Case Studies 

Case Study 1: Same Employer Rehabilitation

An injured worker who is female, twenty-five years of age and employed as an administration assistant. She has suffered a wrist strain while typing as part of her normal duties. The injury occurred approximately 1 month days prior to referral. The injured client is certified fit for suitable duties for 25 hours per week with a 1kg lifting restriction. The employer has stated there are no suitable duties available.

During initial contact with the injured worker, she mentions that she has just been certified totally unfit by her doctor and been referred to a hand surgeon for an assessment. When speaking to the employer, they state that they question the validity of the injury, as the injured worker was being reported a netball injury a week before the injury took place and given she is currently studying a computer course outside of work.

The following barriers would impact on the injured workers recovery that need to be addressed are:
• Obtaining a clear diagnosis of the injured workers injury given the recent referral to a hand surgeon. This would be obtained from the Surgeon / GP and the Consultant (if possible) would attend the next review.
• Exploring with the injured worker other activities outside work that may have impacted on the injury and whether these activities are continuing and may be causing ongoing symptoms.
• Lack of functional improvement given the injury occurred one month ago.
• Potential lack of active treatment, referral to hand surgery has occurred but nothing else.
• Lack of treatment intervention to improve functionality – passive management by NTD.
• Explore the current relationship in the workplace and the support from the employer perceived by the injured worker
• NTD doctor providing an unfit certification after initially certifying injured worker fit for 25 hours a week.

Injury Treatment’s SE case management model incorporates 6 phases:

1. Triage and screening Phase
2. RTW Assessment & Medical Management Phase
3. Strategy Development Phase and Case Streaming
4. Implementation Phase
5. Monitoring Phase
6. Outcome Phase

1. Triage and Screening Phase –Operations Manager RTW SE
Upon receiving referral for this injured worker from Allianz and the employer the following factors would be considered and assessed by the Injury Treatment Operations Manage (SE) during this phase to determine the most appropriate Senior Consultant to be assigned to the referral.

• Nature of the injury – right wrist strain as a result of typing
• Diagnosis – what is it?
• Current medical status – fit for SD’s 25 hours per week with incorporated lifting of <1kg
• Current treatment - is she getting any passive / active treatment / specialist review
• Type of work for which injured worker was employed – administration – keying, phone usage, filing, general office duties.
• Geographical location of injured worker – is this an employer we have dealt with before? Who is the nominated Consultant?
• Employers support of RTW options – It’s stated that no SD’s are available
• DOI – minimal lapsed time between date of injury (one month ago) & date of referral

The screening stage is vital in establishing the type of intervention that is likely to be required and the possible barriers that will prevent a successful RTW outcome in a timely manner. This referral would be allocated to a Senior Consultant by the Operations Manager to an Occupational Therapist Consultant (Renae Englert) who has a) previously worked in a hand therapy clinic, b) has experience in conflict resolution and negotiation as well as c) has worked with the identified Allianz Case Manager and employer and d) has extensive experience in conducting ergonomic assessments. Following allocation of referral an email is sent to agent and employer to confirm receipt of referral and consultant contact details (24 hours) and this is accompanied by a letter in the post to all parties.

2. RTW Assessment and Medical Management Phase
Within 24 hours of receipt of referral both the Operations Manager and the Senior Consultant would make contact with all of the parties, including the Allianz Case Manager, the Employer Supervisor / RTW Coordinator and injured worker to discuss the purpose of referral and intervention, establish the history of the claim and current status and to arrange a suitable date and time to conduct an initial / workplace assessment with the employer and injured worker. Once confirmed, an email would be sent to all parties within 2-3 hours re-confirming the time, date and purpose of the assessment. This assessment would be conducted within 2-4 days of the referral. Upon arriving at the workplace, the Consultant would meet with the employer independently to discuss their concerns around the mechanism of injury and to obtain further information about the employee, their past performance, to discuss their obligations to provide suitable duties and to finally review the injured clients’ workers compensation history. At the assessment an injury history and initial interview would be conducted, specifically addressing the mechanism of injury, current symptomology, treatment, date of next surgical and GP review, other vocations being undertaken, reasons why she believes she is totally unfit current RTW capacity and proposed RTW capacity. At this time, a consent form would be signed and a confirmation that liaison would occur between Injury Treatment and the treating GP and surgeon would occur. Also, a review of the workplace and duties is performed taking into consideration the physical demands of the pre injury role; key duties / responsibilities; environmental, psychological and psychosocial view of the workplace combined with a specific break down of tasks and function and whether the injured worker is able to perform the role at this time. At the time of assessment, Injury Treatment would also acquire signed information consent whilst providing the injured worker relevant Work Cover NSW pamphlets including ‘your rights and responsibilities as an injured worker’.

During this, ergonomic advice would be supplied regarding set up, functional education and exercise prescription. When assessing the suitable duties, the Consultant would specifically focus on the clients injury and likely restrictions (given they are unfit) and establish a tentative agreement with the client and employer regarding timeframe for the commencement of suitable duties. This meeting would involve the worker, employer and the Consultant (and union representative if needed). Following the meeting, the Consultant with Allianz to confirm the outcome of the meeting and proposed actions to move the case forwards. This would also be reinforced in an email.

During this assessment phase, the Consultant would immediately address potential ‘barriers’ from both the injured client and the employer’s perspective. In this case the reluctance of the employer to accommodate suitable duties would need to be explored and addressed as follows:

• Awareness of Workcover Legislation and the roles and responsibilities of employers.
• Addressing the concerns of the employer about the injured worker’s activities outside work however clarifying that under the legislation it is a ‘no fault’ scheme. Should the employer have clear evidence that the injury is not work related then the Senior Consultant needs to pose these concerns to the treating health professionals and establish the nature and cause of the injury and its relationship to the work environment.
• Explaining the benefits in achieving a durable return to work and the impact on the employers insurance premium should a return to work not be achieved.
• Exploring any other potential injured worker performance issues that may be impacting on successful return to work that will need to be addressed to achieve a durable RTW outcome.

During the initial /workplace assessment the Senior Consultant would assist the employer to identify and assess suitable duties that can accommodate the injured workers medical restrictions but will also be meaningful for the employer. The Consultant would then develop a proposed (given worker is unfit) graduated RTW Plan (suitable duties) within 24-36 hours of the workplace assessment, as discussed and agreed upon during the initial meeting by all parties. This plan would be distributed to all parties within 36 hours of the assessment in the desired format. Prior to this occurring, communication with the Nominated Treating Doctor (NTD) would occur to obtain agreement to the plan. This would be attempted in person with the injured client and GP with the intention of establishing a return to work date and clarification regarding hours and restrictions.

3. Strategy Development and Case Streaming
As mentioned, the Injury Treatment Consultant would then coordinate and attend a medical case conference with the injured worker and their NTD. At this conference the Consultant would further discuss the proposed Return to Work plan (if approval had not already occurred) and would also re-confirm (with the injured worker present) the RTW goal according to the Workcover Hierachy and timeframe for this to be achieved. Discussions would also be held to clarify the diagnosis and treatment options for the injured worker given the more recent referral to the Hand Surgeon. From a medical management perspective having an accurate diagnosis and ensuring that evidence based treatment interventions follow a clinical justification model will ensure that costs and durations are minimised and hence achieve a sustainable health outcome for the injured worker. Once signed off on by all parties, the Consultant would then provide the worker, employer and insurer with a copy of the RTW Plan (suitable duties) No.1.

Immediately following the GP conference, the Consultant would liaise with Allianz and the employer to inform them that an upgraded medical certificate had been obtained, the date and time of the specialist review, the confirmed RTW goal and the timeframe for commencement of suitable duties. The Consultant would then obtain written information from the treating surgeon (via a questionnaire) then distribute in the desired format to all parties a strategic RTW Plan Report within 5 days of the workplace assessment, providing all the details relating to the injury, barriers and strategies to mitigate the barriers as well as agreed ongoing interventions, communication, costs and reporting agreed requirements. Once submitted, the Consultant would contact Allianz and the employer to further discuss the recommendations.

4. Intervention Phase
Following commitment of the GP and worker to the RTW Plan (suitable duties), we would then confirm the acceptance of the employer to provide suitable duties within the workplace. The Consultant would work very closely with the employer to ensure they are closely aligned to the return to work process and involved in the monitoring of the worker. Given the identified barriers, it may be valuable to coordinate and attend a further short meeting with the employer and worker to implement the RTW Plan (suitable duties), confirm the worker understands how to set herself up ergonomically correct and also to discuss if and when she would be attending treatment and further reviews with the surgeon. A collaborative approach between the immediate supervisor and the injured worker would ensure success at this point in time. Ensuring that both the injured worker and supervisor are clear about what a graded return entails, what reasonably can be expected of the injured worker in relation to ongoing treatment needs during work hours and expectations in regard to notifying all parties of any deviation away from the RTW Suitable Duties Plan. In addition, the Consultant would ask Allianz for a copy of the IMP and supply a copy of this to the client also. At this stage, the injured worker needs to understand clearly that they are an active participant in the rehabilitation process and not a passive bystander. The consultant would clearly articulate this to the worker and ensure they have signed all documentation, including the consent form, RTW plan and IMP.

5. Monitoring Phase
Following implementation of the graded RTW plan and agreement on the strategy to improve the clients’ condition and working capacity we would then closely monitor her to ensure our objectives were met. Monthly workplace meetings would occur to review the clients progress clinically and according to the RTW Plan. This would involve an onsite 45 minute meeting with the injured worker and employer where discussion would occur regarding how she had coped with each stage of the RTW Plan and confirmation that she could increase her hours / duties as recommended. Further ergonomic advice would occur and the Consultant would ensure the ergonomic principles had been adhered to. Finally the Consultant would discuss the injury status, treatment being undertaken and outcomes from the surgical consultations. Prior to each monthly review meeting, the Consultant would liaise with the treating GP and other medical parties (eg. Surgeon) to obtain their input into the workers progress and ability to increase her hours and upgrade her restrictions. The Consultant would also liaise with the employer and Allianz prior to each meeting to determine if they had any agenda items which needed to be addressed. Fortnightly telephone conversations would occur with the employer, worker and GP to keep parties informed and ensure that all parties are committed to the process. Any barriers that arise during this phase would be quickly identified and addressed at the monthly workplace meetings. Consistent messages need to be communicated to avoid ambiguity about duties, upgrades and roles and responsibilities. Communication will be verbal and supported by an email which outlines agreed actions following meetings to all parties.

6. Outcome Phase
Once the injured worker has successfully upgraded her duties and hour to a point that she can safely and symptom free manage her pre-injury duties, the Consultant would then attend a medical case conference with the worker and her GP to discuss the provision of a PID’s medical certificate. At this conference the Consultant would confirm no further treatment is required and if not would ensure the GP ticks “final” on the medical certificate. Upon receipt of the pre-injury duties certification, Injury Treatment would contact the employer and the insurer (within 2-3 hours) to update them on this. Also, a placement meeting would be scheduled with the worker and employer at which it would be confirmed that the worker had been able to manage their pre-injury duties with no difficulty, no flare ups had occurred and to ensure they understand correct ergonomic principles moving forwards. This placement meeting would occur within 3-4 weeks of the final medical certificate being obtained. Following the meeting, and subsequent discussion with Allianz, the Consultant would generate a Closure / Placement Report to all parties and at this time they would diarise to liaise with the worker, employer and Allianz at the 13 week mark to ensure the placement had been durable and no difficulties had occurred.

SUMMARY POINTS

Overcoming Employer Barriers
• Clearly define the roles and responsibilities of the employer in the return to work process according to the WorkCover legislation;
• Explain impact of not participating in the RTW process and the impact on future insurance premiums;
• Listen to the employer about concerns related to the injured workers extra activities which may have caused the injury and attempt to clarify the cause of the injury with treating health professionals and the injured worker provide feedback to employer and insurer;
• Establish a clear understanding of the ‘environmental’ barriers that have been presented by the employer around suitable duties and explore where the concerns arise and assist the employer in identifying potential suitable duties.

Overcoming Medical Barriers
• Obtain a clear medical diagnosis through case conferences and liaise with all treating providers. Review investigations and seek second opinion from musculoskeletal physician if required and approved by insurer. IMC may be required to resolve issues with nominated treating doctor (NTD);
• Clarify treatment modalities with NTD and discuss evidence based medicine and clinical justification practice to ensure ongoing treatment is considered best practice and achieving functional improvement against documented recovery times;
• Establish clear goals and objectives around functional gains related to workplace duties.

Overcoming Barriers Injured Worker
• Establish the causation of injury and any ongoing activities that continue to aggravate the injury – determine how other activities such as study will impact on return to work duties;
• Identify any ongoing environmental barriers between employer and worker that could hinder the return to work process – address these with both parties using conflict resolution and negotiation;
• Obtain commitment from worker to be an active participant in the rehabilitation process and establish a clear understanding of the injured workers responsibilities.

Case Study 2: Different Employer Rehabilitation

An injured worker who is female, forty-two years of age and was employed as an aged care worker. The injured worker sustained injuries to her right knee and right shoulder from lifting a client in the workplace. The original incident occurred three years ago and the injured worker was terminated six months ago and has been sending in job diaries every month. Currently the worker is fit for suitable duties twelve hours a week; however her pre injury hours are thirty. The worker also has a driving restriction of twenty minutes and reports ongoing chronic pain.

The following barriers will require management in order to facilitate a successful return to work:

• The injured worker’s compensable medical condition including right knee and right shoulder injury and associated inability to return to her pre injury role with her pre injury employer.
• The injured worker’s functional limitations as outlined in her current medical certificate including reduced hours (12 hours per week) and driving restriction.
• The injured worker’s physically de-conditioned status as a result of her injury and subsequent medical restrictions as listed above.
• The injured worker’s reported pain levels and the associated physical and psychological impact this may have on her ability to seek and sustain suitable employment.
• The duration of the injured worker’s unemployment (6 months) and associated disadvantage this may hold when seeking employment in the open labour market.
• The length of time the injured worker has been seeking employment (6 months) and the effectiveness of her job seeking activities may currently be precluding her from seeking and sustaining suitable employment
• If this is the only industry that the injured worker has ever been employed, her current transferable skills and limited employment history may impact on the ease in identification of vocational goals combined with the job seeking and job placement process.
• The injured worker’s age and the unfavourable nature of the labour market towards individuals seeking new employment over the age of 40 years.
• The current financial crisis and associated down turn in employment throughout Australia.
• The injured worker’s inability to engage in occupational rehabilitation services from the onset of termination in order to assist with her RTW, new employer job seeking services.

Immediate actions we would take to return this worker to work

1. Referral and Case Review Phase
Upon receipt of referral, the Injury Treatment Operations manager would contact the referring agent (within 24 hours) to acquire additional information in regards to the claimant in order to match the referral with the most appropriate senior consultant. Factors taken into consideration at this time include nature of referral, nature of injury, date of injury, complexity of claim as reported by agent, the industry in which the injured worker has been employed and the geographical residence of which the injured worker resides. In light of the specific case study, Injury Treatment would refer this client to senior rehabilitation consultant, Mr Justin Court who has extensive experience working with injured workers in the Aged Care / Health Service Industry with varying physical injuries. Following allocation of referral an email is sent to agent and employer to confirm receipt of referral and consultant contact details (24 hours).

Upon allocation of referral, Justin would review all documentation available, conducting a gap analysis of additional documents required and specific information to be acquired from the agent. Taking into consideration the case study the questions most likely to be asked of the agent at first contact (within 24 hours) would be 1) has the injured worker had occupational rehabilitation services in any capacity prior to this time and what were the outcomes 2) has an recent IME, IMC occurred with this case and what were the outcomes 3) what treatment has the injured worker undertaken and were any gains made and if not, why 4) what is the injured worker’s pre injury earnings, current earnings and what section of the act are they currently receiving benefit under 4) are there any compliance / safety or other issues that may impact on our ability to contact the injured worker5) Does the previous employer wish to remain updated in regards to progress of the injured worker’s occupational rehabilitation.

Pending provision of this information, Justin would contact the injured worker (within 24 hrs of receipt of referral) to discuss reason for referral and role of Injury Treatment combined with the injured worker’s rights and responsibilities whilst in receipt of S38/S40 workers compensation benefits. Further, it is at initial contact, that Justin would organise the Initial / Vocational Assessment meeting time (to be conducted within 5 business days). Further, Justin may also contact the employer if deemed appropriate by the agent (within 24 hours) to acquire any additional information and to relay nature of referral. To ensure optimal communication across all parties, Justin would send an email to agent and employer to confirm the Initial / Vocational Assessment appointment date, time and location.

2. Initial / Vocational Assessment Phase
By the time the Initial / Vocational Assessment is due to take place, Justin would have a solid grasp of the case based on the gap analysis as listed above. Justin would conduct a comprehensive Initial / Vocational assessment (within 5 days of referral) in order to gain specific information in regards to the client as follows:

• Injury history
• Current medical status including treatment and medication
• Current physical, psychological, psycho social, financial and other symptoms as a result of the compensable condition
• Injury recovery and employment status
• Educational background including all qualifications / licences / certificates / courses completed to date
• Aptitude / skill level (such as language, written or mathematical skill) acquired through questioning and occupational testing such as the WRAT, DAT, CORT, Brief Aptitude Inventory, ACER Clerical and Numerical Test (testing is chosen based on client’s primary language and previous employment / skill
• Employment history including detailed description of duties conducted by the injured worker, specific places of employment, things they enjoyed most about each role, qualifications required for each role, whether they would return to this role if physically capable and their reasons for leaving this role
• Self reported skills as reported by the injured worker
• Interests and hobbies as reported by the injured worker
• Self reported barriers to redeployment related to injury
• Self reported barriers to redeployment unrelated to injury

At the time of assessment, Injury Treatment would also acquire signed information consent and signed job seeking contract whilst providing the injured worker relevant Work Cover NSW pamphlets including ‘your rights and responsibilities as an injured worker’. Following the Initial / Vocational Assessment identification of vocational goals would occur taking into consideration the injured worker’s medical restrictions, transferable skills, aptitude, interests, employment history, hobbies and pre injury earnings combined with Work Cover NSW vocational assessment and vocational retraining guidelines. Taking into consideration what we know about the injured worker in Case Study 3 it is likely that Dementia Home Monitoring Support Worker would be identified as a suitable goal.

Following the Initial / Vocational Assessment Injury Treatment would organise a GP case conference within 8 business days of referral in order to acquire the following information 1) diagnosis 2) expected prognosis 3) identification of suitable treatment 4) commitment to the identified vocational options identified. The most likely scenario from the GP case conference, based on Injury Treatment’s previous experience is 1) confirmation of diagnosis 2) information in regards to prognosis and the injured worker’s capacity to upgrade their physical capacity 3) identification and agreement to refer for appropriate treatment 4) commitment to vocational goals identified. Often, Injury Treatment gains an upgrade in medical certification at the initial GP case conference with commitment to further increase certification pending treatment as such it the expected upgrade at the initial GP case conference would be an upgrade in the injured workers medical certification to at least 15 hours per week.

3. Strategy Development and Case Streaming Phase
Following GP case conference, completion of Initial / Vocational Assessment Report and liaison with the referring agent (all completed within 20 days of referral) a strategy plan is put in place with the following recommendations taking into consideration the barriers identified:

• The injured worker’s referral to the Optimise Functional Assessment and Treatment program (Medical Advisory Board Program) given physical limitations, limited restrictions outlined in medical certificate and pain focussed behaviour. The program is designed to achieve the following: 1) increase in the injured worker’s physical capacity 2) increased in medical certification to optimal physical capacity (ideally permanently modified duties – 30 hours per week) 3) decreased pain / decreased pain focus
• The injured worker’s referral to the Optimise Psychological Assessment and Treatment Program (Medical Advisory Board Program) given reported pain focussed behaviour. The program is designed to achieve the following 1) decrease in pain focussed behaviour 2) increased psychological coping mechanisms 3) increased confidence and self esteem to seek and sustain employment
• Based on the injured worker’s inability to acquire employment independently within a 6 month period, Injury Treatment identify that the injured worker requires intensive job seeking education (JSE) and job seeking assistance (JSA) in order to be successful in the obtainment and sustainment of employment.
• The strategy plan would also include a clear return to work goal such as “The obtainment of employment as a Dementia Home Monitoring Support Worker, working full time hours’; return to work hierarchy ‘similar job / different employer; expected duration for delivery of service and expected return to work outcome ‘2nd May 2009 – 2nd August 2009 and the associated costs expected on this case.

4. Vocational Intervention Phase
As is identified in Initial / Vocational Assessment and Strategy Plan the injured worker requires intensive job seeking education and assistance given her limited job seeking skills and previous independent job seeking attempts. Tailoring job seeking modules to the injured worker’s needs it is identified that she requires 6 of the 10 modules job seeking education modules including: 1) resume and cover letter preparation; 2) how to disclose the workers compensation injury 3) how to register with employment agencies 4) how to register with job network providers 5) how to apply for advertised job vacancies 6) how to apply for non advertised vacancies.

Following the provision of job seeking education (to be completed within 14 days approval of strategy plan), intensive job placement activities occur (provided over a 13 week period with all attempts to place in employment within this period) in order to achieve an optimal return to work, different employer outcome. Specific job seeking activities occur as follows:

• Review and re iteration of job seeking contract originally signed at initial vocational assessment
• Injury Treatment to conduct at least 15 cold canvassing calls per week to potential employers (this is specifically important at this time given the financial crisis and reduced number of advertised vacancies – Injury Treatment has identified that cold canvassing with the marketing of both work trial and job cover placement program is more effective in the current labour market due to the financial crisis)
• Injury Treatment to submit at least 15 advertised job vacancy applications per week
• The Injured Worker to conduct 10 job seeking activities per week with a focus on cold canvassing for employment
• The Injured Worker to attend at least weekly (preferably 2-3 times per week) meetings with Injury Treatment in the job seeking phase of employment
• The Injured Worker is required to complete daily job logs, providing to both Allianz and Injury Treatment.
• The Injured Worker is to adhere to job seeking contract at all times with all counts of non compliance reported to Allianz on the same business day as the event.
• Injury Treatment to monitor the injured worker’s compliance ensuring extensive, intensive and consistent job seeking occurs for the duration of the job seeking program (13 weeks)

Results of Medical and Vocational Intervention Tailored to Injured Worker’s Needs
Through the provision of appropriate physical and psychological treatment and subsequent review/s with the GP, Injury Treatment is successful in the upgrade of the injured worker to permanently modified duties, working 30 hours per week. Further, through the identification of appropriate vocational goals and the provision of intensive job seeking education and job placement assistance, Injury Treatment are successful in placing the injured worker in to sustainable employment with her current wages exceeding her pre injury earnings.

5. Post Placement Monitoring & Outcome Phase
Through the provision of intensive job seeking education and job seeking assistance, Injury Treatment assist the injured worker in the obtainment of employment as a Dementia Support Worker with employer working 30 hours per week. The injured worker’s earnings are greater than her pre injury earnings and the role is aligned with her medical restrictions. A workplace assessment is conducted and suitable duties schedule is prepared for the injured worker as part of the post placement monitoring period for 13 weeks. Injury Treatment monitor, the injured worker on a weekly basis for the initial 4 weeks of employment, and every fortnight from then 4-13th week. If employment is sustained for 13 weeks (i.e. durability), Injury Treatment will then recommend the closure of the injured worker’s file.