Case management and return to work: opportunities and challenges

Returning to work after an injury or illness can be challenging and costly. It has been at the forefront of debate in the UK in the past two years as evidenced by news stories and government initiatives to get people off benefits and back to employment. Deborah Edwards discusses some of the problems. 

The UK Government’s review of sickness absence shows that when employees lose contact with the labour market this can lead to worse health outcomes in many respects, (Department for Work and Pensions (DWP) response to sickness absence review paper, 2013). Case management has been used to help people regain their functionality for many years in several countries including the US and Australia. This article discusses how case management works, its benefits and the key elements that can help occupational health (OH) providers consider whether or not and how to include case management in their practice.

Traditional OH services have been an essential component in ensuring a healthy and safe workplace. However, even the best and most conscientious of employers with a strong commitment to safety still have accidents at work. And when accidents have happened in the past, there has been a tendency to leave recovery to the GP and/or the NHS. Employers have insisted that employees recovering from injury or illness should not be allowed back in the workplace until 100% fit (Batterson, Fyfe and Weigand, 2009), which meant when the employees were functionally fit and safe to return to their usual job without modifications.

In the US during the 1980s, many employers realised that using a return to modified duty programme prior to an individual’s full recovery aided not only the employer but the employee, resulting in reduced disability days (Batterson, Fyfe and Weigand, 2009). Work can be an effective adjunct to treatment, such as physiotherapy, as a means of improving and maintaining the wellbeing of individuals, their families and communities and thus getting back to work can be a key element of the rehabilitation programme. The DWP’s response to Dame Carol Black’s report “Fitness for work” (2013) stated that when helping more people off benefits and into work “all too often support is only available once someone falls onto out-of-work benefits, in spite of overwhelming evidence that early interventions are most effective in helping people to stay in work”.

In the UK, case management has been utilised by insurers to address recovery and return to work for about 20 years, however, until recently case managers were mainly brought in only once an employers liability (EL) claim had been lodged. And often by this time, early intervention opportunities were lost.

What is case management?

The definition of case management most utilised in the UK comes from the Case Management Society UK which states: “Case management is a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet an individual’s health, social care, educational and employment needs, using communication and available resources to promote quality cost-effective outcomes.”

The case management approach was referred to and supported by Dame Carol Black’s review of the health of Britain’s working-age population (2008) in the summary of evidence submitted. The report reviewed vocational rehabilitation in the UK and concluded that people in work live longer and are happier and healthier while in employment and at work.

Case management is a key feature of the Government’s new Health and Work Service which is scheduled to be launched in late 2014 or early 2015. The detail is not clear yet, however, it is anticipated that employers with OH services will be expected to cooperate with OH bodies to provide case management support for long-term sickness absence under the single organisation initiative (SOG), which aims to create a single representative body for all OH bodies.

The case management model for OH practitioners has not been well defined in the literature. As the conceptualisation of work disability has expanded, so has the number of groups interested in work disability prevention. Return-to-work interventions are not restricted to GPs and their clinics; insurers have a financial interest in ensuring a sustainable return to work is achieved and utilise case managers to facilitate this process.

Employers are recognising that employment policies have an impact on return to work and providers of treatment services have become interested in expanding their practice (Franche, Baril and Shaw, 2005). The case managed style takes the view that a structured approach to designing return-to-work programmes, utilising a multidisciplinary team in conjunction with the employer stakeholders, is an effective means of helping organisations reduce the burden of long-term absence. This is achieved by creating an atmosphere of flexibility resulting in employees sustaining their work role long after an extended absence.

How does case management work?

The first step for an organisation is to adopt a positive approach and to provide the right support for the recovering employee. This requires support from senior executives in establishing the mission and message and communicating it throughout the organisation. Employees must believe the message is authentic if they are to engage in the process. After all, the employee returning to work with ongoing pain or other conditions may feel vulnerable if they do not see the programme in action and them reaping rewards. Trade unions can also support case management when they are confident that the employer is acting in the best interest of their members.

The process works by developing an environment where:

• early contact is established with the injured worker, providing empathy and support and education regarding their current symptoms;
• there is clear diagnosis of the worker’s capacity for work based on the job requirements, and light or modified duties are available;
• the employee gives their permission for the employer or line manager to communicate with the worker’s GP;
• suitable work for the injured worker is identified and assessed, and appropriate and reasonable workplace modifications are accommodated with the agreement of all parties;
• the worker is supported through recovery, ensuring he or she adheres to the treatment/rehabilitation plan, especially if it includes modified duties or hours;
• barriers to a successful and sustainable return to full duty are identified and progress is monitored; and
• if serious injury occurs, case management becomes invaluable to progressing the injured worker through the NHS treatment maze or identifying private treatment where the NHS is lacking.

For employers, the benefits are:

• Case management demonstrates care, value and commitment to the workforce, sending the message that recovery and rehabilitation for injured workers is important to the business.
• Motivation for remaining at work is maintained when there is a fair and structured process, simultaneously focussed on recovery and return to work.
• While perhaps temporarily reduced, productivity does resume more quickly as the employee is back to work rather than sitting at home.
• Employee retention is improved because the business maintains the injured worker’s skills and experience, which is especially important in a highly trained workforce.
• Recruitment costs are reduced as the need for replacement staff may be eliminated or costs reduced using a “remain at work” philosophy.
• Potential lengthy litigation is avoided. More frequently in the UK, EL claims are avoided, negating the costs of litigation and a lengthy claims process.

For employees the benefits are more personal. Case management:

• maintains their status as breadwinner in the family;
• relieves concern that their job is in jeopardy;
• keeps their social status in place, as work is the key social interaction for most employees; and
• physically gets the employee moving, gradually increasing their personal capabilities and endurance.

Although there are certain elements of remain-at-work programmes required universally, there is no “one size fits all” solution. A core team of management, HR, finance, OH and, if appropriate, the trade union, should be brought together to lead the development of a case management project that fits the organisation’s specific requirements. This team will create the policy, design the communication strategy and measure the outcomes to determine the value of the programme.

This core team will lead the communication of the change process, providing training and education to the workforce in respect of what to expect. Awareness campaigns are essential to the communication strategy and can take the form of inserts into pay packets and posters around the workplace, for example.

What is a rehabilitation and return-to-work plan?

Rehabilitation and return-to-work plans should be considered for injured workers when they are off work in all cases, but especially when there is a work-related injury or illness. When the employee needs to be off work for treatment, the rehabilitation and return-to-work plan defines the responsibilities of the worker, employer and other parties in the process of rehabilitation and safely returning an injured worker to the workplace. OH practitioners monitor the return-to-work progress to enable a quick response to any unforeseen complications that could negatively impact a return to full duty.

It is good practice that all injuries reportable under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR) are critically reviewed to determine the likelihood of the employee requiring an absence from work for more than 30 days. Depending on the severity and circumstances of the situation, a triage will assist in determining if any treatment interventions such as physiotherapy are required and will provide recommendations for managing the injury, illness and/or absence. If the triage determines that the current treatment plan is not proactive, then a short burst of privately funded treatment may prove beneficial in allowing the employee back to work quicker.

Medium to large-sized employers are increasingly engaging the assistance of physiotherapists in the workplace to provide treatment for minor injuries on site. The smaller employer may not have the infrastructure for this and therefore a bespoke solution accessing local treatment resources is one of the possible solutions to this issue. All providers, however, do not provide similar services so a careful selection process is essential. Effective baseline assessment with SMART goals (specific, measureable, achievable, relevant and time-related) treatment goals for recovery should be agreed before proposing the treatment programme.

Treatment coordination should be a collaborative process where the OH or case manager discusses the functional demands of the employee’s role with the provider to help focus the rehabilitation plan on functional recovery and return to work. Similarly, a provider should highlight any functional limitations of the employee to allow OH to design a phased return-to-work plan that allows the employee to return to work in a productive role for the organisation.

Managers and supervisors have key roles to play in the process. OH providers must engage line managers to undertake education, cultural change and follow-up support. Ensuring that all stakeholders are maximising their contribution to the process is no small feat. Analysis of return-to-work stakeholder interests suggests that friction is inevitable; however, it is possible to encourage stakeholders to tolerate a variation to original plans while engaging in collaborative problem solving to meet common goals (Franche, Baril and Shaw, 2005).

Conflicts arising from different paradigms relating to the case management process can be resolved by specific return-to-work interventions including: calibration of stakeholders’ involvement; clarifying the role of supervisors and of insurance case managers; and addressing procedures used in return-to-work interventions. Franche, Baril and Shaw concluded that further research is required to develop varied and effective methods for engaging stakeholders, determining the optimal level and timing of stakeholder involvement and expanding the research to more diverse work settings. OH practitioners are engaging in case management approaches to managing workplace absence through proactive communication with employees’ GPs. At South Bank University, the programme for OH nurses includes a module on case management. The government has recognised case management has benefits to offer and is including it as an element within its plans for addressing long-term sickness absence. Not all employers or GPs embrace this philosophy yet; however as the case management model gains acceptance and much needed research is gathered on the cost and benefits of service delivery, hopefully this practice will become the norm.

References

Batterson LM, Fyfe BJ and Weigand D. “Return-to-work programs”. Risk Management/Insurance Practice Specialty tri-annual electronic newsletter.

Black, C (2008). “Working for a healthier tomorrow”. Crown Copyright.

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Department for Work and Pensions (2013). “Fitness for work: the Government response to ‘Health at work – an independent review of sickness absence'”.

Franche, Baril and Shaw (2005). “Workplace-based return-to-work interventions: optimising the role of stakeholders in implementation and research”. Journal of Occupational Rehabilitation.