Week 2 - Workplace Rehabilitation Legislation, Compensation Schemes and Key Stakeholders_ Lecture Slides.pdf

EHR524 WORKPLACE ASSESSMENT AND REHABILITATION WEEK 2 – LECTURE WORKPLACE REHABILITATION LEGISLATION, COMPENSATION SCHEMES AND KEY STAKEHOLDERS Karina Liles (ESSAM AEP, AES) E: [email protected] Ph: (02) 6338 4102 Exercise Physiology from an Insurer’s Perspective Outline: Roles of AEPs wit...

EHR524 WORKPLACE ASSESSMENT AND REHABILITATION WEEK 2 – LECTURE WORKPLACE REHABILITATION LEGISLATION, COMPENSATION SCHEMES AND KEY STAKEHOLDERS Karina Liles (ESSAM AEP, AES) E: [email protected] Ph: (02) 6338 4102 Exercise Physiology from an Insurer’s Perspective Outline: Roles of AEPs within compensation What are the schemes? Common Injuries – physical and psychological Claims process Treatment – approval / declinature Importance of effective communication RTW upgrades and case conferencing 2 Compensation Schemes Workers Compensation Compulsory Third Party (CTP) Life insurance ‒ All schemes have their own legislation and provision of treatment 3 Roles of AEPs in Compensation Rehabilitation in “clinical” settings – directly facilitating return to work/rehabilitation following injury primarily via exercise programs and case management – Referrals in Workers Compensation must come from NTD or NTS. – Referrals from CTP and Life can be provided by treating GP/Specialists, Physio/Chiro/OT, rehabilitation providers or insurers Return to ‘life’ roles is also a large focus particularly in CTP/life insurance schemes Working as a Rehabilitation Provider - RTW plans (on behalf of the employer) to assist injured workers back to work. No direct physical treatment provided Injury Management – Working directly for insurers and employers to assist with treatment needs following injuries at work / MVA 4 Approved Workplace Rehabilitation Providers Workplace Rehabilitation Providers are allied health professionals (Occupational Therapists, Physiotherapists, Exercise Physiologists, Rehabilitation Counsellors and Psychologists) who help to resolve problems with worker’s compensation claims. Workplace Rehabilitation Providers can: – Perform functional, workplace or vocational assessments – Assess an injured worker’s capacity for work and the activities they can currently perform – Assess suitable work options – Advise about modifications to the work environment or work practices to reduce work demands – Work with injured workers, employers, NTD’s and treatment providers to design a plan for recovery at work – Advise about work options where an injured worker is unable to return to work with their pre-injury employer 5 Insurance Agents Insurance agents are authorised to act on behalf of the nominal insurer / regulator in their jurisdiction: ‒ Issuing policies for workers compensation insurance (in some jurisdictions) ‒ Calculate, determine and collect insurance premiums (in some jurisdictions) ‒ Payment of workers compensation benefits to injured workers ‒ Workers compensation claims management ‒ Provision of support services for injured workers such as rehabilitation ‒ Assistance or RTW services ‒ Management of third party service providers (i.e. medical or rehabilitation services) 6 Insurance Agents The Case Manager (CM) is responsible for: ‒ Managing a workers recovery when an injury occurs in the workplace ‒ Coordinating the claim day to day strategy ‒ Calculating weekly entitlements ‒ Paying weekly entitlements ‒ Reviewing and approving treatment requests and provider invoices ‒ Continually reviewing liability and work capacity ‒ Claims costs estimation ‒ Stakeholder communications ‒ Legal and whole person impairment (WPI) decisions 7 Insurance Agents The Injury Management Advisor (IMA) is responsible for: ‒ Review and advise of recovery at work and return to work strategy in claims ‒ Provide advice and opinions on medical and treatment requests ‒ Liaise with medical and treatment providers with regards to cases ‒ Managing workplace rehabilitation provider’s performance ‒ Review vocational rehabilitation requests ‒ Case conferencing - internal and external ‒ Coaching and education for Case Managers ‒ Quality Assurance of WPI assessments 8 Return to Work vs Injury Management Programs / Plans Return to Work Program: A summary of the system the employer will use to manage workers with work related injuries or illnesses. Injury Management Program: An insurer-developed strategy for managing all aspects of work related injuries or illnesses. 9 Return to Work Coordinator The RTW Coordinator carries out the day-to-day duties of the RTW Program, and is the link between the worker and their support team The RTW Coordinator does not make decisions on claims liability or funding for treatment – this is the insurer’s responsibility. The RTW Program must outline the RTW Coordinator’s role in recovery at work planning, and managing workers with a work related injury or illness. These duties must include: ‒ Compiling the initial notification information ‒ Coordinating the worker’s recovery at work, including identifying suitable employment opportunities ‒ Preparing, monitoring and reviewing a Return to Work Plan (in consultation with key parties) that documents the worker’s capacity and duties available 10 Return to Work Coordinator ‒ Liaising with external stakeholders, such as the Nominated Treating Doctor (NTD), insurer, treatment providers, union and Workplace Rehabilitation Provider ‒ Implementing the RTW Program ‒ Supporting the redeployment of workers (internally or externally) into suitable employment when they cannot return to their pre-injury duties ‒ Keeping injury and recover at work statistics ‒ Keeping confidential case notes and records in line with laws and guidelines ‒ Promoting the health benefits of good work to the workforce ‒ Contribute to the improvement of relevant policies and systems 11 Return to Work Coordinator Return to Work Coordinator ‒ Have experience with workers compensation legislation ‒ Understand the roles and responsibilities of all stakeholders ‒ Know and understand the legal obligations of employers ‒ Be experienced in supporting workers to manage injuries and recover at work ‒ Have strong written and verbal communication skills ‒ Be able to consult and negotiate with stakeholders ‒ Have conflict resolution experience ‒ Be organised and skilled in time management 12 Return to Work Plan - Example 13 Return to Work Plan - Example 14 Return to Work Plan - Example 15 Hierarchy of Return to Work Goals 16 Common Physical Injuries Most common in Worker’s Compensation: Lumbar spine injuries Also common are shoulder injuries, hernias and fractures However, there are many soft tissue injuries that can occur Most common injuries seen in CTP: Whiplash of cervical spine, lumbar sprain Remember, however, diagnosis of injuries are not always clear on initial medical certificates i.e. low back pain is not a diagnosis 17 Common Psychological Injuries Post-traumatic Stress Disorder (frequently misdiagnosed or over diagnosed) Anxiety leading to Adjustment Disorder Depression Can also be a secondary condition (very common following compensation related injuries) due to multiple psychosocial barriers Important to remember that as a practicing AEP you may be the first to identify potential psychological barriers i.e. fear avoidance, pain focus, etc. 18 Acceptance / Declinature of Claims Liability on insurer - investigation on accident circumstances or injury at work. Additional information sometimes required to determine i.e. factuals - obtaining witness statements from others regarding incident Declinature - In CTP, deemed denials can be pending investigations or straight denials. In WC, difficult to decline if a frank incident has occurred. Requirement: significant evidence for declinatures to occur 19 Acceptance / Declinature of Treatment Requests SMART goals are a necessity. It allows the insurer to understand why treatment is required and the end result / outcome Reasonable and Necessary (CTP) or Reasonably necessary (WC) Relationship to reported injuries Rationale for the number of treatments required to achieve stated goals Generally declinature is due to lack of communication or lack of progress or treating areas that are not certified. If ongoing treatment required, discuss with insurer prior to submission of new plan 20 AEPs as Treatment Providers A CLOSER LOOK Worker’s Compensation – A Biopsychosocial Approach 22 Worker’s Compensation – A Biopsychosocial Approach The ‘Flags’ Model 23 The Worker’s Support Team 24 The Worker’s Support Team You may find it helpful to contact the employer to discuss the worker’s needs. The employer can assist by: – Providing information about the workplace, the worker’s usual job and available short- term suitable work options – Discussing any risks or barriers that may have an impact on the worker’s recovery – Developing a Return to Work Plan to ensure the worker’s recovery progresses as expected and that they receive adequate support in the workplace 25 The Worker’s Support Team The employer’s insurer appoints a Case Manager who coordinates all aspects of the worker’s compensation claim. They are the primary contact for the worker and the support team The Case Manager helps the employer meet their legal obligations. They also arrange assessments or services for the worker, authorise payment of reasonably necessary medical expenses, and determine the worker’s entitlement to weekly compensation payments You are encouraged to discuss the worker’s capacity with both the NTD and the Case Manager. To facilitate case management you should respond to telephone calls from the Case Manager as soon as possible 26 The Worker’s Support Team While it is usually the employer or insurer who makes the decision on which Workplace Rehabilitation Provider will be used in each situation, the worker should be consulted on the decision and given the opportunity to refuse or request a change in provider The insurer is responsible for engaging the Workplace Rehabilitation Provider and paying for their services. These costs are recorded as a claims cost 27 Your role as the Allied Health Treatment Provider As the allied health practitioner, your primary objective is to support the injured worker and help optimise their recovery at/return to work. This is generally achieved through evidence-based clinical intervention and management. The injured worker will look to you for information about their condition and recovery. Your role may involve: – Setting expectations from the first consultation regarding their recovery at/return to work, active participation in recovery, planning and treatment – Conducting a detailed worker assessment and (where applicable) providing information to inform and/or confirm diagnosis and treatment strategy – Obtaining information from the insurer and/or employer to assist with goal setting and tailoring of treatment interventions 28 Your role as the Allied Health Treatment Provider – Providing information to the support team regarding the worker’s progress and capacity for work – Educating all parties about the health benefits of work – Your role does not include advocating for the injured worker in relation to the management of their claim, litigation or other compensation processes 29 Provision of Services All allied health practitioners in Australian workers compensation schemes are expected to adopt the Clinical Framework for the Delivery of Health Services. The five principles of treatment are: 1) Measure and demonstrate the effectiveness of treatment 2) Adopt a biopsychosocial approach 3) Empower the injured person to manage their injury 4) Implement goals focused on optimising function, participation and return to work 5) Base treatment on the best available research 30 Upgrading / Case Conferencing Objective evidence of improvement Durable and sustainable increase in functional abilities Progress with exercise should be reflected by an increase in capacity to perform activities (work, home, social) - Make the exercises mean something to the person doing them In regard to Case Conferences go in with a plan and with evidence, don’t try to ‘wing’ it The NTD or NTS is looking for your ‘expert’ analysis in regard to treatment so that it can assist with appropriate functional capacity. Be open and transparent with all progress or lack thereof to allow for progression (either upgrades or additional investigations or treatment) 31  AEP Fees Order - NSW 32  AEP Table of Costs - Queensland 33  AEP Fee Schedule - Victoria 34  AEP Fee Schedule – South Australia 35  AEP Fee Schedule – South Australia 36  AEP Fee Schedule – Western Australia 37  AEP Fee Schedule – Western Australia 38 AEP Fee Schedule – Western Australia 39 Readings and Resources WorkSafe Victoria. (2012). Clinical Framework for the Delivery of Health Services. Retrieved from: https://www.worksafe.vic.gov.au/resources/clinical-framework- delivery-health-services 40