Preventing Needless Work Disability by Helping People Stay Employed

Introduction/Background Each year, millions of American workers develop health problems that may temporarily or permanently prevent them from reentering the workforce. In most cases, employees are able to stay at work or return to work after a brief recovery period. However, approximately 10% of these workers incur significant work absences and/or life disruptions that can lead to prolonged or permanent withdrawal from the workforce. During this nonworking period, these individuals are described as “disabled,” and many become involved in one or more of the existing disability benefit systems and laws, eg, sick leave, workers’ compensation, short-term disability, long-term disability, Social Security Disability Insurance, the Family Medical Leave Act, or the Americans with Disabilities Act (ADA). The estimated total annual cost of disability benefits paid under all these systems exceeds $100 billion. This report focuses on the large number of people who, due to a medical condition that should normally result in only a few days of work absence, end up withdrawing from work either permanently or for prolonged periods. For many of these workers, their conditions began as a common problem (eg, a sprain, strain, depression, or anxiety) but escalated, resulting in short-term, long-term, or permanent disability. This potentially preventable disability absence has unfortunate consequences for both the employer and the employee. The fundamental reason for most medically-related lost workdays and lost jobs is not medical necessity, but the nonmedical decision making involved in and the poor functioning of a little known but fundamental practice used by U.S. and Canadian disability benefits systems: the stay-at-work/return-to-work (SAW/RTW) process. This process determines whether a worker stays at work despite a medical condition or whether, when, and how a worker returns to work during or after recovery. The SAW/RTW process presently focuses on “managing” or “evaluating” a disability rather than preventing it. This report describes the SAW/RTW process, presents recommendations to improve the process, and provides information on current best practices and initiatives. What Is the Stay-at-Work/Return-to-Work Process? The usual steps included in the SAW/RTW process are as follows: The SAW/RTW process is triggered when a medical conditionD or another precipitating event occurs—in this example, a worker with a badly infected cut on his or her foot—raising the question whether the worker can or should do his or her usual job today. The worker’s current ability to work is assessed on three important dimensions: Functional capacity—what can he or she do today? Has the infection made him or her so sick he or she simply cannot function at all? If not, what can he or she do in his or her current condition? Functional impairments or limitations—what can the worker not do now that he or she normally could? The acute pain makes it uncomfortable to wear regular shoes and conduct activities that require being on one’s feet. Medically based restrictions—what he or she should not do lest specific medical harm occur? Would walking, standing, and being on his or her feet all day actually worsen the infection or delay healing? Next, the demands of the usual job and/or available temporary alternative tasks are compared with the worker’s current functional capacity, limitations, and medical restrictions. To make this comparison, the functional demands of the tasks or job must be known, including what knowledge, skills, and abilities—physical, cognitive, and social—are required. Specific medical qualification standards (such as those for airline pilots), legal requirements (such as those for truck drivers and crane operators), company policies, or concerns about the safety of coworkers, the public, or the business may also apply. Finally, the actions necessary to resolve the situation and return the worker to work are identified. If the worker can be safe and comfortable doing his or her usual job or can independently make any necessary modifications, he or she should be able to return to work. If the worker is only able to do temporary alternative work that requires the cooperation of others, or if permanent modifications to the job must be made, the employer must make arrangements and implement them. If that happens, the worker can go to work. If not, the worker remains out of work until either the medical condition resolves or the situation changes. If the job does not demand too much use of the impaired body part or function, the medical condition is minor, and the worker wants to go to work, the preceding steps are accomplished rapidly. However, some situations do not resolve as quickly and require additional steps. At this stage, the SAW/RTW process evolves into a negotiation between the employee (and his or her advisors) and the employer (and its advisors) regarding whether the employee can return to work. Therefore, steps 2 through 4 may need to be repeated at each level. During each repetition, more participants tend to become involved and the situation can escalate with progressively more opinions, data, resources, and time being required to decide when and if the employee can return to work. For example, in more difficult situations, successive passes require additional assistance from more specialists such as a nurse case manager, physical therapist, an occupational medicine physician, an independent medical examiner, a lawyer, and/or other experts. Functional capacity evaluations may be required to document work capacity. Job analyses may need to be done to document the job demands. The additional effort and resources often produce a paradoxic effect of clouding the situation rather than it by and the of the SAW/RTW process from to most The process when a is worker or not return to work. 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