Tag Archives: job loss

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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September 7, 2015

FMLA may be a Godsend – but not for me or Kristina

I’m in Indiana this week for my second stint at tending to my 92 year old father in law.   In late August, I flew here on an urgent basis because he had been admitted to the hospital in heart failure and was not doing well either mentally or physically.  He went downhill in the hospital.  Imagine four nurses and an orderly trying to restrain a 92 year old man who thinks he’s being kidnapped, and you’ve got the picture.   When things calmed down, he was transferred to a specialty heart center in Indianapolis and had a remarkable non-invasive and HIGH TECH procedure called a TAVR (transcatheter aortic valve replacement – watch the amazing video).  Since then he has made a good physical recovery but continues to have some heart failure as well as confusion and forgetfulness, and we are unsure how much of this cognitive problem is new vs. pre-existing, and whether it might be temporary (due to lingering effects of anesthesia).

After that first week, my husband flew out to relieve me and I flew home.   He presided over Dad’s discharge to a rehab facility, and helped Dad get used to that new environment.   After a few days, we traded places again because David has some work that MUST be done at home, and I can take my work just about anywhere.  (We arranged our flights so we could have a 2 hour “date” at the airport.)    So here I am back in Indiana.   The issue on the table now is:  can this 92 year old guy continue to live alone, cook and clean for himself, and drive himself 20 minutes each way to the doctor’s office and the grocery store in his car?   My father in law insists the answer is yes.   We (his two sons and their wives – a physician and a nurse) are trying to figure out how to make it work.  What is the RIGHT level of supportive services and is there a way to provide them in his teeny tiny hamlet community   – so small there is not a single store of any kind.

Reality has intruded:  I’ve gotten almost no work done this week, nor the week when he was in the hospital.    Dealing with his medically-, administratively-, and emotionally-complex situation is VERY time-consuming and energy draining.    I am keeping him company, reassuring him, entertaining him,  making him comfortable, and ensuring that services are delivered when needed.  Then in hallways with the doctors and nurses, and in off hours with the family, I am acting as his medical advocate while anticipating and planning for the future.   For example, I have so far spent about 5  hours figuring out whether we can get him a cell phone that will work better with his hearing aids and his severe hand tremors, and then arranging for it  – so he can more reliably RECEIVE and MAKE calls with his “support network”  when he’s back at home.

In the meanwhile, it has become obvious that I am simply incapable of radically switching gears and lives in the same day.  I have to FORCE myself to slow down and get into the glacial rhythm of life in a nursing home with a tremulous deaf 92 year old and his compatriots who deserve respect and compassion.   I am not mentally / emotionally flexible enough to INSTANTLY reconstitute myself as an impatient, driven professional and resume my usual pressured work pace in the few hours I have in between events. (This predicament feels familiar – a reminder why my masters’ thesis remained incomplete for such a long time while my kids were little and underfoot.   I just COULDN’T snap into and back forth between the “way of being” for Attentive-Mommy-Household-Manager vs. Graduate-Student-Writer during nap times.  My hat is off to those who can!)

This experience is also a reminder of how important the Family Medical Leave Act (FMLA) is.   It protects the jobs of working people while allowing them to take leave to care for illness in close family members. However, this experience is also a reminder that FMLA is not the WHOLE answer.   For example, it doesn’t protect ME in this situation.  First, I am the daughter-in-law, not the daughter – and the FMLA explicitly excludes in-laws.  Also, I work for myself so I can’t be fired.  But  I can lose my livelihood by not being able to do my work – since as a consultant I generally get paid by the hour or by the deliverable, assuming it is produced on time!   No work, no pay. Luckily, my financial situation is such that I CAN forego the income for now so I CAN be here and support him in an hour of need.   If forced to choose, I will put my time and expertise to use in helping my husband fulfill his duty to this vulnerable and incredibly kind old man who deserves to be treated kindly after a lifetime spent in humble service to his family, friends, neighbors, and parishioners as a Methodist pastor.   There are limits, of course, and I know I can’t sustain this pace forever.

The limits of the FMLA also became apparent last week when I talked to Kristina Phillips, a young woman in New York City whose life was turned upside down by a work-related injury about 18 months ago.  Kristina had recently moved to the city.  She’s a sales person and was assaulted on a subway while riding between accounts.   Her longest-lasting injuries were to her neck and shoulder, and still interfere with her ability to lift and carry.  The treatments the doctor recommended for the first 6 months were inadequate, did not reveal the correct diagnoses, and did not get her better.  The insurance company initially denied more extensive care.  She sought help from a lawyer who wanted to expand her claim and have her see more doctors to talk about her PTSD – but what Kristina wanted was to focus on the future, get the right treatment, and get well.   All the state ombudsman did when she called to ask for assistance was tell her to request a hearing.   Hearings take MONTHS.

Her employer was very solicitous and helpful, but after Kristina couldn’t perform the essential duties of her job for more than 6 months, she did lose her job.  (FMLA only protects jobs for 12 weeks.)  Kristina couldn’t afford COBRA payments on her workers’ comp checks, so she lost her health insurance, too.   Her family couldn’t come to her aid.   She is an only child of parents with very constrained financial circumstances living in a very remote area of the Pacific Northwest.  Kristina started worrying about becoming homeless.   A new friend saw her distress and brought her some food.  He had taken Landmark Education courses and made it possible for Kristina to take the 3 day Landmark Forum workshop in which she realized she had to figure out how to get better and back to work by herself, while she continues in therapy.  She applied for and got some jobs that turned out to be beyond her capabilities. Kristina has now invented a new consulting business for herself which is starting to take off.

And in her spare time, she wants to DO SOMETHING so that others will not have to struggle the way she did.  Kristina wants to create resources to guide people who have been injured on how to get back on their feet – because “the system” doesn’t do that.   Needless to say, we are now talking about how I can support her in that endeavor!

August 12, 2015

Who will address working people’s reasonable concerns when illness or injury disrupt their lives?

What do working people wonder and worry about when their lives (and work) have just been disrupted by a new illness, injury, or a change in a chronic condition?

While creating a course to train doctors how to meet their patient’s needs, we realized we had to know what those needs were.  It seemed obvious that patients would want to know what is wrong with them and what kind of medical care they need.  But beyond those things, we came up with a list of predictable and totally reasonable issues:

How long am I going to be laid up (out of commission)?
How long do I have to take it easy?
When I can go back to doing my usual stuff?
In the meanwhile, what can I still do? What shouldn’t I do?
What can I do to speed my recovery?
If I can’t work, how will we pay our bills next month?
When will life be back to normal? …..if ever?
What does this mean about me?   My future?
What is this going to do to my livelihood?  What will this do to us financially?
Who will help me?  Who can I trust?  Who has my best interests at heart?

I often show this list when I am speaking to groups about how to improve outcomes for people with common health conditions like back pain.  It always rings true with the audience.  After one presentation, an influential executive (in a wheelchair with quadriplegia) told me that she had had all of those concerns immediately upon awakening after her accident.

Here’s my question:   How are people getting these questions and concerns answered — when and by whom?  The standard design of a medical visit (memorized by all physicians during our medical training) DOES NOT include a time for doing it.  There is no sub-heading in our report format called:  Patient Education,  Instruction, and Guidance.  If it is happening, it is spotty at best.

So if most doctors are not answering these questions, who is?   Which of the other professionals who are responsible for responding to life & work disruption in working people IS going to address them?   Unless one of these “experts” does so, the people will have to come up with their own answers.  Yet how many are prepared to do that?   They will come up with their own best guesses (which may be wacky) or may turn to their family, friends, co-worker, neighbor, union steward, or a lawyer for answers (who may or may not give them a bum steer).

What does this mean for you?  If you are committed to better service (and/or want to avoid the trouble caused by bad advice), figure out a way to meet people’s totally reasonable needs for information and advice.   If you are a treating clinician, consider making a revision to your standard visit protocol and report templates by adding that missing section:  Patient Education, Instruction & Guidance.

Another simple idea for healthcare providers, employers or insurers is to create a standard operating procedure to mail out or hand out a brochure.  The 60 Summits Project developed a fact sheet for employees whose health conditions have just started to disrupt their work — and a fact sheet for supervisors on how to manage the situation in the workplace..  Feel free to use these sheets as is, or remove the 60 Summits logo and revise them to suit yourself.  But please do SOMETHING!

 

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August 7, 2015

Who should be accountable for NEEDLESS job loss due to medical conditions?

Who do you think should be held accountable when workers needlessly lose their jobs because a newly-acquired or changed health condition or disability?

Right now, none of the professional participants who play front-line roles in the stay-at-work/return-to-work process feels a responsibility to prevent unnecessary job loss.  Doctors, employers, insurance companies, lawyers and so on simply think it’s a shame when it happens — if they are even aware of it.  Unnecessary job loss is being viewed as a private tragedy rather than a sentinel indicator of service and system failure.  A lot more sunshine is needed to illuminate this dark corner.

Gap

Even though OSHA ensures that employers record the number of work-related injuries, lost work-days and deaths, there is no requirement that they record job loss.  Why isn’t it being tracked?   It will almost always be a much worse consequence than the injury itself.   Job loss, especially in someone who was previously healthy but now has some degree of impairment, can be DEVASTATING.   Few people are prepared to deal with this double- barreled challenge.   For the unlucky ones, this means losing their footing in the world of work forever.

We do not even KNOW how many people lose their jobs as the result of work-related injuries much less personal health conditions — and how many fail to find new jobs. I personally don’t think it matters what the cause of the health condition is.

These days, more than a HALF of the people entering the Social Security Disability Insurance program are doing so because of adverse secondary consequences of common health conditions like back pain, joint pain, anxiety, and depression.  But notice this:  there are literally MILLIONS of people who keep working DESPITE back pain, joint pain, anxiety and depression.  These conditions should NOT be forcing people into a bleak future of on-going worklessness, especially because unemployment and poverty will WORSEN their health and well-being — and that of their families.

Needless job loss can occur because of decisions that doctors and employers make as well as decisions made by workers, their lawyers, and insurance companies. Anyone who COULD have actively supported a worker in staying at work but DIDN’T plays a part in unnecessary job loss.  Doctors may thoughtlessly select treatments that worsen instead of improve function, or impose work restrictions that “over-limit” someone who COULD actually perform their job.  Employers may refuse to make temporary adjustments that WOULD permit recovery “on the job” — and as a result workers sit home and begin to believe they really are “too disabled to work”.   Employers can refuse to engage in a real problem-solving discussion with workers that WOULD have let them come back to work with a very minor modification.  Employers can neglect to ask for help from a return-to-work expert who COULD have told them about a $200 piece of equipment or work process alteration that WOULD have made it possible for the worker to keep doing her regular job.  Insurers COULD routinely (instead of occasionally) make career counseling and job finding services available to workers who appear headed for job loss or have already been terminated.  Etc. Etc.

So, who DO you think should be held accountable for job loss in those situations?  You and I as taxpayers are going to pay benefits for the rest of these people’s lives if they end up on SSDI because the right things didn’t happen.  Less than 1% of SSDI beneficiaries ever come back off the rolls.

Here’s a place to see and comment on my DRAFT recommendations for what the government can do to create a lot more visibility for unnecessary job loss due to acquired health conditions and disabilities.  You can also contribute your own ideas on this matter at:  http://workashealthoutcome.epolicyworks.org/

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June 5, 2015

Why aren’t we saying and doing THESE THINGS about the ADA?

I’ve been listening to the prevailing conversation about the Americans with Disabilities Act, as amended (ADA), in workers’ comp and disability benefits circles. Most often it has a negative tone: the ADA imposes obligations and creates complicated legal dances that can get us in trouble unless we do things exactly right. I almost never hear ANYONE in these industries (other than disability rights advocates) talking about what we can do to FULFILL the social purposes for which that law was created!

I am also a member of the US Dept of Labor’s Stay-at-Work and Return-to-Work Policy Collaborative, As a result, I met the EEOC‘s Senior Legal Counsel Aaron Konopasky, PhD, JD.  He opened my eyes to the fact that the ADA now applies MUCH EARLIER and MORE FREQUENTLY in health-related employment disruptions (both workers’ compensation and short / long-disability benefits cases) than has traditionally been thought. (See the mini-white paper Aaron and I co-authored on this issue.)

Seems like one of the key purposes of workers’ comp and disability benefits programs SHOULD BE to help workers who get injured or sick or who lose functional ability over time to KEEP THEIR JOBS / LIVELIHOODS and if needed, FIND NEW WAYS TO EARN A LIVING appropriate for their changed capabilities so they can MAINTAIN THEIR ECONOMIC INDEPENDENCE.  If that is so, then it seems like EMPLOYMENT OUTCOMES should be included in the metrics by which effectiveness / success / value of these programs is measured.   (I don’t see this being done now — do you?)

Now let’s look at the flip side:  bad outcomes.  (more…)

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