An evidence-based overview of indicators for return-to-work

John Walsh

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The role of KPIs in the continuous improvement cycle

KPIs are the evidence base to inform the continuous improvement cycle

CONTINUOUS

IMPROVEMENT

CYCLE

Return to Work performance &

KPIs

Interventions

Impacts & KPIs(e.g. improved capacity to RTW)

Scheme Redesign

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A role for efficient risk profiling in the continuous improvement cycle?

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Example of what is possible – predictive modeling of outcome for workers compensation

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What have we learned from this?

Statistical estimation is far more predictive than (even educated) gut feel !!

Predictability improves as the claim develops (eg payment history)

However much variance is still unexplained

“Known” predictors of claim outcome are often either:

– poor predictors, eg injury severity, bodily location

– or probably spurious, eg occupation, culture

“Better” predictors are likely to be soft data, currently not collected

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Several key questions underpin the development of a framework of predictive indicators

• What are the current issues and factors to consider when determining RTW indicators?

• How should RTW be defined and measured?

• What are the modifiable impediments influencing RTW?

• How can we measure return to work and associated modifiable factors?

Main Question: What are the next steps to develop and utilise these

indicators?

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The universe of possible influencing factors is very large, but not all of them are modifiable

All Factors Affecting Return to Work

First RTWFactors

Durable RTWFactors

Non-Modifiable

Factors

ModifiableFactors

Factors that affect both First and Durable RTW

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The universe of factors influencing RTW is very large

Employer – Attitudes & Perceptions

· Injured worker willingness to RTW· Availability of workplace

accommodations· Capabilities to supply suitable and/

or modified duties

Injured Worker – Attitudes & Perceptions

Self Perceptions:· Of injury and impairment· Of functional ability· Ability to recover· Ability to RTW· Pain· Fear of re-injury· Depression, anxiety and stress

Perceptions of Employer, Workplace & System:· Job satisfaction· Supervisor’s first response to injury· Support offered to employees· Attitudes and support of co-workers· Suitability of duties,

accommodations and modified work· Satisfaction with insurer· Satisfaction with care provider

Injured Worker – Health, Psychological & Social

Characteristics

· Physical impairment· Psychological impairment – pain,

fear, anxiety, stress· Pre/post injury income· Social factors

Demographic characteristics

· Age· Gender· Level of pre-employment education· Martial status· Language spoken at home· Union membership

Employer Characteristics

· Size of employer (wages, employees)

· Job category (desk or labour)· Ergonomic risk of work· Financial rewards of job· Job tenure· Workplace environment· Preventative interventions

Injury Characteristics

· Injury nature, location & circumstances

· Type of treatment· Completion of rehabilitation program· Injury history – chronic, acute

Claim characteristics· Previous claim history· Date of injury· Date of claim· Workers compensation benefits type

Rehabilitation & Medical Care

· Treatment type· Timely treatment· Rehabilitation completion· Treatment location

Health & psychological Outcomes

· Employee attitudes to RTW· Physical and psychological

functioning· Capacity to RTW· Social functioning outcomes· Job satisfaction· Employer support

Return to Work Outcomes· First RTW, Durable RTW· Employment characteristics at RTW· Recurrent injury, work absence and

claim

Unmodifiable factors Modifiable factors

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Interrelationship between dimensions: they are part of an intersecting ‘whole’

Modifiable dimensions and Durable RTW

· Worker perception of employer attitudes to injured worker and suitable duties

· Worker expectations of recovery

· Worker motivation to RTW

· Willingness to provide suitable duties

· Management support and encouragement of injured workers

· Flow of information between key stakeholders

· Extent of cooperation· Attitudes of stakeholders

towards RTW

Durable RTW

Workplace InjuryInjury nature, location & severity

· Fitness to return to work

Capacity to return to work

Health and psychological functioning

Willingness to return to work

Employer attitudes to RTW

Management of the relationships between key stakeholders

Physical

Psychological

Psychosocial

DurableRTW

· General health functioning · Psychological health and

functioning· Job satisfaction· Pain

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The life cycle of claim reflects both positive and negative influences – sometimes we call these interventions!

4 weeks 3 months 6 months

Negative RTW experience

Positive RTW experienceInterventions/experiences

Injury & Claim

Time

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From the evidence, we should be measuring very different dimensions to those currently measured

Routine data currently collected:

• Mostly include demographics, injury characteristics, workplace characteristics and claim characteristics

Key Dimensions which should be measured if we are to understand and influence the life cycle of a claim:

• First return to work

• Durable return to work

• Capacity to RTW

• Health and psychological functioning

• Willingness to RTW

• Perception of employer attitudes to RTW

• Relationships between key stakeholders

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A timely, safe and durable return to work for injured workers

WorkCover RTW objective

RTW ImpactsRTW

outcomes

Example:Insurer interventions

Example: Case management

Example: Policy

Example:Employer interventions Durable RTW

First RTW

Capacity to RTW

Health & psychological functioning

Willingness to RTW

Employer attitudes to RTW

Management of the relationships between key stakeholders

Using the evidence base if it existed: Scheme objectives - inputs – impacts and outcomes could/ must be systematically linked

RTW Inputs/ Interventions(out of scope)

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Approach 1 – Extending and improving current data collection systems

• Immediate improvements in existing routine/ administrative data collections could be achieved, to test and demonstrate the gains in terms of better predictive modelling (eg risk profiling, statistical case estimation)

Eg Claims and Policy data bases Mandating new variables Recommendations to improving the quality of insurer data on key variables

Eg National Return to Work Monitor (e.g. Campbell Research & Consulting)

Modify existing and include additional variables Improve survey design and sampling

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Approach 2 – Collecting new data

Recognising that outcome in workers compensation reflects the inter-relationships between key stakeholders suggests several supplementary data collection strategies to understand their impact:

Eg - Employer, insurer and provider surveys

Eg- multidimensional case studies using the injury event as the point of sampling over the course of recovery from Return to Work exploring over time:

willingness to RTW

capacity to RTW

attitudes to RTW

relationships between stakeholders

attitudes towards interventions

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Longer working life Any addition to retirement age would give a material one-off increase in

workers compensation costs (and liabilities?) depending on benefit structure.

Would possibly increase nature & condition and latent claims

Increased incidence of chronic disease in the workplace Complex and chronic disease prevalence (eg mental illness, diabetes,

arthritis, cardiac disease, respiratory disease) is increasing, and increases with advancing age. The workplace (and workers compensation) will need to deal with these

A complication ………. importance of work health will be more than ever

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Fitness for duty issues (could go two ways) With change in physical and mental capacity, exposure to disease (eg

stress, chemical exposure) and injury (eg musculo-skeletal strain) in some jobs may functionally increase (ie people don’t cope as well, exposure goes on for longer ‘working lifetime’)

Alternatively, exposure may actually decrease if people start to move to other work areas through earlier retraining etc (eg construction field job vs desk job), particularly in the face of “smart” strategies to target markets and skills shortages (eg ‘grey tellers’ for banks to better match the population of customers

Retaining skilled workers The Finland experience several decades ago is interesting in this regard.

The aging bump and the early retirement of affluent societies hit there some time ago, with a consequent looming huge skills gap

Work health (cont)

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The case study approach – holistic analysis examining the injury event from all perspectives

Injury

Employee

Employer

Insurer Provider

CaseManager

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Conclusions

Effect of claim streaming and risk profiling is limited – because of the data available

A new approach is difficult – mainly because of the paradigm we are working in

But…. The paradigm needs revisiting if we are to move forward