An understanding of limitations makes RTW efforts work for all

Supervisors play a key role in smooth transition

Return to work (RTW) is one of the occupational health professional’s primary services to patients. But RTW is not just about the employee — it’s also about the employer and the workplace. Recognizing that fact can mean the difference between a successful RTW plan and one that’s not.

"The key to a successful return to work is the supervisor," says Jennifer Christian, MD, MPH, president of Webility Corp., a disability management consulting firm based in Wayland, MA. "Unfortunately, not enough supervisors have received training they need to help employees return to work."

RTW is a proposition that can be fraught with difficulty: The employee’s physician might impose restrictions that make accommodating the worker inconvenient for employers or co-workers; supervisors might be unsure about what restricted or light duty is appropriate.

Communication with the employee and his or her physician can solve many of these problems. Getting specific instructions from the physician, rather than a vague "light-duty" prescription, is important. Privacy laws do not prohibit employers from discussing the RTW restrictions with employees’ physicians. Employers cannot discuss the actual diagnosis, but can ask physicians about the specifics of what physical activity is limited as the employee phases back into his or her job.

Preplanning can save $$

Employers may feel a bit uncomfortable asking an employee’s physician questions about RTW restrictions, but getting workers back to work as quickly and safely as possible can have a real impact on a company’s bottom line, according to studies. The National Safety Council, in its Injury Facts (2004 edition), estimates that off-the-job injuries in 2003 cost U.S. businesses 160 million days of production time; on-the-job injuries in 2003 cost 70 million days of production.

The biggest stumbling block to employees returning to work — and thereby stemming the loss of production time — are doctors who do not understand exactly what the employees’ jobs are, causing the physicians to be more or less restrictive than the employee’s injury and job duties require.

Employees on transitional work assignments (TWAs) draw paychecks, but injured people who stay home collect benefits; with a TWA, the company is receiving something for its money, but when paying out benefits to a homebound worker, the company is losing.

It’s common to hear supervisors complain of having to create busywork for employees returning to limited assignment following injury. Christian says the complaints are often valid, but could be eliminated with some pre-planning and training. "It’s not always easy, but it’s worth the effort," she says.

The work assigned a light-duty employee might involve less strenuous tasks, tasks that do not irritate the affected body part; part-time duty; or temporary modification of the regular job.

Addressing TWAs for each position or area in a company before an RTW is necessary is the best way to determine what specific jobs and what degrees of limited work can be adapted for each position and area. Besides knowing how much a physician limits an employee’s workload, it also is important to monitor employees to make sure they don’t exceed the physician restrictions. Highly motivated people may insist that they are ready for full duty, and that gung-ho attitude could lead to a quick reinjury, Christian says. "If that happens, everyone will blame you," she warns. "[It would be] a very messy and expensive situation."

Keep an eye on co-workers of the employee, as well. If co-workers are hassling their light-duty colleague or the injured worker persists in exceeding the physician-set limits, disciplinary action is an option.

Christian says research bears out that employees on TWA recover much more quickly than those who convalesce at home. Plus, an employee who is at work, even just part-time, is able to maintain a connection to the job and to co-workers, and this is critical for morale, she adds. The working employee has a can-do attitude, while an employee who sits at home increases his or her risk that the injury will become permanently disabling.

But the TWA must involve more than make-work that does not provide a sense of satisfaction to the returning worker. The work must be appropriate to the employee, the company, and the medical provider’s conditions.

With an adaptable plan for TWA in place prior to an injury, an employer can help foster rapid recovery by returning the employee’s life to some degree of normalcy as quickly as possible.

The American College of Occupational and Environmental Medicine (ACOEM) developed guidelines to help employers and occupational health care providers develop RTW plans that best benefit workers and their employees. Recognizing that physician input is critical to ensuring the best outcome for the patient and the effectiveness of the employer in designing TWA for the patient, ACOEM states that treating physicians should spell out recommendations on the following:

Physical and functional limitations or restrictions — The employee’s functional capabilities and vulnerabilities should be considered and matched against the demands of the job and working conditions.

Limitations — Any existing constraints in the employee’s physical or mental capability to perform tasks. A mild increase in symptoms with increased activity is appropriately viewed as a non-medical issue. Patient self-report may not always be a reliable method of making this determination. Self-imposed limitations may be based on subjective perception or secondary gain. The physician is advised to rely on objectively determinable findings to the maximum extent possible.

Specific restrictions — Any protective measures required to prevent injury or foster recovery. These should be specific (e.g., the exact weight and height for lifting restrictions; the amount of time per hour and per shift an activity can take place; postures to be avoided). Duration of restrictions should coincide with the expected increase in endurance associated with the increased activity of a graduated return to work.

• Social or environmental limitations or restrictions.

Schedule modifications — These should be noted when return to a normal schedule is medically appropriate.

• Medical aids, adaptive equipment, or personal protective equipment.

Because recovery usually occurs in stages, the treating doctor may lift the restrictions on the employee’s activities bit by bit. As this happens, the occupational health nurse or physician should progressively increase the demands of the TWA, moving the injured employee closer to his or her usual job step by step. Don’t keep employees stuck on light duty when they are capable of performing more demanding work, ACOEM recommends.

TWA differs from the "reasonable accommodations" that the Americans with Disabilities Act requires employers to provide to workers with longstanding or chronic health problems in that for an employee on TWA, productivity expectations can be reduced — not the case for an employee with longstanding or permanent health problems.

(Editor’s note: The American College of Occupational and Environmental Medicine consensus opinion statement, The Attending Physician’s Role in Helping Patients Return to Work After an Illness or Injury, is available at www.acoem.org/guidelines/pdf/return-to-work-04-02.pdf.)

For more information, contact: Jennifer Christian, MD, MPH, President and Chief Medical Officer, Webility Corp., Wayland, MA. Phone: (508) 358-5218. Web site: www.webility.md.