinator in the employee health service at the 10,000-worker facility. The program’s success ensured its continuance. With workers’ comp costs at about $3 million annually, the six-month pilot saved $429,000. Although savings have not been recalculated since then, Uhl says she is sure the amount saved is even greater now.
The program has three objectives, she notes:
• to facilitate the return to work of employees with work-related injuries/illnesses as part of a progressive rehabilitation program;
• to provide maximum support to employees following a work-related injury/illness;
• to minimize institutional costs associated with workers’ compensation claims.
Although cost savings was a driving force, Uhl says the program genuinely aims to assist workers in their recovery and eventual successful return to full-time, full-capacity employment.
"People don’t like to be out on workers’ comp," she says. "It has a bad rap. Work doesn’t have to be all or nothing, and most people are not disabled. People don’t even have to go out on workers’ comp anymore. They can stay in the workplace, earn 100% of their money, and be a productive employee with good job security."
Free help is welcomed’
Unlike the program at Kennebec, all transitional-duty employees at MGH are paid out of a central budget administered by Uhl. The injured worker’s department pays nothing.
"It’s a good incentive to take back these injured employees, because no matter what they can do, it’s free help for the department. In a cost-containment, downsizing, restructuring environment, any free help is welcomed," she states.
For transitional duty placement, the first choice is to put injured workers back into their own jobs in their own departments. Second choice is a different job in the same department. Third choice is a different job in a different department. Uhl says 90% of workers in the program do their own jobs in a modified manner. For example, a nurse might perform her usual job functions, except for lifting. A housekeeper with a back problem might forgo heavy lifting and floor-buffing while retaining dusting and polishing duties.
"We try to get them back in their original job because it can be very destructive for employees who are injured to have their lives messed up. Employees like to be with their peers in a familiar, comforting environment," she says.
About 75% of injured workers can be put on transitional duty. The time limit is 12 weeks, at the end of which employees either return to their original job or go out on workers’ comp.
While in the program, workers must report to employee health every Friday for follow-up and medical evaluation. If they fail to show up, they don’t get paid.
"We also serve as a support system for them if they have any problems," Uhl says. "Sometimes they come in and say, My co-workers don’t understand,’ so we talk with them. Sometimes we have to switch their jobs, and sometimes their symptoms exacerbate and they have to go back out on comp, but we’re there for them every week, and they know that someone is monitoring them."
When an employee is injured, an EHS nurse practitioner evaluates the injury; employees are not referred to an outside doctor unless the problem is severe enough to warrant medical attention. EHPs are available 24 hours a day, either in the office or by beeper. Generally, the nurse practitioner determines whether employees are are disabled or have the ability to work on full or transitional duty. If treated outside, the physician must complete a functional capacity evaluation.
At the end of 12 weeks, it’s over’
Forms are sent to department managers specifying workers’ restrictions and what job duties they could perform (see insert). Duties should increase each week, with the goal of returning to the original job. "We don’t put people [in transitional duty] if they have permanent disabilities," she says.
Uhl emphasizes the importance of communicating to everyone involved that transitional duty is time-limited. "You have to let the injured employee know, as well as the supervisor, because it is a progressive rehab. At the end of 12 weeks, it’s over," she states.
While return-to-work programs generally are advantageous to both employers and workers, Diane J. Knoblauch, JD, MSN, RN, CS, ANP, an attorney with Rohrbacher, Nicholson & Light Co., LPA, in Toledo, OH, points out several legal concerns. No worker on transitional duty should be downgraded in title or salary, but for hospitals with unionized workers, other concerns arise. For example, some labor union contracts prohibit employers from requiring "light duty," she says.
"Even the phrase light duty’ has negative connotations, and there could be problems with seniority issues if there is preferential placement. If a seniority system is in place under a union contract, and you’re bringing an individual back to work, the question becomes, are you bumping a senior union employee out of a position and giving it to someone with lower seniority? That could be a problem," says Knoblauch, who recently wrote a chapter on legal and ethical issues related to occupational health nursing for the core curriculum of the Atlanta-based American Association of Occupational Health Nurses.
Providers might refuse to divulge information
Another potential problem involves access to health care provider information if an injured employee is examined by an outside provider. Case law has shown that some provisions within state workers’ compensation statutes could impede an employer’s ability to return someone to work after an injury. Issues of employees’ rights could arise in terms of whether an employer is interfering with a physician-patient relationship or with privacy issues.
"Theoretically, even if a worker is seeing a family physician, the workers’ compensation statutes allow employers access to medical information from the provider. However, sometimes physicians don’t recognize that, and there can be extreme difficulty getting information from physicians as well as from employees regarding medical conditions and plans," Knoblauch explains. "If you’re trying to set up a return-to-work plan, you can run into a number of obstructions from providers who might refuse to give you any information. Employees may tell providers that they don’t want to go back to work at all, that they want time off. Providers may lack knowledge of their rights and responsibilities under the workers’ comp system."
Finally, Knoblauch says another legal difficulty could arise if injured employees on transitional duty are put to work on units that are understaffed to begin with. For example, if a nurse with a back injury is performing modified duty in an understaffed patient care ward and incurs another injury or exacerbates the original one, the hospital could have additional liability. Institutions planning to implement a transitional work program need to be "very cautious" about the situations into which they place injured employees, she warns.
"If there are not enough non-injured workers available to do the work that needs to be done, and an injured worker is placed into that situation, a legal question could arise as to whether that was intentional. I’m not aware that it’s happened yet, but I can see that could be a real issue," she says.
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