Tag Archives: functional restoratoin

January 5, 2017

Why Public-Private Collaboration Is Necessary to Prevent Work Disability

My goal now is to raise awareness about the need for concerted governmental, philanthropic, and private sector action to find better ways to support the millions of workers who lose their livelihoods each year due to injury or illness.  In many cases, this outcome could have been prevented.  And in the New World under President Trump, it will probably be more important than ever to make sure that people get the help they need to KEEP earning a living and STAY in the workforce.

You may be wondering … why work disability is a problem?  Let’s start with the basics. As a practical matter, we already know that lack of work is bad for people and for communities.  Just think about the many millions of dollars the government spends to create jobs and reduce unemployment!  But now, formal research has started confirming how harmful worklessness really is for adults — documenting the consequences for their physical and mental health as well as for their marital, family, social and economic well-being.

Since that’s so obvious…. let’s agree that preserving people’s ability to function and work should be a fundamental purpose of health care services.  Successfully doing so should be seen as an especially valuable health care outcome, second only to preserving life, limb, and essential bodily functions.  And the failure to do so should be called a poor outcome.

Today’s reality is … that whether or not a person with an newly-acquired medical condition is able to function and work afterwards is not even counted as a health outcome!  And there are gaps in our social fabric that are actually creating job loss and work disability.

Here’s one big example of a gap: … None of the three professionals typically responding to workers who are dealing with life disruption due to injury or illness feel any responsibility for actively supporting the workers to keep their jobs or find new ones if necessary. That includes health care professionals, employers, and benefits administrators.  Occasionally, some of these professionals actually advise against work — not realizing the consequences, of course.  The workers are left to fend for themselves;  some lack the confidence or skills to do so successfully.  We need better public policy, stronger governmental efforts, and more support from the private sector in order to prevent this needless work disability.

Do you realize… that roughly half of the people now receiving Social Security Disability Insurance (SSDI) and other prolonged disability benefits started out with very common health problems like back pain, depression, and anxiety?  And do you realize that the vast majority of people in the country who develop those same conditions don’t even take any time off work or are able to return after just a short absence?   So the people who end up on SSDI are members of a subgroup that has had unexpectedly poor outcomes — including job loss.

You might ask …why does this sub-group have such poor outcomes of conditions that normally don’t cause much work disability at all?  It’s logical to assume that these people had the most severe cases of back pain or depression and so on, but in most cases there’s actually no objective data to support that idea.  For every person now on long-term disability there are others who started out with the exact same condition, but are still working.  From the strictly medical point of view, they looked identical at the beginning.  What is different is the way the illness episode unfolded in the two groups:  what happened; how others talked to them and treated them; the decisions they made about the best way to manage this life challenge; the effectiveness of the medical treatment they received; the other kinds of support they got and the opportunities that were or weren’t available.

My personal hope is that … more employed people who are dealing with new injuries or illnesses are going to get what they need at the right time to avoid needless impairment work absence, job loss, withdrawal from the work force, and long-term reliance on disability benefits — which really means a life of poverty.  That would be good for them, for the tax payers, and for our society as a whole.

Now that these issues are in the spotlight …. It is time for policy makers, employers, healthcare providers, health and disability insurers, other service providers, and affected individuals to start talking together about solutions — and then do their part to make those things happen.

For the last three years, Mathematica‘s policy researchers Yoni Ben Shalom, David Stapleton, and I have been collaborating in the SAW/RTW Collaborative sponsored by the Office of Disability Employment Policy in the US Department of Labor.  On September 13, 2016, Mathematica held a forum and webinar during which several speakers presented some actionable policy options that can improve outcomes and prevent needless work disability.

If you want to go deeper … Read my short Work Disability Prevention Manifesto by downloading it from the “Current favorites I’m Sharing” section on my blog homepage.  Or you can look at / listen to the recording of the SAW/RTW Collaborative’s September 13 forum/webinar..  Some of the ideas presented by the policy researchers came from surprising angles — and were quite creative / innovative!

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September 9, 2016

Pithy 4-min Video & 1-page Manifesto for you to use

Mathematica just released a 4-minute video of me pointing out why the work disability prevention model is important — in plain language.  The video was made at the request of the US Department of Labor’s Office of Disability Employment Policy (ODEP).  The main messages in the video are:

  1. MILLIONS of Americans lose their jobs every year due to injury and illness;
  2. Worklessness and job loss have been shown to harm physical and mental health as well as personal, family, social, and economic well-being;
  3. Worklessness and job loss should therefore be considered poor healthcare outcomes;
  4. Unexpectedly poor outcomes can often be prevented and there is good research evidence about how to do that;
  5. Changes need to be made so that vulnerable people get what they need at the time when they need it — and as a result are able to have the best possible life outcome, stay in the workforce, and keep earning their own living.

In addition, the video also explains WHY and HOW some people have unexpectedly poor outcomes of conditions that do not normally cause significant work disruption and job loss.  Unless you’re in my line of work, it is hard to understand why things turn out badly in some cases and not in others — especially if they looked exactly the same at the beginning.

The video is loosely based on a one-page Work Disability Prevention Manifesto I wrote.  I put a draft of it on this blog last spring and got many useful comments.  After many revision cycles, it is now as succinct and compelling as I know how to make it.  ODEP had no hand in the Manifesto; it’s my independent work.

I’m glad I can now share these two items with you because the WORLD needs to know more about these issues—and most PEOPLE in the world have a very short attention span and no interest in the topic to begin with.   I hope you will pass this stuff along to the people whose thinking you want to change or whose buy in you need. Then maybe THEY will pass it along to others as well.  Social norms ONLY SHIFT when people share powerful mind-opening ideas with one another.

Lastly, let’s all stop speaking ABOUT these problems.  It is time for us all to start speaking FOR action and FOR changes.

WORK DISABILITY PREVENTION MANIFESTO
©Jennifer Christian, MD, MPH August 2016

Preventable job loss demands our attention

  • Millions of American workers lose their jobs each year due to injury, illness or a change in a chronic condition.
  • Preserving people’s ability to function and participate fully in everyday human affairs, including work, is a valuable health care outcome, second only to preserving life, limb, and essential bodily functions.
  • A new medical problem that simultaneously threatens one’s ability to earn a living creates a life crisis that must be addressed rapidly and wisely. Most people are unprepared for this double-headed predicament. It can overwhelm their coping abilities.
  • When medical conditions occur or worsen, especially common ones, most people are able to stay at or return to work without difficulty. However, many prolonged work disability cases covered by private- and public-sector benefits programs began as very common health problems (for example, musculoskeletal pain, depression, and anxiety) but had unexpectedly poor outcomes including job loss.
  • Loss of livelihood due to medical problems is a poor health outcome. Worklessness is harmful to people’s health, as well as to their family, social, and economic well-being.

Why do such poor outcomes occur?

  • Medical conditions by themselves rarely require prolonged work absence, but it can look that way. Both treatment and time off work are sometimes considered benefits to be maximized, rather than tools to be used judiciously.
  • Professionals typically involved in these situations (health care providers, employers, and benefits administrators) do not feel responsible for avoiding job loss.
  • Unexpectedly poor outcomes are frequently due to a mix of medical and nonmedical factors. Diagnosed conditions are inappropriately treated; others (especially psychiatric conditions) are unacknowledged and untreated. The employer, medical office, and insurance company (if there is one) operate in isolation, with little incentive to collaborate.
  • Without the support of a team focused on helping them get their lives back on track, people can get lost in the health care and benefits systems. With every passing day away from work, the odds worsen that they will ever return. After a while, they start to redefine themselves as too sick or disabled to work.
  • When people lose their jobs and do not find new ones, they barely get by on disability benefits and are vulnerable to other detrimental effects.

How can we fix this problem?

  • Good scientific evidence exists about how unexpectedly poor outcomes are created, how to avoid them, and how health care and other services can protect jobs.
  • Health-related work disruption should be viewed as a life emergency. Productive activity should be a part of treatment regimens.
  • When work disruption begins, it can be both effective and cost-beneficial to have a coordinator help the individual, treating physician, and employer communicate and focus everyone’s attention on maximizing recovery, restoring function, accommodating irreversible losses, and making plans for how the individual can keep working, return to work, or quickly find a more appropriate job.
  • We must urgently establish accountability for work disability and job loss in our workforce, health care, and disability benefits systems and build nationwide capacity to consistently deliver services—just in time, when needed—that help people stay at work or return to work.
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July 28, 2016

Video on tools & techniques to aid recovery & RTW

You may like watching the video of a group discussion on Tools to Aid Recovery and Return to Work that was presented (and recorded) via Blab yesterday.  It was a stimulating exchange of ideas about both tools AND techniques with my colleagues Les Kertay, PhD and Chris Brigham, MD — as we each sat in our own offices.  Each of us were visible in our own little boxes on the screen.

The session was aimed at professionals in any discipline who want to hone their skills at working with individuals who are having trouble getting back on their feet.  It was sponsored by R3 Continuum and hosted by John Cloonan, their Marketing Director.

The video is now available on You Tube.  There are a few static-y and jumpy spots in the video, but I believe you will find the 60 minute conversation is worth your time.
Here’s the link to the YouTube version:  https://www.youtube.com/watch?v=jAwJFMD0hBo

Afterwards I talked to John Cloonan about Blab.  Apparently it has a built-in link to Twitter, so Twitter users can watch the live Blab video using Twitter’s Periscope capabilities.  Comments from Twitter users are fed to the Blab screen and are visible to presenters, which enables audience participation.  In addition, John was able to simultaneously link the live video to Facebook.   So while we were talking among ourselves, an unknown number of people were watching our discussion via R3 Continuum’s website, Facebook AND Twitter.   If you go any of those places, you can still find it.

Wow, talk about the ability to extend one’s reach and connect with many audiences!   Looks like John Cloonan (as a marketing guy who wants to disseminate messages far and wide) is drawn to Blab because it is possible to attach such a big social media megaphone to it!

As is typical with new technology, there are more challenges than are obvious at first glance.  For example, Blab works much better with a high-speed wired connection.  Some users may find their firewall is blocking it and have to figure out how to unblock it, etc. etc.  I had to restart my silly computer to get the microphone to work.  So having a “tech rehearsal” ahead of time was absolutely essential.

Les, Chris and I are all members of the Praxis Partners Consortium, by the way.

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June 9, 2016

Interview with Val Lougheed about recovery and her book Be Still

I recently asked Val Lougheed some questions about her book Be Still and her experience recovering from major trauma.  I have summarized our dialogue for you below.

At the time of the head-on automobile collision that nearly cost her life in 2003, Val was the owner and president of a successful rehabilitation company then called Northern Lights Canada, with a large staff in Ontario.  The accident caused a significant head injury, internal injuries, and multiple broken bones. She made a remarkable recovery and was left with subtle limitations. If you want to see Val in action, here’s a brief 4 minute YouTube video of her speaking at a conference. She was able to return to her company, and then found a new calling as a speaker and author on head injury and recovery.   Her book Be Still is a very personal set of vignettes from her hospitalization, her recovery and rehabilitation — and her reinvention of herself.

Val and I met in person a few years ago.  She has been a longtime valued contributor to the multi-disciplinary Work Fitness & Disability Roundtable email discussion group I run.  I recently read Be Still and recommend it to you.  Her book offers a very personal glimpse into the inner experience and outer realities of someone bound and determined to heal from devastating injuries.  She has been working on a second book to be released later this year.

DR J:     Why and when did you decide to write your book, Be Still?
VAL:      It was serendipity.  At the time of my accident, I had almost finished a Master’s Degree in Community Rehabilitation and Disability Studies at the University of Calgary. My advisor knew I had kept a journal while I was in the hospitals, and suggested that I write a narrative about my recovery for my thesis. She encouraged me to write only about my personal experience – no research, no literature references, no nothing. She said to write it so that when someone read it they would feel like they were going through the experience with me. As I analyzed my journals, the particular themes that stood out were trauma, pain, depression, acquired brain injury, narcotic pain killers, and methods of helping. Writing that paper was sort of like an exercise in do-it-yourself narrative therapy. I believe it augmented my recovery. And then I realized I could self-publish it as a book.

DR J:  What did you want your book to accomplish?
VAL:     I wrote it in hopes that it would provide some useful insights into the following questions:
1.    What does it mean to recover?
2.    What can I do, myself, to recover and return to a life that includes work?
3.    What can we do — as practitioners, as family, as friends — to aid recovery and  return to work?

I have realized that the meaning of my accident for me comes from writing, studying and speaking about recovery. So every time I speak, I feel like I owe my life to the people who are listening. Every time someone reads my book, it’s the same – I owe my life to them. To my complete delight, people respond to my talks with the same amount of passion (and tears) that I have in giving them. I am driven by the hope that my work can, in some small way, lead to the development of a more sensitive, effective and in-tune system within which practitioners and patients/clients can work together to achieve successful returns to life and work.

DR J:   You have some very personal experiences to share with us — but before we go there, do you have any advice for people now trying to recover in the “system”?
VAL:     Of course!  Here are my six best suggestions.

  1. Play your own game. Don’t fall into the trap of believing you are disabled and can’t work, or that you don’t want to work/be functional.
  2. Be curious about your recovery. Try to learn and understand everything about all aspects of your recovery. Read, talk to people, write a journal – whatever you like to do. This helps to put the ‘problems’ outside of you so you can look at them with some distance between you and them. This helps to preserve your inner self from being consumed by your problems.
  3. Functionality is everything. Be clear about what a functional life for you looks like, and work towards that. Don’t get sidetracked with standardized measurements and pronouncements, or with the need to prove that you are disabled. For sure, do whatever you have to do to get the money and help you need to recover — and play the game if necessary. But always continue working towards your own vision of personal functionality.
  4. Get good psychological help. If you can afford it, or convince the insurer to pay for it, find a good psychologist or counsellor who can support you in your efforts to recover. My preference is narrative therapy, for a couple of reasons. First of all, it helps you to separate yourself from your impairments/illnesses/problems and work on them from a distance, so that you don’t drown in them. Secondly, it helps you to re-story yourself and your life, which is so important when you are going through a ‘re-organization of self’.
  5. Look for ‘angels’. There are some people out there who are truly angels. They are the ones who are prepared to listen to you, respect you, understand you and even love you. If you find one, spend time with them, listen to them, and let them help you.
  6. Stand up for what you know you need. You will be called all sorts of names (malingerer, non-compliant, unmotivated, etc, etc). Do not listen to this. Be clear about what you need and then search out people who can help you in this regard.
  7. Never, ever, ever give up!

DR J:   What have you learned about how recovery really happens?
VAL:    I know now how recovery happens on different levels. There is the outside recovery – the physical aspect of it. That part can be measured, quantified and standardized (e.g., how long does it take a broken collar bone to heal and what will it look like?). Healthcare professionals assess and fix this kind of stuff.

But then there is the inside recovery, which I found to be a deeply personal experience. In reality, there is no difference between the physiological and the psychological – no split between the mind and the body. The combined whole person can’t be standardized, measured, quantified or partitioned (which is very frustrating for a disability benefits system based on those things).

Shortly after I woke up after the accident I realized that I had lost myself. By ‘myself’ I mean my spirit, my soul, my energy – whatever it was inside of me that was ‘me’ was gone. I realized that I was becoming someone else, but I had no control over the process. Very scary – like all of a sudden not knowing who or where you are….like floating with no ground under you and no net to catch you. In clinical terms, I would call it an ‘existential crisis’.

In Judith Herman’s excellent book, Trauma and Recovery, she contends traumatic life events can shatter the sense of self.   Since an event is traumatic if the involved person perceives it to be traumatic, there must a lot of people out there with shattered selves!  And typically, it’s not exclusively the doctors and other healthcare professionals who help put the inner person back together – it might be social workers, friends, family, a minister, a nun, or maybe even just a comment from a person in passing.

Beyond this, a good recovery requires an alignment of the stars so to speak, in terms of the presence of positive family and social support along with other facilitating factors (a safe place to live, relatively good general physical and mental health, enough money to manage, and so on) to realize progress.

DR J:   How did the knitting back together of Val, the whole person occur?
VAL:     Here’s one little story:  About four months after the accident, I was talking to Sister Brenda, a nun at St. John’s Rehab Hospital in Toronto where I was a patient.  I shared with her my sense of loss of self.  By virtue of her amazing listening and empathy skills, I suddenly found myself.  My “me” was all rolled up in a little ball in my stomach!  I thought back to the accident, and suddenly it made sense to me why that was where it was.  As the other car approached, I must have realized that I was not going to be able to escape a collision — so the me that is ‘me’ hid away. As soon as I found where “me” was, I knew that was the start of true recovery.  I believe this experience of a ‘split’ between the mind and the body is the result of trauma.

Coming back to life required major internal change, a re-organization of myself on a grand scale. It required me to have a strong sense of personal control, personal power, and raw courage to follow through with necessary (and often painful) treatments and rehabilitation activities.I needed to be around people an practitioners who could help me with these things.  In his amazing book, The Upside of Down Thomas Homer-Dixon describes the process of ‘”coming back” as a “novel and unpredictable recombination of elements”.  That is exactly what it felt like for me.

Jon Kabat-Zinn has my favourite definition of what rehabilitation is really all about. He says that “rehabilitation is the learning to live inside not only one’s body, however it is after an injury or illness, but inside one’s very being”.  That quote really resonates with me.

DR J:   Who and what helped or hindered your rehabilitation?
VAL:     When I think of who helped me most to come back to life, there was of course a literal village of wonderful doctors, nurses, physios, OT’s, psychologists, etc. etc. who helped put my body and my head back together.  But specific people and particular moments — both bad and good — stand out in my mind.

I felt very vulnerable all the time during my recovery – physically obviously, but also emotionally. I felt that anyone could hurt me so easily that it was very hard to trust anybody.  This issue of trust is a huge one, in my opinion, in terms of facilitating recovery. If I trusted someone, I loved them and would try my hardest to do whatever they asked. If I did not trust someone, I hated them because I felt like my life was being threatened by them, and I would do whatever I could to get away from them. This led me to define what trust meant for me…..

I trust (love, feel safe with, will try hard for) people who:
•    Listen to me
•    Understand me
•    Respect me
•    Are competent.

In terms of being a client in the disability benefits system, when trust, positive regard, respect, and so on were absent, I could sense it – like an animal instinct. If someone treated me like this, I would feel threatened, and become REALLY uncooperative (I couldn’t help myself!), and do everything in my power to get away from that person. This is a good example of what’s called avoidance behaviour in the world of neuroscience (Rock, 2008).  I think it is often mis-labeled as non-compliant, malingering, unmotivated, etc. etc. in the system.

When my personal experience of impairment was not taken into consideration, when my recovery was measured against published norms that did not reflect exactly where I was in time and space, when I was not trusted, when I was not understood or respected, I not only lost my physical and cognitive ability to function, I also lost my will to recover.

But on the other hand – I definitely needed the money that I got from the insurance company to support me and to pay for necessary therapies when I could not work. And of course, in order to secure such monies, I had to continually prove that I was still disabled, with on-going health care assessments.

But frankly, it’s hard to recover when you are having to prove you are disabled in order to get help. It casts you in a crazy world of damned if you are recovering (because then you lose your benefits) and damned if you aren’t (because then you lose your functional life). The contentious, confrontational and distrustful atmosphere within which this plays out only serves to make it all so very much worse.  This is the reality of the disability paradox that plagues the current system adn that is what I’m researching and writing about now.

DR J:   Thank you, Val Lougheed, for sharing your personal experience of a difficult but successful recovery with us.
VAL:     Thank you for the opportunity.

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November 19, 2015

Early EVENTS influence outcomes: You have power to make good things happen!

Few people realize how important early EVENTS are in determining the eventual outcome of a work disruption due to a health problem, particularly the most common kinds of conditions:   low back pain and other kinds of muscle and joint sprains and strains, depression, and anxiety.

Let’s call this a poor outcome:  a failed medical recovery that results in over-impairment and excessive “disability” accompanied by work absence and loss of employment that could have been avoided.  And let’s call this a good outcome:  the fullest possible medical recovery with the least possible physical or mental impairment and the smallest possible impact on the rhythm of everyday life, including minimal lost work time and continued employment.   Do you agree?

Here’s the exciting “so what” about this news that EVENTS influence outcomes:  all three of the professionals who respond to an individual CAN influence what some of those EVENTS are going to be.  Those three professionals are:  the treating doctor, the workplace supervisor, and the benefit claims handler.  This news means that each of them actually has some POWER to nudge things in a good or bad direction!!

See below for a brief description of why early events are so important, and how the experience of  people destined for lucky or unlucky outcomes differs.  In fact, these ideas are some of the main concepts of the work disability prevention model.  (NOTE:  The scientific articles that support the  evidence-based concepts are briefly noted in parentheses.  Their full literature citations appear in the list of References in our report that recommends the establishment of a nationwide Health & Work Service.)

When a working person’s life is disrupted by a new or changed illness or injury, the first few days and weeks after onset are an especially critical period.  The likelihood of a good long-term outcome is being influenced, either favorably or unfavorably, by some simple things that either do or do not happen during that interval (Bowling 2000; Cornelius et al. 2011; Franklin et al. 2013; Loisel and Anema 2013; Nicholas et al. 2011; Shaw et al. 2013; Waddell and  Burton  2004; Waddell,  Burton,  and  Main  2001).  It  is  the  optimal  window  of  opportunity  to improve outcomes by simultaneously attending to the worker’s basic needs and concerns (Shaw et al. 2013)  as  well  as  by coordinating  the  medical,  functional  restoration,  and  occupational  aspects  of  the situation in a coordinated fashion (Wickizer et al. 2011).

The  way  the  episode  unfolds  over  time  in  all  dimensions — biological,  psychological,  social,  and economic — can have a big impact on the outcome. Events that occur can either mitigate or aggravate existing  risk  factors  in  the  situation,  leading  to  better  or  worse  outcomes.  There  are  usually  many opportunities to actively influence the course of events immediately after onset of a health problem (and  many  fewer  opportunities  later  on),  but  today  there  are  few  resources  devoted  to  finding  and exercising these opportunities.  Most of the current attempts to steer situations to a better outcome are made long after the best opportunities have passed by.

The best opportunity for basic intervention appears to last about 12 weeks or three months (DeWitt 1995; Franklin et al. 2013; Hashemi et al. 1997; Johnson and Fry 2002; Loisel and Anema 2013; Turner et  al.  2008)  although  some  data  shows  it  ending  by  6  months  (Rumack  1987;  Waddell  and  Burton 2004). A modest set of simple services —that embody an immediate, systematic, pro-active, integrated, and multidimensional approach — can mitigate the potentially destructive impact of common injuries, illnesses, and chronic conditions on quality of life among the working population (Burton et al. 2013; Hill et al. 2010; Iles, Wyatt, and Pransky 2012; Kendall et al. 2009; Lagerveld et al. 2012; Loisel and Anema  2013;  McLaren,  Reville,  and  Seabury  2010;  Mitchell  2012;  Nicholas  et  al.  2011;  Shaw  et  al. 2013; Sullivan et al. 2005; Turner et al. 2008; Waddell and Burton 2004; Wickizer et al. 2011).

This new approach will allow people to avoid the kind of adverse secondary consequences of medical conditions that they too often experience today (Institute of Medicine 2001; Dartmouth 2008; Franklin and  Mueller  2015).  Those  consequences  are  not  usually  obvious  until  months  or  years  later,  after unfortunate things have happened. The unlucky ones have received sub-optimal health care, been left with undertreated or iatrogenic impairment, become dependent on opioids, found themselves socially isolated, lost their jobs, withdrawn from the workforce, lost economic independence, and ended up on long-term disability benefits programs or SSDI in order to survive (Darlow 2011; Franklin et al. 2008; Franklin et al. 2014; Franklin and Mueller 2015; Habeck, Hunt, and VanTol 1998; Nguyen et al.)

CLARIFYING KEY TERMS

Figuring out where the opportunity to improve outcomes actually lies will be easier if we first clarify some terms that are often used carelessly or that mean different things to various audiences.

Work Disability vs. Disability
In the world of employment and commercial insurance, the word  “disability” is carelessly used.  In this world, the correct term is often “work disability” –which means absence from or lack of work attributed to a health condition.

According to the ADA, disabilities are impairments affecting major life functions (such as work).  Having a disability need not result in work disability.  This is a core concept embodied in the Americans with Disabilities Act. Similarly, having symptoms or a diagnosis need not (and usually does not) result in work disability.

Medical Recovery vs. Functional Restoration
Medical recovery refers to the resolution (disappearance or remission) of the underlying pathological process. Functional restoration refers to reestablishing the usual rhythm of participation in everyday life including the ability to go about one’s regular daily business: performing necessary tasks and enjoyable activities at home and work, and participating fully in society. Functional restoration often accompanies medical recovery, but not always.  Even when medical recovery is not possible, restoration of function often is.   In some cases, it may require separate and specific professional attention.  Functional restoration may include rehabilitation (broadly defined), the successful use of assistive technology, adaptive equipment, and/or reasonable accommodation in the workplace.

Anticipatory  programs  that  ensure  the  right  things  happen  from  the  start  and  include  early identification of those needing extra support are the simplest and most effective way to prevent later adverse secondary consequences of these conditions. A professional needs to provide the following services throughout the immediate response period (which typically ends with stable RTW or 12 weeks post onset).  These services are not generally available today, especially to lower-wage workers and those who work for small firms:

  • oversee and champion the affected individual’s stay-at-work and return-to-work (SAW/RTW) process until it is successful.
  • conduct a quick initial assessment and planning session that considers the individual’s entire situation, screens for known risks for poor outcomes, helps the individual and/or employer make a  SAW/RTW plan and  support them  in  carrying  it  out;
  • drive towards the best outcome by:
    — expediting and coordinating external medical,  rehabilitative  and  other  kinds  of helping services, including referrals for specialized services as needed to address remediable obstacles in a variety of life domains;
    — facilitating communications among all involved parties, ensuring they get the information they need so everyone has a shared picture of the situation and the goal;
    — taking a problem-solving approach with affected individuals, treating physicians, employers, and payers.

If RTW has not occurred by the time the 12 week period has ended, that should trigger a hand-off  to another professional with broader expertise for a deeper assessment which is likely to reveal the need for a different strategy, revised goals, a new approach, or the involvement of other disciplines.

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November 18, 2015

Our proposal for “upstream” services to reduce “downstream” inflow onto SSDI

Kim Burton, Tom Wickizer, and I have a good idea for how to reduce the inflow onto Social Security Disability Insurance.  Ours was among only twelve proposals selected for further development during a “competition of ideas” held by the SSDI Solutions Initiative sponsored by the Committee for a Responsible Federal Budget.

Once selected, we fleshed out the proposal in a written report.  It recommends the development, testing, refinement and launch of a nationwide Health & Work Service (HWS) that would assist workers who have recently developed potentially disabling conditions to maximize their functional recovery, stay at or return to work — and either KEEP their jobs or FIND new ones!  Our report describes why the service is needed and how it would work.  It includes many literature citations that provide a solid foundation for our proposal as a whole as well as specific design features of the HWS.

SSDI Solutions Initiative

The full reports have just been released to the public.   You can find all 12 of them here:   http://ssdisolutions.org/selected-papers.

And you can find ours here:  http://ssdisolutions.org/sites/default/files/christianwickizerburton.pdf  There is a main report and 3 (juicy) appendices.  One oddity is that the editors removed all biographical or organizational info about the 3 authors.  We could be 3 dogcatchers or 3 priests or 3 unemployed hula dancers for all the readers will ever know.  Here’s info about me and my co-authors:  Jennifer Christian, Thomas Wickizer and Kim Burton.

I verbally presented our idea in just 6 MINUTES at the SSDI Solutions conference on August 4, 2015.   Here’s a video of the entire event.  (My presentation starts about minute 36).

Do you happen to know any professionals who would LOVE to be part of a national effort to help people mitigate the impact of illness and injury on their lives and futures — and prevent needless work disability?  I do!!!  Among them are many of my physician and psychology colleagues in the American College of Occupational & Environmental Medicine, the many professional members in a wide variety of disciplines on the Work Fitness & Disability Roundtable — and most especially the 100 Founding and Charter members of the nascent but still unfunded Praxis Partners Consortium.

Hey, I have an idea!  If you like the idea of a HWS service, why not get in touch with the people at the Committee for a Responsible Federal Budget and tell them so!   Here’s a link to their “contact us” page:  http://ssdisolutions.org/contact/ssdi

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October 10, 2015

Some specifics: Our proposal for a Health & Work Service

In our August 2015 proposal to the SSDI Solutions Initiative sponsored by the Committee for a Responsible Federal Budget on Capitol Hill, we recommended that a community-focused Health & Work Service (HWS) be established.  The services to be provided by the HWS are generally not available in our country today, particularly to lower-wage workers and those who work for small firms.This service would be dedicated to responding rapidly to new episodes of health-related work absence among working people in order to help them:

— Minimize life disruption and get things back to normal as quickly as it is medically safe to do so
— Focus attention on treatments and services to restore ability to function at home and at work
— Understand and navigate through the healthcare and benefits programs and systems
— Avoid being abandoned; learn how to be a squeaky wheel and get their needs met
— Communicate with all parties to expedite both medical care and the return to work process, including resolving non-medical obstacles to recovery and return to work, making temporary adjustments or arranging reasonable accommodation when appropriate.
— Keep their jobs or promptly find new ones if that is necessary.

(The material below summarizes our written proposal.  If you’re interested in the scientific research that underlies these ideas, the 30+ pages and 3 appendices of our “real deal” formal report support all key assertions with literature citations and an extensive bibliography.  Along with the 12 other proposals commissioned by the SSDI Solutions Initiative group, it is scheduled to be published electronically in late October, and in print in January 2016.)

The first few days and weeks after onset are an especially critical period during which the likelihood of a good long-term outcome is being influenced, either favorably or unfavorably, by some simple things that either do or do not happen during that interval. It is the optimal window of opportunity to improve outcomes by simultaneously attending to the worker’s basic needs and concerns as well as coordinating the medical, functional restoration, and occupational aspects of the situation in a coordinated fashion.

The best opportunity for basic intervention appears to last about 12 weeks or three months, although some data shows it ending by 6 months.  Many studies have show that a modest set of simple services—that embody an immediate, systematic, pro-active, integrated, and multidimensional approach—can mitigate the potentially destructive impact of common injuries, illnesses, and chronic conditions on quality of life among the working population.

In the USA today, a large and growing fraction of Social Security Disability Insurance (SSDI) awards are being made to people deemed totally unable to work due to conditions that are among the most common health problems in America and the world, but which only rarely cause permanent withdrawal from the workforce. Low back pain and other chronic musculoskeletal conditions (MSK), and common mood disorders (CMD) —particularly depression and anxiety—are the most prominent conditions in this category.

Near-immediate assistance from a community-focused Health & Work Service will allow people with these kinds of common conditions to avoid the kind of adverse secondary consequences they too often experience today. Those consequences are usually not obvious until months or years later, after unfortunate things have happened. The unlucky ones have received sub-optimal health care, been left with under-treated or iatrogenic impairment,  become dependent on opioids, found themselves socially isolated, lost their jobs, withdrawn from the workforce, lost economic independence, and ended up on long-term disability benefits programs or SSDI in order to survive. Anticipatory programs that ensure the right things happen from the start and include early identification of those needing extra support are the simplest and most effective way to prevent later adverse secondary consequences of these conditions.

As we envision it, the HWS will build strong collaborative relationships with referral sources in local communities: treating physicians, employers, and benefits payers. Service delivery in individual cases can be largely telephonic and internet-based because these technologies are proving to be as or more effective than face-to-face care delivery. The quadruple goal is to maximize service quality, optimize outcomes, minimize logistical challenges, and control costs. The HWS service will:

(a) — get its referrals from affected individuals, local treating physicians, employers, benefits payers and others when work absence has lasted or is expected to last more than four weeks;

(b) — champion the stay-at-work and return-to-work (SAW/RTW) process from the time of referral through the end of the immediate response period (usually 12 weeks post onset);

(c) —  quickly evaluate the individual’s situation, screen for known risks for poor outcomes, help them make a SAW/RTW plan and support them in carrying it out;

(d) —  facilitate communications among all involved parties as needed to get everyone on the same page and driving towards the best possible outcome.;

(e) — expedite and coordinate external medical, rehabilitative and other kinds of helping services, including referrals for specialized services as needed to address remediable obstacles in a variety of life domains;

(f) — take a problem-solving approach in collaboration with affected individuals, their treating physicians, employers, and payers.

Of course, developing the HWS will first require a commitment to funding, either by the government or by a foundation that is committed to system change. Once that has been obtained, the initiative will unfold in a series of steps including design, prototyping, development, and field-testing in different geographies, followed by a large randomized controlled trial.  After that, the HWS can gradually roll out across large geographic areas.

What does this mean for you?   First, if you like the idea of working people getting the kind of support they need and deserve — and when it is most likely to make a difference,  please support this idea in whatever way you can.  Why not call or email your Congressman?  Second, if you are a professional with the expertise and passion required to help people get “right back on the horse” — and are now stymied and frustrated by the current system’s inadequacies / dysfunctions, you have probably realized that the HWS service might create a lot of fulfilling and satisfying jobs for specialists like you.  If so…. that’s another reason to call or email your Congressman!

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July 20, 2015

My “mini-manifesto” to reduce spine disability

You may be interested in the “mini-manifesto” I delivered this past Saturday 7/18 at the Spine 10×25 Research Summit in Chicago hosted by the North American Spine Foundation.  They have declared a worthy and very ambitious goal:  to reduce spine disability by 10 percent by the year 2025.  Thus the name: Spine 10×25. Pronounce it like you’re buying lumber – “10 by 25”.

(You can see the video and listen to my talk —  or even the ENTIRE 8 hour event because it was live-streamed and recorded.  Click here to do so.  Advance the recording by moving the blue dot along the horizontal line.  My talk starts at 5:31:50 and goes until 5:51:30.)

Do you know of any other medical group that has drawn a bold line in the sand like that?  I don’t.  It had never occurred to me that a professional society would set out to measurably move the needle.  They just don’t take on that type of project.  Most healthcare professional associations content themselves with pontificating:  being experts and telling other people what to do and how to do it.

My own professional society (ACOEM – the American College of Occupational & Environmental Medicine) has made many significant contributions to society.  In particular, our evidence-based treatment guidelines are very well regarded and in use by several states.   ACOEM has produced many other useful publications that have had a positive impact.  In fact, some of them were developed under my leadership.  But, in the end, they all amount to pontification.

In 2006, I told ACOEM I didn’t want one of those documents to just sit on an electronic shelf. We had developed it in order to introduce the work disability prevention paradigm and shift the way all stakeholders think about work disability.  Entitled “Preventing Needless Work Disability By Helping People Stay Employed“, that report needed to go out into the world.  Thus, the 60 Summits Project was born to carry it into the 50 US states and 10 Canadian provinces of North America.  We created groups of volunteer professionals who planned and held 20 multi-stakeholder summit-type conferences in 12 states and 2 provinces.  We invited the attendees to consider ACOEM’s 16 recommendations for improving the stay-at-work and return-to-work process.  We asked them to decide if they liked each recommendation, and if so, to make a plan for how they were going to carry it out in their own business, community, and jurisdiction. (60 Summits eventually ran out of money and was mothballed.)

Then last month, the boldness of the Spine 10x 25 initiative made me realize that even The 60 Summits Project had a pontification angle to it.  Propagating a new way of thinking and discussing a set of recommendations for change is not the same thing as CARRYING them OUT.  I felt compelled to go and check out these NASF people and participate in their Spine 10×25 Research Summit.

My assigned topic was “Precedents and Prospects for Success” in a 15 minute time slot that got expanded to 20.  It seemed important to speak straight and share my ideas about what needs to be true in order for their goal to be realized.  I offered the audience a (draft) conceptual foundation to use as a context for change, as well a summary-level vision of the way things will look in the future WHEN things have ACTUALLY changed and spine disability is BEING REDUCED by 10%.  View it here. Remember to advance the recording to 5:31:50.

I may expand a bit on some of the main points of that mini-manifesto in later posts.  I developed all of those slides at the conference in order to take into account what the speakers said who had gone before me!  Luckily, I also had some time at lunch.  The tight time limit meant a few big ideas got short shrift.

 

 

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July 9, 2015

Here is where healthcare delivers VALUE — at the most fundamental level

When Professor Michael Porter did some “deep thinking” about where value is actually delivered in healthcare, he created a simple table that displays three tiers.   I found his second value tier EXCITING:   a Harvard Business School professor was validating my own “gut feel” about what really counts.   I summarize Porter’s three tiers this way (you can see his own table below this post):

Tier 1:   Delivering a desired health status — Avoiding death; optimizing health or extent of recovery.
Tier 2:   Minimizing the time it takes to restore the normal rhythm of everyday life — the cycle time required to produce a return to full participation in life (or best attainable level).
Tier 3:   Sustaining health or recovery, minimizing recurrences and iatrogenic (care-induced) illnesses and consequences.

Porter’s free article appeared in the December 23, 2010 issue of the New England Journal of Medicine.  In his comments on Tier 2, Porter said:  “Cycle time is a critical outcome for patients — not a secondary process measure, as some believe.”  I have focused most of my professional energy for the last couple of decades on shortening cycle time — because it clearly produces better overall life outcomes.  I hoped Porter’s article would catalyze a lot of discussion and much more attention to Tier 2 — but not much luck so far.

Personally, I believe that the purpose of being alive is to live a fully human life.  From that perspective, the most VALUABLE healthcare services are those that minimize the impact of illness or injury on the rhythm of everyday life.  I want all healthcare professionals to START here:   Our FUNDAMENTAL purpose is to avert premature death, relieve fear and suffering, and to enhance, preserve,or restore as quickly as possible every patient’s ability to participate in the specific activities that make life worth living — which for many includes productive engagement / work.

We are a social species.  We have an innate drive to be useful in some way, to have a role to fulfill.  We are happier when we have a clear purpose in life. Those of us in the middle years of the human lifespan are DESIGNED to work — to hold up our end and contribute to the well-being of our family, clan, community or nation.  The well-being of our country, and even more broadly, the survival of our species depends on maintaining the right balance between dependents and contributors.

The AFL-CIO’s website says this about work:  “Work is what we do to better ourselves, to build dreams and to support our families. But work is more than that. Work cures, creates, builds, innovates and shapes the future. Work connects us all.” As the Episcopal Book of Common Prayer‘s Order for Compline (an evening prayer service) poetically puts it:  “Grant that we may never forget that our common life depends upon each other’s toil.”

From What is Value in Healthcare by Michael Porter, NEJM 363;26 Dec 23, 2010, p 2479

From What is Value in Healthcare by Michael Porter, NEJM 363;26 Dec 23, 2010, p 2479

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June 17, 2015

Communications Clarity Dept: Useful distinctions

I keep getting reminded how fuzzy words can be — and how much clarity matters to those of us who work across traditional boundaries between specialties, disciplines, or sectors of society.

We just submitted in a paper that will be presented at the McCrery-Pomeroy SSDI Solutions Conference on August 4 and then published later this year.    During the peer review process, it became clear that we, the authors, were confusing readers by using terms differently than they do:  “disability,” “early intervention,” and “recovery” .  So in our new and improved version of the paper, we began by making three key distinctions.  I offer them to YOU, in case they are useful.

Disability vs. Work Disability
According to the ADA, disabilities are impairments affecting major life functions (such as work).  In the world of employment and commercial insurance, work disability is absence from or lack of work attributed to a health condition.  Having a “disability” need not result in “work disability”, a core concept embodied in the Americans with Disabilities Act.   Similarly, having a health problem need not (and usually does not) result in work disability.

What this might mean for you:   Train yourself to add a modifier in front of the word “disability”, especially when you are working with someone in another organization or discipline.    I try to say “work disability” or “impairment disability”– because even if I define how I’m using the word “disability,” people LISTEN their habitual way. 

Medical Recovery vs. Functional Restoration
Medical recovery refers to the resolution (disappearance or remission) of the underlying pathological process.  Functional restoration refers to re-establishing the usual rhythm of participation in everyday life.  That means the ability to go about one’s regular daily business: performing necessary tasks and enjoyable activities at home and work, and participating fully in society.  Functional restoration does not necessarily require medical recovery.  It may include figuring out new ways to accomplish the stuff one needs or wants to do.  So function can be restored through rehabilitation (broadly defined), and can even include the successful use of assistive technology, adaptive equipment, and/or reasonable accommodation in the workplace.

What this might mean for you:   Remember to consider these two issues separately in every case.  In order for the affected individual to end up with an optimal outcome, especially when there’s not much to offer on the medical side, paying specific attention to functional restoration is important.

Early Intervention vs. Immediate Response
Our opportunity to influence the occupational outcome of an injury or illness episode DOESN’T really start the day a problem is reported, or the day YOU first get involved. The opportunity clock DOES start on the first day an affected individual stays home from work or admits to having difficulty working – because that is when the period of life disruption and uncertainty starts.    A pro-active work disability prevention program involves immediate response which begins within the first few days and no later than 6 or 8 weeks after onset.  This triggering event (and timeline) is different from the so-called early intervention used in many programs.  In general, those programs start from an administrative date:  claim notification,  date of referral or application for benefits, etc.  It is PATHETIC to see how LATE most referrals for early intervention are ACTUALLY made:  typically 6 or 9 months.   Naturally, the intervener WANTS to look responsive to the paying customer so they hop on the case promptly, within 48 or 72 hours. But hey:  Life moves at the speed of life, you guys, not administrative procedures.

What this might mean for you:   It is inappropriate to let anyone get away with counting from administrative dates — unless you are content with LOOKING responsive rather than BEING helpful.  On EVERY chart or file, keep an on-going record (at every visit or update) of how many days have elapsed since the episode began.  Also include data about how many days it typically takes someone with that particular condition to get back to work.  It will keep your and your collaborators’ feet to the fire.

Personally, when I’m doing my physician version of case management,  I use MDGuidelines.com to keep track of how long the episode SHOULD last, and a website called timeanddate.com to calculate elapsed time to date.   I put those numbers at the top of my reports. This keeps me and my customer REALLY aware of the passage of time, because otherwise, the days just keep slipping away — along with the individual’s chances of EVER going back to work.

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