Months 1 to 3 Post Injury
In the following document many of the challenges an
injured worker faces in the first four months after injury are outlined. Suggestions are made of strategies the
injured worker / your patient / client may be able to try to help to facilitate
progress. This information is also
provided to employers - see “employer
information files”, of strategies they can adopt to support their injured worker return to work.
The issues workers and employers face are often
the same or similar to those of their treatment providers and doctor. The obstacles outlined and strategies
suggested may help you better understand what may be happening to stakeholders
in the workers compensation system at a given point in time. Ideas are offered
for supporting the various stakeholders assisting injured workers recover and
get back to work.
What is
happening / should be happening?
It
is a month after injury and many things should have happened and be
happening to assist your patient recover from their workplace injury or illness. About
85% of injuries being relatively minor and uncomplicated should have resolved
and they will be either, fully recovered or nearly recovered. Those workers back at work on full or selected
duties should have had their wage entitlements paid, (see tables for
entitlements at various stages under the new and previous Workers Compensations
Legislations), money owing for medications and travel to medical appointments
should now be claimed, and should soon be reimbursed. All going well the employer and agent will have a copy of the latest Workcover Medical Certificate
and the injured worker should now be certified as fully fit or partially fit for your pre-injury
work.
The other 15% - There are many
reasons why the remaining 15 or so percent
of injured workers may be still off work and some of these reason are outlined below.
The injury itself
-
- The injury may be more serious or complex. For
example a construction worker for a small company may have had a fall and
broken a leg, arm and sustained fractured ribs. Surgery may have been required
and more surgery is pending in coming weeks.
With smaller employers no suitable duties such as clerical or
administration work is available, even if the nominated treating doctor (NTD)
certified the worker as fit for “Selected duties - administrative work”
- There may be uncertainty about what is actually wrong - Despite time having
passed and no “red flags" being initially
assessed, the injury is not improving as expected despite rest and conservative treatment. The injured worker may be complaining of
severe pain and restrictions, yet there is no obvious organic basis for the
symptoms identified at this stage. The
investigative procedures at this stage are likely to have been basic and
relatively low cost ” – i.e. x rays, blood tests - More comprehensive and
expensive tests such as MRI’s, bone scans, and nerve conduction tests may not have not been considered or approved.
- Physical and Psychological Injury Occurring simultaneously.
There are some situations where an accident or incident occurs at work
where both physical and psychological injuries may result. These occur typically where there is
significant traumatic event. Some of
these include a significant injury such as a loss of limb or major fracture in
an industrial accident, an armed hold up and assault, a significant motor vehicle
accident - whilst travelling from one
job site to another. With these types of
incidents the consequences in terms of injury, particularly psychological
injury, may not be experienced immediately, or are overshadowed by the need for
urgent treatment to stabilise a physical injury. For example in major industrial accident,
where several workers may have been injured significantly, the focus initially
will be on managing a life threatening physical trauma. It is only at a later stage, days, weeks or
months later that it becomes apparent that significant trauma has occurred and
this has a become a barrier for returning to the same workplace setting.
Problems with
Employer
Occasionally industrial and workplace issues may prove to be
a major barrier to an injured worker returning to full or near full capacity in
his or her preinjury job. Some of the specific
issues that can occur include:
- An employer being reluctant to accept an injury is
work related (despite liability being partially or fully accepted by the insurer)
and is therefore also reluctant to support the restrictions made on the medical
certificate
- An employer not being aware or being unwilling
to accept their obligations to provide suitable duties for an injured worker
- An employer agreeing to provide but then not
accommodating the restrictions or hours of a medical certificate
- Lack of management and co-worker support - an
attitude that the injured worker is a malingerer, weak or not pulling their weight
and “dragging the chain”
- Subsequent problems with the injured worker
being fearful of returning to work
Problems with Diagnosis of Injury/injuries
Unless an injury is relatively minor and it heals completely
with little or no treatment input, a holistic and
comprehensive assessment of the injured worker is essential. The model that is supposed to be used and
accepted in general health, medicine, and rehabilitation is the bio-psychosocial
model. What this means is that it is not only the physical aspects of person’s
health that needs to be assessed and planned for in treatment. The person’s psychological, and social
situation also needs to be considered.
For example, psychological responses to injury are inevitable if the
injury is significant (or trauma is involved).
When injury doesn’t resolve or considerable discomfort occurs which may
affect sleeping, energy levels and ability to carry out activities at home at
work. Financial difficulties also result when income is affected by the injury
and there is an incapacity to meet commitments. All of these changes and
potential challenges are likely to result in increased stress for the injured worker,
and have the potential to become associated with clinical anxiety and
depression if the underlying issues aren’t addressed. The environment the injured
worker lives and is exposed to at work also affects stress levels. An unsupportive employer or limited support networks
at home can and usually do compound coping difficulties and treatment
responsiveness.
The NTD is supposed to have the skills and experiences to
assess and identify possible problem areas.
Unless the NTD is able to identify barriers and is proficient in making
relevant referrals, treatment access is likely to be delayed and treatment responsiveness reduced.
Problems with Treatment
There are a number of potential issues concerning treatment
and responsiveness. These include:
- The treatment being inappropriate for the injury
- the correct diagnosis may not have been made or more information needs to
available before the most appropriate interventions applied. This may involve referral for a more sophisticated
test, such as a MRI, because rest and interventions such as physiotherapy are exacerbating symptoms or
having no positive results.
- Treatment inappropriate at this stage - There are
situations where a treatment, although appropriate in the medium to long term
may be inappropriate if used to early.
For example an exercise and strengthening program being ordered in the first
2 months after injury may be premature if uncertainty remains about diagnosis
and a range of red or yellow flags are present.
- Quality of treatment - The skill levels and
expertise of treating practitioners and doctors vary. Some are better than others, some have better
“bedside manner” and can engage and motivate their patients. These factors influence treatment responsiveness
and outcomes.
- Treatment access issues - The ability to access treatment
is a factor that has a huge impact on than injured workers recovery, ability to
return to work and the overall cost of a claim.
Typical problems experienced by injured workers include:
- Treatment access declined by insurer (deemed
as unreasonable and unnecessary)
- Extended delays in treatment being approve
- Conflicting opinions between the workers
team and NTD and the insurer about ways to treat and manage an injury
- Extensive delays in getting appointments to
see specialist
- Long times between appointment to see
specialists or treatment providers due to supply and demand issues
Insurer/ Agent
Issues
The insurers / agents are the managers, gate keepers and bean
counters of the NSW Workers Compensation system. Since the 2012 legislation was passed they
have been give increased powers and responsibility for managing the claims and
in ensuring costs are controlled, particularly in ways that may have adverse consequences
for employers and their profitability.
For injured workers, nominated treating doctors, treatment
providers and rehabilitation providers the relationship they have with the
claims officer managing a particular injured workers claim can and does make an
enormous difference to how quickly decisions are made, referrals and treatments
approved and payments made. Although
there is legislation in place and guidelines set by Workcover about what can
and cannot be done and when, the level of efficiency, attitude and
professionalism of agency staff varies greatly.
The majority of complaints made to Workcover by injured
workers and treatment provider relates to agent related problems. Some of these are appropriate and relevant to
Work cover, some are related to legal issues that need to address through legal
representation by a lawyer. As result of
the changes to the Workers Compensation Act in 2012 there are some decisions
that can no longer be appealed by an injured worker. i.e. aspects of work capacity decisions (see
changes to the act), and there are some areas where funding is no longer
available for legal representation.
At the one to 3 month stage of a claim the most typical
challenges from agents are in the following areas
- Liability – As mentioned previously the 4 potential
claims status are:
- Full liability
- Provisional liability
- Reasonable excuse
- Declined claim
Potential problems with the status are overviewed below.
Full liability -
With full accepted liability a claim is accepted in full within the guidelines
of legislation - wages should be payed, travel and medically related expenses
refunded and “reasonable and necessary” treatments provided. Problems most frequently reported by injured
workers relate to delays or denial of treatmen s or specialist referrals and
late or non-payment of wages and expenses. Calls to The agent and then Workcover is the
best way for injured workers to address these issues
Provisional Liability
-The rights and obligations of workers with a provisional liability claim
are the same as those with a full claim, however their claim is usually under investigation
as to whether the injury - physical or psychological is work related. The investigation is organised by the agent
who recruits medical or Para medical specialist called “independent specialists”
and other agencies who are contracted to perform a specific role - i.e. private
investigators or factual investigators. Occasionally an agent may request a
report from a NTD, treatment provider or specialist the worker has been
referred to by their NTD; however the agent is not obliged to do so.
If the agent makes a decision that the claim is not work
related they must provide a reason consistent with the act that supports their decision. At this point a worker may need to consult a lawyer
whether and how to appeal the decision.
Reasonable Excuse - An
agent may make a decision after a claim is lodged that they will not pay any benefits
or treatment expenses until after the claim has been investigated and the
workers reported injury has been assessed.
This usually occurs when the there is evidence reported that the claim is
not work related - i.e. the injury or illness was pre-existing or did not
happen at work, or that the reported injury (particularly stress injuries)
occurred as result of reasonable action by the employer – i.e. the worker was reprimanded
for constantly being late, underperforming or stealing.
The Agent will apply the same procedures and be under the
same time frames for a decision to be reached as with provisional
liability. This may mean that the
injured worker receives no entitlements or treatments expenses for a period of
3 months. If liability is accepted they
will be back paid. Workers can apply
for Cenrtrelink benefits in the meantime, but these will have to be back paid
if the claim is accepted. Injured
Workers are advised to contact a lawyer at this stage for advice; however no
action can be taken in terms of an appeal until a decision has been reached. If
the agent takes longer than those of the guidelines- a call to Workcover may
help in decision being made with the time frame guidelines.
Declined Claim- A decision is made in writing with reasons according the
Workers Compensation Act outlining why the claim is declined. A worker may need to consult a lawyer whether
and how to appeal the decision.
Problems
with Treatment and Specialist Access
Agents are supposed to support payment for referrals to
specialists, for investigations and for reasonably necessary treatments. Problems for injured workers and treatment
providers occur when:
There is a delay in approval, particularly when responses
are not made within the WorkCover time lines.
For initial psychological, physiotherapy, and chiropractic interventions,
treatment can be commenced even without written approval for a specified number
of sessions - different for each discipline - providing there is a valid claim. This aspect of treatment has NOT changed in
the 2012 legislation. Further treatments may be delayed however if the agent
does not consider treatment reasonable and necessary. A call to Workcover may
help in decision being made with the time frame guidelines.
Problems occur one month to three months after injury more
commonly with referrals:
- For investigations such as MRI’s or
other relatively expensive procedures
- To specialists, particularly if the
agent believes that the injury is relatively minor
- For specialised programs such as
Pilates, pain management
- For rehabilitation initiatives such an
Activities of Daily Assessment or a driving assessment particularly if assessment
finding could mean more money has to spent on the claim
- To a rehabilitation provider of the
workers choice particularly, if it is perceived by the Agent that the non-preferred
provider will cost more than the one they chose.
Nominated Treating
Doctor (NTD) issues
It was mentioned in the preceding document concerning
injuries from day 1 to the end of the first month that the role of the
Nominated Treating Doctor (NTD) in the workers compensation system is a critical
one. The medical certificates they give
regarding work status have binding practical and legal implication s for the
injured worker, treatment providers and agent.
Most specialist referrals can only be made through the NTD.
The skills, knowledge and experience a NTD has in managing a
particular injury and in negotiating the system has major implications for all stakeholders. Some of the problems injured workers, treatment
providers and employers report include:
- Inadequate initial and follow up assessment
- It is the NTD’s job to assess properly and diagnose accurately. The NTD
should identify red flags immediately - potential serious or life threatening
symptoms, but at the same time not over pathologise a relatively minor
injury. An experienced NTD will usually
get this right!
After a month or so most injuries
should be resolving - if they are not resolving the NTD should be finding out why. To do this they need the knowledge and skills
to be able to identify the factors that may be barriers to progress and treatment. This means that the NTD should also be aware
of “yellow flags - social and psychological barriers - things such as an
unsupportive workplace, or extreme fear of re-injury. This will help to ensure that the fears are addressed and approporiate interventions made.
After one month it is also
possible that there is organic pathology that has not been identified and referral
for appropriate investigation and specialists needs to be made. Return to work outcomes are affected when the
barriers are not identified and / or appropriate actions to address them have
not been initiated.
- Poor Communication to Worker - Feedback
to the injured worker is important in alleviating anxiety about symptoms and in
reinforcing their commitment to the strategies being initiated to help them get
better and return to work - A doctor who listens to patients concerns and
clarifies issues can be helpful in alleviating concerns. Doctors who do not communicate effectively
with their patient may promote fear of reinjury and a sense that the injury is more
serious than it is. This will perpetuate their fears further and lead to the worker trying to avoid upgrading hours
or duties.
Likewise a doctor who does not
identify and address risky behaviours - i.e. excessive medication and drug use
to manage pain and symptoms beyond their real injury tolerances, is likely to
end up with a patient who has a
significant symptom relapse, injury and health complications. This will mean a far poorer return to work outcome.
- Poor Communication to Stakeholders
If information is not provided to agents,
employers and treatment providers who are trying to support a worker to get better
or return to work, inappropriate strategies and counterproductive attitudes in communication
may result. Employers who are not given
clear guidelines on what duties should or shouldn’t be undertaken may provide
work that is beyond the injured workers capacity that results in re-injury, or
at least tension and friction if the worker then refuses to do the task. Agents
may take the stance that the injured worker is malingering and that the doctor
is “reinforcing illness behaviour”.
Worker Issues
Return to work out comes are affected by the nature and type
injury, the proficiency of the doctor and treatment provider in getting the
injured worker better and the support the employer and agent provides. Of at least equal if not greater significant
however are factors related to the
injured worker themselves. Some of
these factors include:
- Fundamental drive and need to get back to work
- Work means different thing to different people.
Some people are compelled to work and feel useless or frustrated if they are
not at work
- Financial motivators play a role as does
- Job satisfaction particularly with the workers
pre-injury work role
- The need for support and enjoyment of working
with the team vs. lack of support when that worker needs it also influences
motivation
- The feedback and support by family member also effects
motivation levels, psychological outlook and treatment responsiveness
- A worker’s motivations and resilience
- Stress levels and mental health having had a
work place injury and being integrated into the worker compensation systems.
Assuming all has gone
well and none of the barriers outlined are present the internal drivers that
will influence a successful return to work outcome include:
- General health and fitness prior to injury
- Previous injuries or illness
- The personality of the worker
- Internal resilience
- What the job meant for the worker before injury
and their general job satisfaction levels
- Adaptability
- to making changes in life style and attitude to accommodate their injury
In the current NSW Workers system even the most resilient, motivated worker is likely to find the situation
stressfull, particularly if their injury has not recovered or nearly recovered
after a month. The potential obstacles
cited above can lead to:
- Financial difficulties
- Treatment delays
- Conflicts between stakeholders
- Bullying by stakeholders
- Communication breakdown
- Stress on the injured worker and other
stakeholders
- Secondary depression
- Changes and reduction in motivation
Secondary physical and mental health problems can result. The consequences of depression, anxiety and poor injury management coping skills can result in reduced physical activity levels, associated health issues, weight changes, poor diet, social avoidance and relationship strain.
