Tag Archives: work disability

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!


October 31, 2016

Social Security Administration seeks input from YOU

I hope you will read — and respond — to this Request for Information issued by the U.S. Social Security Administration.  SSA is looking for input in order to decide whether to undertake a demonstration project (at the community level) for early intervention in musculoskeletal (MSK) conditions – in the first few weeks (<12) after onset of work disruption.

I’m sure SSA will really pay attention to thoughtful input they get from “front line” professionals and researchers / practitioners with expertise in this field — and from patients who have personal experience with the gaps and holes in our systems today that push them towards disability and job loss.

SSA will ONLY proceed with this demonstration project idea if they think it WILL decrease job loss, workforce withdrawal, and eventual applications for SSDI — by reducing needless impairment and disability while preserving livelihoods among the workers.   At this stage, SSA is asking basic questions about the level of evidence supporting the efficacy of early intervention, what the interventions should consist of, as well as the wisdom, practicalities, and potential efficacy of such an effort.

The deadline for responses is November 18.   There is a real possibility this demonstration will actually happen.  The President’s proposed 2017 budget has $200 million allocated for demonstration projects by SSA.    Whether or not that money will ever actually be appropriated will depend on many factors, including which candidate is elected President and the composition of the Congress.

While I was scanning the RFI to find the response date, I was stunned and delighted to see my name listed in one of the 3 references cited at the end!  SSA listed the concept proposal for a Community-Focused Health & Work Service that Tom Wickizer, Kim Burton and I contributed to the SSDI Solutions Initiative sponsored by the Committee for a Responsible Federal Budget.  All of the proposals, including ours, are available here: SSDI Solutions: Ideas to Strengthen the Social Security Disability Insurance Program .Maybe our work has actually made some difference – at the very least, SSA is now interested enough to seriously explore our ideas!

Now it’s YOUR turn to make a difference — by reading and responding to SSA’s RFI.


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.

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.


June 17, 2016

Free webinar on getting off opioids next week — offered by CIRPD

See below for the topics and schedule for a series of (free) summertime webinars sponsored by  the Canadian Institute for Relief of Pain and Disability (CIRPD).  They’ve got some excellent and expert presenters lined up.   The first one is on a technique for reducing dependence on opioid medications — on Wednesday next week!

I have been on the CIRPD board for a couple of years now.  I am impressed with their focus on educating professionals alongside patients as well as their efforts to build a web portal to expedite translation of evidence from academic researchers to real world practitioners.

I am certain there OUGHT to be an analogous organization here in the USA.  One reason why CIRPD manages to survive is that it has kept getting annual grants from the British Columbia government’s “gaming” revenue.  Seems like a good use of that money!

See much more at www.cirpd.org — where you can also register for one of the webinars shown below.  Here’s an idea:  Put the ones you like on your calendar now!
——————————————–
Upcoming (free) CIRPD Webinars

Targeting Pain and Prescription Opioid Misuse with Mindfulness-Oriented Recovery Enhancement (MORE)
Eric Garland, Ph.D., LCSW – Associate Dean for Research and Associate Professor in the University of Utah College of Social Work
Dr. Eric Garland will discuss his research on the clinical benefits and neurobiological mechanisms of Mindfulness-Oriented Recovery Enhancement, a novel therapy designed to target chronic pain and prevent opioid-related problems.
DATE:            June 22, 2016 – 11:00am PDT / 2:00pm EDT

Keeping the Boom(ers) in the Labour Market: Can Existing Workplace Policies and Accommodations make a Difference?
Monique Gignac, PhD – Associate Scientific Director and a Senior Scientist at the Institute for Work & Health
Dr. Gignac will discuss current research on understanding the interplay between accommodation and chronic diseases so employers can better retain older workers.
DATE:            June 8, 2016 – 11:00am PDT / 2:00pm EDT

The Be Well at Work Program: Managing Depression, Absenteeism, and Presenteeism in the Workplace
Debra Lerner MS, PhD – Director, Program on Health, Work and Productivity, Tufts Medical Center
Dr. Debra Lerner will discuss current research on how depression in the workplace affects levels of absenteeism and presenteeism. She will also present strategies for working with employees with depression.
DATE:            June 15, 2016 – 11:00am PDT / 2:00pm EDT

The Difference Gender and Sex Make to Work Disability Outcomes
Mieke Koehoorn, PhD – Professor and Head, Occupational and Environmental Health Division, University of British Columbia
Gender and sex can have an impact on the outcomes of workplace disability. Dr. Mieke Koehoorn will discuss recent research on how gender and sex affect disability outcomes and will provide some practical steps for handling the differences.
DATE:            July 13, 2016 – 11:00am PDT / 2:00pm EDT

Exercise Management for Chronic Fatigue Syndrome – The Evidence and Current Approaches
Suzanne Broadbent PhD – Senior Lecturer, Clinical Exercise Physiology, Southern Cross University
Dr. Broadbent will provide an over view of exercise management for Chronic Fatigue Syndrome and discuss current research describing the most effective types of exercise practices to use.
DATE:            August 23, 2016 – 4:00pm PDT / 7:00pm EDT

Pain-related Distress: Recognition and Appropriate Interventions
Tamar Pincus PhD – Professor in Health Psychology, Royal Holloway, University of London
Many people who live with chronic pain report that they also suffer from low mood, irritability, and withdrawal from activities and relationships. Dr. Tamar Pincus will discuss new research which helps distinguish whether these behaviours are based in depression or pain-related distress.
DATE:            September 20, 2016 – 8:30am PDT / 11:00am EDT / 4:30pm UK


May 18, 2016

It’s time to establish accountability for job loss

My report on Establishing Accountability to Reduce Job Loss After Injury or Illness (commissioned by the US Department of Labor’s Office of Disability Employment Policy) was originally conceived as a simple effort to lay out the rationale for adding work and participation in life to the list of positive health outcomes.  (I suspect that I was asked to write it because they thought a physician like me would focus on medical practitioners and the healthcare delivery system.)

Almost immediately, it became obvious to me that in order to make a solid contribution to the on-going public dialogue about health outcomes, the paper would have to explore the meaty issues of explicit expectations, accountability, metrics, credible data, rewards for best practices, and incentives for both participation and performance.

Soon after that, the absurdity of discussing expectations and accountability for the healthcare system alone became obvious —because organizations in other sectors of society play a role in the SAW/RTW process, each of which has enough discretionary power to support or thwart it.

Thus, over time, the purpose of the paper shifted to answering this question:  What has to happen in order to engage the professionals at the front-line  — the ones who work directly with affected individuals and make discretionary decisions about how much effort to make and for what purpose — so they start making a real effort to help people stay employed?

Who are those front-line professionals?

(1) Healthcare professionals.  Most of us view our purpose as making accurate diagnoses and providing appropriate treatment.   We are generally not trained to assess work capacity and prevent work disability.  Yet our opinions about work have considerable weight under law, regulations, insurance policies and traditional business practices.  We generally don’t spend much time and energy thinking about issues outside the exam room.

(2) Workplace supervisors or HR professionals.  Their focus is the business of the organization, producing its goods or delivering its services,as well as abiding by company policies and applicable laws. They can decide how much effort to make to help the employee stay at work and keep their job.  With rare exceptions, they are neither aware of the preventable nature of most work disability, nor are they trained how to negotiate and arrange stay at work or return to work plans, identify alternative temporary tasks or reasonable accommodations.  And they are not incentivized to do so.

(3) Claims/benefits administrators.  Their focus is administering the benefit programs correctly, establishing eligibility, compensability, meeting deadlines, making payments, and other requirements. In between these duties, they decide how much effort to make to help the beneficiary/claimant. Like the workplace professionals, with only rare exceptions, they are neither aware of the preventable nature of most work disability, nor are they trained how to negotiate and arrange stay at work or return to work plans, identify alternative temporary tasks or reasonable accommodations.  And they are not incentivized to do so.

Job loss is the third worst outcome of an injury or illness

As I thought about these players and those who influence their behavior, the biggest realization dawned more slowly:  job loss is a potentially devastating secondary consequence of a health-related employment disruption or a failed SAW/RTW process — because it often leads to permanent withdrawal from the workforce.  In fact it is the third worst outcome of a health condition, the other two being death and loss of limb or core functions like sight and hearing.

Yet we have not seen it that way.  Unlike death and serious injury, job loss is generally not noticed.  It’s actually a hidden outcome.  The frequency with which it occurs can only be estimated indirectly — because it is untracked and thus invisible.  When someone loses their job due to long-lasting illness or injury, they often end up leaving leave the workforce permanently, becoming dependent on public benefits programs like SSDI.

Some years ago, a senior Social Security Administration official commented to me that SSDI is the largest insurance fund IN THE WORLD and yet it has no risk management program, no loss prevention program.  Private sector insurance companies view these as core functions of their organizations.  They know they must identify and take steps to reduce risks and mitigate losses in order to meet their responsibilities and stay solvent.

In my view, government should be likewise obligated to take steps to protect SSDI (and the taxpayers who fund it) from the economic consequences of the dysfunctions, inadequacies and gaps in the upstream social structures and programs — because their failures end up on public benefit programs.

Government will make a major contribution to reducing demand on SSDI by:
(1) establishing policy that job loss/withdrawal from the workforce is a very unfortunate outcome of a health problem and should be avoided whenever possible,
(2) enabling all parties to see more clearly when it happens by requiring reporting of these events; and
(3) establishing consequences of some sort when involved organizations are non-responsive (negative incentives such as financial penalties, loss of privileges, or public exposure) or do take appropriate action (positive incentives such as credits, privileges, or favorable publicity).

This combination of outcomes visibility and accountability should then start to shift how parties in the private marketplace choose vendors and suppliers.

How will things look different when there IS real accountability for job loss?  

Implementing the broad range of actions recommended in the Establishing Accountability report will require a significant long-term effort because of their comprehensive, complex, and varied nature.  Taken as a whole, these actions have the potential to create truly transformational change.

Success will mean that more workers living with adult-onset chronic conditions and impairments (acquired disabilities) will be able to stay fully and productively engaged in their own personal, family, and community life; protect their household’s standard of living; remain economically self-sufficient contributors to their local area economy; and avoid dependency on government programs—which will in turn protect their future health and well-being and improve their children’s future prospects.  At the national level, success has the potential to stem the tide of declining labor force participation, lighten taxpayer burdens, and bolster the nation’s social fabric and the vitality of the economy.  All in all, the initiatives proposed make good use of limited government resources.

The ultimate success of the initiative will hinge on the ability of Federal policy leaders and supporters to create and sustain real multi-stakeholder buy-in and enthusiasm for achieving the future vision described in the paper.   A good next step is for the federal and state governments to decide whether and where to start.  It will take time and effort to achieve consensus among key stakeholders that this kind of initiative is necessary, timely, and deserves priority for person-power and funding.  Once that preliminary groundwork is laid, more detailed planning work can get underway.

Whoever you are, I hope you read the Establishing Accountability paper and agree that change and action is needed.  If my suggested recommendations spur you on to creative thinking, you do NOT need to wait for the government to act.  You can start factoring these issues into your decisions about who to collaborate with now.


May 11, 2016

Best & worst states for people with disabilities who want to work

Have you heard of RespectAbility?  When I went to their website, I found a COOL CHART showing some HOT NUMBERS:  the best and worst states for people with disabilities who want to work.

Before you look at the chart (I’ve pasted it below):
•    Guess which state has the highest employment rate for people with disabilities – 50.1%?   Do you think it’s a blue or a red state?
•    Guess which state has the lowest rate – 25.6%?   Is it blue or red?
•    Answer:  Almost all of the best AND the worst states for people with disabilities with regard to employment are in the red zone of the USA.

So, what else might be the reason for the differences between states?   Hmmmmmmmm. Is it the underlying health of the state’s economy?  I went to Mr. Google to find a ranked list of state economies.  This list on Business Insider was the first one I found.  Yay, here’s the answer, I thought (for a moment).   The WORST state for people with disabilities is the LAST state in the ranking – the state with the weakest economy over all (West Virginia).

BUT then I noticed that two other states among the bottom 10 of Business Insider’s list of state economies are in RespectAbility’s the TOP FIVE for employment of people with disabilities:  North Dakota and Wyoming.    And at the other end, of the 10 states that Business Insider ranked most economically healthy, only 1 was also in RespectAbility’s top group for people with disabilities (South Dakota).

I started to wonder whether Business Insider’s list was the “right” one, and found three other lists, here, here, and here — all of which purported to describe the health of state economies.  Each one has a VERY DIFFERENT RANKING of the states!!   The difference seems to be the method they used:   the underlying data sources and the formula used to calculate the results.

So I said uncle.  As an economic babe-in-the-woods who is unable to sort through this stuff, I have given up my extremely short amateur quest to understand WHY some states are better places to be if you have a disability and want to work!   For now, it is what it is, to use the jargon of today.

CLICK ON the table from RespectAbility pasted below and check out the numbers.  Then go to the full article on the RespectAbility website to read their analysis of why the numbers look the way they do – and what it all means.  And while you’re there, RespectAbility has also asked the current candidates for President of the USA to answer questions about their position on people with disabilities.  Their answers were NOT all the same!

Table-Best and worst states for disabled employment


March 7, 2016

Manifesto – Preventing Needless Work Disability (DRAFT)

I’ve tried to squeeze all the main ideas of the work disability prevention (WDP) model into one page (see below). The model has matured over the last several years as key dynamics have become more apparent.  I’m curious to hear your reaction to this new version.

After promoting the WDP model in the private sector for a long time, I started introducing it to the Federal / State disability sector in 2011.  Now seems like the right time to get a compelling and very succinct document circulating so it gets in front of many more eyes  – for example, lots of eyes on Capitol Hill and in regulation-creating / law-making (sausage making) circles.

The members of the Work Fitness & Disability Roundtable are also helping me craft a 3 or 4 bullet “sound bite.”  However, in my view it will take more than that to get influencers and decision-makers to decide to explore these issues further. They need a quick summary of WHAT the problem is, WHY things look the way they do, and WHAT might be possible instead — but just a bit.  Thus, this one-pager.

I’m not yet clear what to do with this draft – other than to post it here and solicit your comments.   Am also hoping to get your ideas for the best organization to issue and disseminate a manifesto like this — so it has the maximum impact.  What are the chances of it going viral?  Please leave a comment below or email me your ideas and suggested revisions.

Work Disability Prevention Manifesto (DRAFT)

  • Preserving people’s ability to function and participate fully in everyday human affairs, including work, is a valuable health care outcome, second only to avoiding loss of life, limb, and essential bodily functions.
  • Loss of livelihood due to medical problems is a poor health outcome because worklessness is harmful to people’s health as well as their personal, family, social, and economic well-being.
  • A new medical problem that threatens the ability to continue earning a living is a big challenge – a life crisis that must be addressed. Most people are unprepared, never having faced this double-headed predicament before. It can overwhelm their coping abilities.
  • When medical conditions occur or worsen, especially common health problems, most people are able to stay at or return to work without difficulty because the right things tend to happen during the first few days or weeks.
  • However, many of the prolonged work disability cases in both private and public sector sickness programs, disability benefits, and workers’ compensation programs began as very common health problems (for example musculo-skeletal pain, depression, and anxiety) but had unusually poor outcomes.
  • Unusually poor outcomes are frequently due to the interplay of sub-optimal health care and non-medical factors. Without a team focused on helping them get their lives back on track, people can get lost in the healthcare and benefits systems. Remediable issues in the situation are overlooked and not addressed. Incentive alignment among the involved parties is poor.
  • Medical conditions by themselves rarely require prolonged work absence, but it can look that way. And with every passing day away from work, the odds are worsening that people will ever return to work. After a while, they start to see themselves as too disabled to work.
  • Unlucky people lose their job and do not find a new one. They leave the workforce and eke by on disability benefits, in poverty, and vulnerable to its detrimental effects.
  • Today, most professionals typically involved in these situations (healthcare professionals, employers, and benefits handlers) do not feel responsible for avoiding job loss.
  • Good scientific evidence exists about how unusually poor outcomes are created, how to avoid them, and the health care and other services that can optimize function and protect jobs.
  • When work disruption begins, it is both effective and cost-beneficial to have a coordinator assist the individual, their treating physician, and their employer with communications, as well as focus everyone’s attention on restoring function, accommodating irrevocable losses, and making plans for how to keep working, return to work, or quickly find a more appropriate job.
  • Urgent priority should be given to establishing accountability for work disability and job loss as well as building nationwide capacity to consistently deliver services that help people stay at work or return to work – just in time, when needed.
  • Helping more people with medical problems to keep their jobs or find new ones in a timely manner will benefit them and their families, and will benefit our society as a whole.

March 7, 2016


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.


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