vocational management

RTW and ACC in New Zealand – RTW Matters Analysis

This just in from RTW Matters – Dr Mary Wyatt analyses the New Zealand RTW Monitor results and makes her predictions about whether, in the light of financial pressures and declining RTW rates, NZ  is in for a RTW thaw or a snap freeze.  It’s available only for subscribers, but here’s a brief summary… (oh and subscription isn’t much in financial terms but packs a punch in information terms!)

  • RTW rates are declining in both New Zealand and Australia
  • ACC indicates that this is because of ‘a number of factors, including the ageing population, the increasing complexity of claims, and claims management inefficiencies. The resulting impact has meant that clients are staying on the Scheme longer and costing more.’

As an aside, I wonder how it can be that claims are becoming more complex?  Can someone enlighten me?  Certainly I don’t see this in pain management: people with chronic pain are, almost by definition, complex, and this has not changed on iota in the 20 years I’ve been working in pain mangement.  The only significant changes I’ve seen are that fewer people are attending for pain management with multiple surgeries, and more people are referred slightly earlier than the previous pain duration of 3.5 years.

  • The focus of the Government for ACC is cost containment
  • The ACC has taken the common scheme approach of dealing with financial problems by trying to moving long-term claimants out of the scheme.  Long term claimants are the most costly part of any scheme, and removing them is the most cost-effective ways to deal with cost blowouts.
  • Mary Wyatt points out that one strategy used by ACC to do this is the increasing use of FCE to ‘predict’ whether someone can return to work.  As she says, ‘As a tool to define a person is having a work capacity and therefore no longer being eligible for scheme payments, they may be an effective, however this does not mean they are valid.  Moving people on from the system after a few years is basically declaring a failure of rehabilitation.  If they are capable of returning to the workforce at that point, why haven’t they done so earlier?’

I’d mitigate this last statement by saying that because of legislation, economy and fear, amongst other reasons, people who are ‘fit to work’ in some capacity may not always obtain employment, hence the ‘work testing’ or ‘vocational independence assessment’ that ACC conducts in New Zealand.  The intention of the legislation is not ‘return to work’ but ‘return to work readiness’.  The end of rehabilitation assessment is a slightly different approach from some areas of the world and consists of:

(1) a review of the assessment recommendations that have been made over the course of the claim to establish whether all rehabilitative efforts have been completed

(2) a vocational assessment that details the work options a person may be able to do given ‘education, training and experience’ – without considering functional ability

(3) a medical assessment that reviews the medical status of the person and, in collaboration with the person reviews the various work options to establish whether he or she can sustain ’35 hours or more’ in any of them

For those unfamiliar with New Zealand legislation, there is no ability to litigate for personal physical injury, as ACC provides 24 hour ‘no-fault’ cover forpersonal physical injury for all people whether working or not, funded by levies from employers, employees and various other taxes.  It was first introduced to New Zealand in 1974, and has continued to be a model for many commentators on accident compensation.

It’s difficult to establish why rehabilitation ‘performance’ appears to be less effective than previously.  I can only observe that management of claims is often fragmented, that multiple treatment providers are often involved with quite contradictory aims, that contracts for services to claimants appears very prescriptive and often clumsy, and that case management can be quite different depending on the individual case manager working on a claim.  Perhaps one factor could be the increased use of ‘multidisciplinary’ pain management but using teams of clinicians who rarely meet, may not have any specific education, training or experience in pain management, and who’s membership changes often, and within a programme framework that may be ‘pain management lite’ – or less than the recommended 50 – 100 hours of consolidated input (Main, Sullivan & Watson, 2008).

Back to RTW matters – as a taster, take a look at the free information available, and make your own mind up about its value.

Main, C., Sullivan, M.,  & Watson, P.  (2008). Pain Management: practical applications of the biopsychosocial perspective in clinical and occupational settings. 2nd Ed. Churchill Livingstone, Elsevier, Philadelphia.

The gap between pain management – and returning to work

One of the most satisfying experiences I have in my job is seeing someone who has been off work for ages finally return to work.  It’s like seeing the person open up and bloom again. 

I often see people who have been off work for several years – most of them don’t have jobs to return to, and most of them have experienced a couple of attempts to return to work that have, for some reason or another, failed.  Often pain is given the blame for this, and the remedy is thought to be ‘develop pain management skills’ – and I guess in part that’s true.  But not completely.

There is a difference between using pain management skills at home, where for the most part, activities can be picked up and put down as needed, and at work where other demands are present.  There’s an element of discretion about when and how things are done at home.  People can, if they want to, take it a bit quietly on days when their pain is worse, and fit things in more readily on days when they’re feeling better.  Not so at work!  At work we have to do things to fit into an external timetable – deadlines exist! There are jobs we have to do that are not so forgiving – we have to do them in a certain way, or at a certain time whether we’re feeling great or not.

And therein lies the one of the reasons I think there is a gap between pain management and returning to work.  There’s a whole lot more riding on being able to keep going at work.

Let’s take a case like Allan.  Allan has been off work for three years now.  Before his accident he’d been working for two years as a night supervisor in a food production factory, and before that he’d been the primary caregiver for his wee girl who is now 8 years old.  And before that he’d been a professional athlete.

When he hurt his back he thought it would resolve quickly – but after a series of unsuccessful nerve blocks attempting to ‘find and obliterate the cause’ of his pain, and after two multidisciplinary physical rehabilitation programmes, he finally had to accept that his back pain wasn’t going to just go away.

He lost his job after he tried to return to work for about six weeks on a graduated return to work programme.  Allan had an occupational therapist visit his work place and was advised that he could do X, Y and Z tasks – but this wasn’t practical given the nature of the work, not even as a supernumerary.  Like many employers, his employer didn’t have any ‘selected duties’, and needed to employ someone else to cover Allan’s shift, and eventually told Allan that he couldn’t come back to work until he could manage certain tasks.  Allan’s employer terminated his employment after both of them decided that he wasn’t going to make it back in the next two or three months.

Allan was finally referred for pain management, and attended a three week interdisciplinary pain management programme.  He struggled with many of the concepts, particularly activity regulation (pacing was his least favourite word!), and he experienced panic when trying to use relaxation techniques.  He had been using a walking stick, and although he tried to stop using it during the programme, shortly afterwards he fell, and the stick became an ongoing fixture.  Allan was trying very hard to learn how to do things differently – but needed another twelve week programme of pain management using a cognitive behavioural approach before he could consistently maintain even his normal home activities.

Work was out of the question initially.  Allan’s confidence was shot – he knew he could do ‘some’ pain management, but much of what he did involved minimising fluctuations in pain, and when he did have an increase in pain he’d either push himself very hard to ‘get the job done’, or he’d use medications or rest to get through the tough patch.

Let’s make one thing clear, Allan really wanted to go back to work.  He told me he felt worthless, not a ‘real man’ because he wasn’t providing for his family and he felt trapped in his own home.  His confidence though, was at rock bottom.

The specific issues he saw as obstacles to going back to work were:

  1. Managing his pain without resorting to prn medication
  2. Coping with the side effects of his medication
  3. Confidence to tell an employer that he would be reliable
  4. Confidence he could be reliable and work consistently
  5. Confidence to be assertive and let others know what he could and could not do
  6. Worry that he would increase his pain and the other important aspects of his life would be under strain
  7. Feeling out of touch with the technology and specific skills in the workplace
  8. Not knowing how to present himself positively in a job interview – how would he answer those tricky questions about the time he’s had off work and about his health?
  9. Knowing his own functional abilities – he knew what he couldn’t do, but not what he could rely on doing consistently
  10. Identifying specific job options now that he couldn’t work the way he used to

You can see that the gap is not just about job seeking skills, although that’s certainly a part of it, but it’s also about how to use his skills to be reliable at work – to experience pain but persist and be consistent with his output.

How confusing it would be for Allan to be seen by a vocational provider who had a limited knowledge of chronic pain management.  How scary would it be for Allan to start to return to work after having failed in the past.  How demeaning to feel inadequate about his own skills and lack confidence to ask for help not only with every day work technology, but also with his pain (after all, that’s what lead to his loss of job early on).

The literature on returning to work after illness or injury is clear.  It’s not simply about coping with pain, it’s not simply about coping with disability, it’s not just about finding work, it’s not just about the person with the pain problem.  Vocational management is anything that helps a person remain at work or return to work – and it includes all of us on the team, including the employer.

For the most extensive review on vocational management that has been published recently, go to here for the executive summary of the report into vocational rehabilitation ‘What works for Whom’ by Waddell, Burton & Kendall (2008). 

Go here for a great set of downloadable documents about work and health (Working for Health, UK government)

And of course, RTW Matters  (Australasian) and ACC (New Zealand) Return to Work search page

RTW Matters!

My copy of the weekly update from RTW Matters has arrived with some great new articles for people working in the field of helping others return to work.
If you haven’t been there before, head on over to take a look at the free stuff, then if you’re excited by it, think about subscribing. It’s well worth it with some of the most prominent researchers and workers in the field contributing from their experience.
Some of the articles this week:

  1. Comparing Australian and New Zealand rates and duration of durable and non-durable RTW over time
  2. Early intervention and good communication: everyone’s responsibilities. The top points from the Dr William Shaw interview.
  3. oh, and yes there’s one from me! New Zealand’s Bronnie Thompson looks at the next steps back to work – looking broadly at the path forward.

Why should we look at return to work for people with chronic pain?
Well, lots of reasons actually, but some of the most consistent findings are that people who return to work are healthier than those who don’t. In fact, being off work increases the risk of ill health (Waddell & Burton, 2006).

The link between work disability and receiving compensation means that those who continue to be off work are often still engaged in a health care system such as insurance or ACC (in NZ) that means the person has to maintain ‘disablement’ or illness behaviour to retain compensation – this means repeated assessments, programmes and justification to both health providers and the compensation provider that the person is still unfit. This isn’t conducive to people living a full and healthy life. (Hadler, 2006)

Is return to work a legitimate part of pain management? Well, apart from the need to specifically address it as an outcome for general health reasons, many people give poor pain management as their reason for not returning to work. There is no doubt that for some people, functional limitations do prevent their return to specific tasks permanently. For many, however, it’s the sense of self efficacy, or confidence to reliably manage their pain and function at work that limits their actual return.

While authors like Gordon Waddell, Kim Burton & Nick Kendall (Vocational Rehabilitation: What works, for whom, and when? 2008) suggest that ‘Vocational rehabilitation [is] defined as whatever helps someone with a health problem to stay at, return to and remain in work: it is an idea and an approach as much as an intervention or a service’, and needs to start immediately, they also state that ‘the evidence in this review shows that effective vocational rehabilitation depends on work-focused healthcare and accommodating workplaces. Both are necessary: they are inter-dependent and must be coordinated.’

I’d suggest that separating vocational management efforts from health care and especially pain management (as has happened over the past few years in New Zealand) is not effective. Both elements need to be integrated, so that the two efforts support each other.  If that means pain management needs to learn about how people experience the workplace and help them develop effective coping skills that can be used at work, then so be it! Similarly, if vocational providers need to learn about effective chronic pain management so they can provide a consistent message that hurt does not equal harm and pain should not be a guide – then so be it.

Why pain management for work is different

There are many people who have completed a pain management programme, know how to do things like breathing, working to quota (pacing), relaxation strategies, distraction and exercise – but when they are asked about returning to work say ‘I can do these things at home, but not at work’.

I have many books on pain management – self-paced learning books, books on cognitive therapy for pain management, academic texts on pain management methods and concepts. What I don’t yet have is a book dedicated to ‘how to apply pain management in the workplace’.

Why should it be different? Well I think for one thing, it’s about the demand characteristics at work alongside the power differential many of the people I work with experience. At home it’s entirely possible to decide ‘I can leave that for a while and come back to it’ – this is often called pacing, although I’m not sure that it really is. While it works at home, where many things can be carried out in ‘chunks’, it’s a very different situation in, for example, a production line, or a plumbing business, or a lawyers office. Deadlines rules in each of these situations – and the individual has little control over what needs to be done, and more importantly, when it can be done.

The power differential at work is really evident for semi-skilled or unskilled workers where they are employed to get a job done, done quickly under the supervision or direction of a skilled worker. For many people this has been their whole working life, and despite years of experience, in the workplace they are required to work as directed. This work is characterised by ‘high demand, low control’ – and it’s common. The demands are to work fast, don’t argue – and many employees feel they have no choices and no power. Their opinion doesn’t count – or they agree that ‘get the job done’ is just the way it’s done at work.

If an individual has only developed pain management strategies that focus on avoiding or controlling pain (eg relaxation and pacing), and the ability to tolerate variations in pain intensity hasn’t fully been developed, it makes sense that it’s going to be difficult to cope with situations where activities need to be maintained despite pain fluctuations.

What are the implications of this? Is there a need for ‘targeted’ pain management to specifically address pain management at work?

I think so – and I think part of why it hasn’t been recognised and developed is that many clinicians are fearful of provoking a flare-up in their clients, perhaps afraid of ‘pushing’ their clients, and/or are themselves unconvinced that it’s possible for people to cope with increases in pain.

Another part of the problem? To date, pain management has been fairly generic – one size fits all. In fact, it’s only been recently that we have become aware that people experiencing chronic pain are not a homogenous ‘chronic pain group’ – they have quite distinct subtypes, even though refining what those subtypes are is yet to be complete!

If we have a complex model of pain, which the biopsychosocial model is, we are likely to have quite complex hypotheses about the factors maintaining disability. This means we need to have tailored approaches to pain management to suit the individual’s needs.

Here are some suggestions for developing pain management for work:

Suggesting to someone, even inadvertently, that they can ‘push through’ the pain won’t work – after all, they have probably been told this before, tried it, had a flare-up, and learned that it’s not pleasant.  Even if they are using a ‘boom and bust’ pattern,  they are usually fully aware that this isn’t the most effective way of managing.

What might work? Identifying what is going through their mind when they start to experience increased pain, and establishing a way to work through that thought. This might mean problem solving, reality testing, using the ‘good’ and ‘not so good’ decisional balance, and perhaps even developing a graded hierarchy of activities so the person can develop confidence that the world won’t end because their pain has increased.

Not allowing the person to experience a flare-up during therapy, not expressing confidence in their ability to cope, not being specific about the skills they have used.  Measuring ‘success’ in terms of pain intensity or avoiding a flare-up sends the message to the person that the primary aim of therapy is to avoid pain, and that a flare-up means they have failed.

What might work more effectively?  Working through pain fluctuations using coping strategies – not, as I’ve mentioned above, telling the person to ‘work through’ the pain!  Find out what’s going through the person’s mind, help them see that although it’s an unpleasant experience, it can be tolerated even when it increases from baseline.  Success needs to be measured in terms of two things:

  1. Did they use the skills they’ve been developing?
  2. Did they manage to get the task they were working on done?

Flare-ups are inevitable: minimsing flare-ups is not necessarily a helpful goal.  Developing confidence in the skills they are learning, learning to use them consistently – now that is a helpful goal.

Developing only passive coping skills (yes, I think relaxation and pacing can, at times, be passive coping!).  These skills are easily recognised and named (therefore often recalled), they can reduce pain intensity and physiological arousal (so reduce distress) – but in many cases, especially the longer forms of relaxation like Jacobsen/progressive relaxation, can’t be carried out readily in a workplace.  Where do you think a builder is going to find to lie down and spend half an hour relaxing?!  More importantly, they can’t readily be used while the person is carrying out activities.  Yes, even pacing means altering the time spent on an activity, which in many workplaces just can’t happen (think of a meatworks production line, a paintbrush assembling factory, a bakery in full swing).

What might help?  Developing other skills such as mindfulness, positive coping statements, body scans and ‘take 5s’, differential relaxation, and so on.  Helping people think about, and practice, applying their skills during activity – even during exercise sessions, while doing the grocery shopping, when driving. This requires specific problem solving to help the person bring the skills to mind, and begin to integrate into their everyday activities.  It doesn’t seem to be enough to simply mention that the skills can be applied in these situations, being specific about when and how to use them seems to be important (as well as monitoring and reinforcing their use before the person is discharged).

Divorcing vocational rehabilitation and pain management from each other will not work. It especially will not work if a person hasn’t developed robust skills that can and are applied consistently.  And it won’t work if vocational rehabilitation is carried out before pain management skills are addressed.

Although they are distinct phases for reducing disability, pain management strategies need to be supported in the challenging context of the workplace. Practitioners who help an individual during the return to work phase need to be familiar with the factors that are prevalent in a workplace – attitudes, beliefs, controls and so on – and be prepared to be respectful of the individual’s concerns then help them address the concerns.  IMHO this is a specialist role, you really need to be someone who has been to workplaces, knows the literature on occupational/workplace culture, and is thoroughly versed in cognitive behavioural pain management (not simply vocational therapy, not simply pain management).

Generalising pain management skills into the ‘real’ world involves a whole raft of skills that I am not sure have been thoroughly researched or analysed – yet.  Certain professions have an advantage in this, and yes, I think occupational therapists are well-suited to the task – IF and only IF they have developed skills in cognitive behavioural pain management.  A challenge to consider huh?