Workplace Disability Management (WPDM) Programs – their evaluation, configurative nature and

outcomes

Ulrik Gensby, PhD, Postdoctoral researcher National Centre for Occupational Rehabilitation (AiR), Norway E-mail: [email protected]

Is meaningfull work the succesfull outcome of occupational rehabilitation? If yes…. Is workplace integration then part of occupational rehabilitation? If yes… Then workplaces matters!

The question is how do we guide sustainable workplace integration in occupational rehabilitation?

Return to work form a workplace perspective  Evidence suggests a closer linkage between RTW interventions and the workplace (Franche et al. 2005)  Evidence underline how RTW is highly influenced by organizational dynamics at work (MacEachen et al. 2006)  As employees move beyond the acute stage of injury and illness, the workplace is now considered a potential “therapeutic environment” (Shrey & Mital 1994; Durand & Loisel 2001)  However, the therapeutic potentials rely on the outcomes of several managerial “clashes” in RTW processes:     

absence vs. presence disability vs. functioning well “fix the person” vs. “fix the environment” the re-entering employee vs. the work group individual resources vs. workplace infrastructures

Occupational rehabilitation as a socio-political challenge

Gensby 2014

Why work disability management in organizations?  Companies may establish formal work disability management structures to guide the sensitive issue of RTW (Amick et al. 2000)  A way to balance the human side and the business side of RTW engagement  A way to foster a managerial culture that take into account both individual and collective needs  A way to coordinate internal and external information and knowledge sharing in ongoing RTW processes

 .....Knowledge gap on the nature and effects of employer provided work disability management to inform policy and practice (Williams & Westmorland 2002; Krause & Lund 2004)

The concept of workplace disability management (WPDM)  Workplace disability management (WPDM) is an employer based strategy to RTW (Shrey & Lacerte 1995)  An umbrella term covering:  Theoretical concept (Habeck et al. 1991; Akabas et al. 2002)  Planned intervention (Franche et al. 2005)  Counseling practice (Habeck et al. 1994)

 A WPDM program offers a systematic employerbased intervention approach provided by a company wide departement in close collaboration with key parties at the workplace (Gensby et al. 2012)

Relevance of workplace disability management in a Nordic context?  Little attention to WPDM policy and practice in Nordic work disability systems:  RTW typically part of active labor market policies (Jacobi 2013)  Largely organized away from the workplace setting:  Community based vocational rehabilitation programs

(Aust et al.

2012; Høgelund 2003)

 Clinical based occupational rehabilitation programs

(Eftedahl et al.

2013)

 ...with limited employer co-responsibility (Høgelund 2002), and follow up guidance and action (Tjulin et al. 2010)  Link between employer and injured/ill employee appear vulnarable!  RTW follow-up is to important to rely on company motivation alone  Bring back in the workplace as arena for work disability management and assess research to support employers …..Suggest that there is a scope to intervene at the company-level!

Synthesis research  A family of research methods to summarize Qual and Quan research studies (Hannes & Lockwood 2012)  Evidence based management (Transfield et al. 2003; Gulik & Weller 2012)  Donald Campbell’s vision of the experimenting society (Campbell 1971)

 Cross cultural learning as an ”experimental laboratory”

• The Campbell Collaboration

(http://www.campbellcollaboration.org/)

 Systematic reviews on social-organizational interventions  Knowledge on what works, but also ambition to include context  Synthesize research results in a meaningful manner to inform research, policy-makers, and practice

A Campbell systematic review of WPDM programs promoting RTW  Primary objective:  To enlarge the existing knowledge base on workplace disability management and inform workplace stakeholders and researchers to take action  Secondary objective:  To synthesize existing evidence on the nature and effectiveness of WPDM programs promoting RTW, as implemented and practiced by employers, and if possible, to examine program components more highly related to positive outcomes

Synthesis methodology  Inter-disciplinary research team • Sociologist, epidemiologist, economist, ergonomist • Content, statistical, and methodological experts

• Campbell review methodology (Shadish & Myers 2004)  Guiding review protocol (Gensby et al. 2010)  Broad inclusion criteria of study design – Data triangulation – Understand the research area and its potentials

• Meta-analysis • Avoid narrow technical report

• Narrative assessment with content analysis

The Campbell method  At protocol stage the PICO framework was used to specify and guide study inclusion criteria (Gensby et al. 2010):  (P)articipants, (I)ntervention, (C)omparison and (O)utcomes

 Twelve databases were searched between 1948 to july 2010 for peer-reviewed studies of WPDM programs provided by employers to re-entering workers with occupational or nonoccupational illnesses or injuries  Screening of identified articles, risk of bias (RofB) assessment and data extraction were conducted in pairs of reviewers  Included studies were clustered around various dimensions of the design and context of programs

WPDM program inclusion

Type of intervention

Setting

The presence of a WPDM program refers to: • An in-house program managed and implemented at the workplace Q1?

DM or RTW program

Outsourced Community based

Hybrid Workplace directed

In-house Workplace integrated

Single component

v

Intervention features

• Provided by the employer or Q2? initiated through a company wide department Q3? •

Multi-component

Surrogate outcome(e.g. workers’ comp.) RTWOutcome Direct outcome (e.g. lost days from work)

Q4?

Describing a clear linkage between a planned research intervention and a program provided

• …..and addressing the duration and/or extent of an inability to work due to physical injury, mental health problems (Gensby et al. 2012)

Data collection  16932 hits were identified by the initial search strategy  136 studies were found through a ‘snowball’ approach (ref lists)

 Searches in ‘grey literature’ did not yield additional studies  28 studies were found through hand search in scientific journals  An inter-disciplinary panel of 20 international researchers helped identify 19 potential studies, which yielded one included study  599 potential papers were assessed for relevance (based on 1 level screening)

Editorial flowchart

The Campbell systematic review process

Title approval June 2009

Protocol approval Dec. 2010

Review approval Sept. 2012

Narrative assessment  Two NRS  Eleven B&A  Lack of attention to guiding conceptual framework and program evaluation theory  Risk of bias was reported for the included NRSs according to the Cochrane guidelines 

The two NRSs are both assigned a high risk of bias in the dimension of selection/sample bias

 Insufficient reporting on sample characteristic, and statistic data to perform a meta-analysis  Rich descriptions of program characteristics, components and human resources involved

Narrative synthesis - I  WPDM program institutional context  Northern American work disability systems (US, CA)

 WPDM program setting and setup  Large companies within industry and health care sector  Initialized through the labor management commitee  Administred in human resource management or health and safety departments

 Human resources and competences:       

Senior management The joint labor-management committee Human resource manager Supervisor Union representative (in some cases safety rep.) Internal case-manager / RTW-coordinator Onsite physiotherapists / ergonomists

Narrative synthesis - II  WPDM program scope and outcomes  Primarily focused on the off-work and pre-return phase of the RTW process  Examined outcome related to  costs savings  time lost from work  duration until RTW

 WPDM program targeted health conditions  Mainly tailored to MSK conditions  Only one program tailored to common mental health conditions

WPDM programs are multi-component • Most often used program components: • • • •

• • • • •

Joint labour-management commitment Organisational RTW-policy Early contact and intervention Case monitoring and work disability information system Corporate located RTW-coordinators or casemanager Workplace assessment with job-analysis Offer of suitable work accommodation Multidisciplinary onsite physical therapy Tailored modifications in work tasks/hours

Occupational Management Program

Primary prevention, off work and pre-return

Corporate Physical Therapist and Supervisors

International MSI Disability Management Program

DisAbility Management Program

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Musculoskeletal back, hand, shoulder and wrist Off work and pre-return injuries

Corporate Medical Service Department, Onsite Physicians and Physical Therapist

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Non occupational illness or injury such as uncontrolled diabetes, Off work and pre-return hypertension, pregnancy, low back conditions and chronic depression

Corporate Health Services, and Human Resources, Benefit and Legal Department, Onsite Certified CaseManagers, Departmental Corporate Physicians, Local Occupational Nurses, and Supervisors

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Pre-return and post return

A registered Occupational Therapist, Treating Staff Physician, and Supervisors

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Disability management and Rehabilitation Program

Non-specific injury or illness

Off work and pre-return

Onsite disability management coordinator, labormanagement representatives, supervisor

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The program did not target any specific occupational group, body part, or mechanism of MSI

Primary prevention, off work, pre-return and post return

A interdisciplinary team comprised of a program leader, a full time occupational therapist, a full time physical therapist, a part time physician and a part time program administrator/data clerk

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Primary prevention, off work, pre return and post return

A multidisciplinary team consisting primarily of a nurse coordinator, physiotherapist and occupational therapist/ergonomist working under the direction of a rehabilitation physician.

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Off work and pre-return and post return

Corporate Joint Committee on Health, Safety and Environment and Health, Safety, and Environment Department. Internal Occupational Health Nurse, Occupational Physician, Nurse Case-Manager, Environmental Health Officer (Safety Representative), Industrial Hygienist and Supervisors

Prevention and Early Active Return-to-Work Safely Program (PEARS) Prevention and Early Active Return-to-Work Safely Program (PEARS),

Early Return-toWork Program

Musculoskeletal soft tissue back injuries

Work-related injuries and illnesses

* PEARS program components only counts once. (same program components in the Yassi et al. (1995) study, and the two reproduction studies by Davies et al. (2004) and Badii et al. (2006)).

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RTW policies

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Workplace accommodation

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Physical rehabilitation services

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Workplace assessment

Joint labormanagement commitment

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Return-to-Work Musculoskeletal back Therapy and Light and knee injuries Duty Program

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Pre-return and post return Onsite Physical Therapist and Supervisors

Modified/tailored work

Corporate Joint Labor-Management Committee. Onsite rehabilitation team including the Occupational Physician, Occupational Therapist, Supervisors, and various LaborManagement Representatives

RTW coordinator or case management

Pre-return and post return

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Disability case information and monitoring system

Transitional Work Work-related injuries Return Program and illnesses

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Early contact & intervention

Primary prevention and off Management and supervisors work

Musculoskeletal Workplace Returnstrained spine or to-Work Program shoulder

Active employee participation

The Onsite Medical Disability Coordinator, Occupational Health Nurse, Line Supervisors

Personnel ReturnLow back injuries to-Work Program

Musculoskeletal low back and upper extremity disorders

Transitional work opportunities

Depression and hypertension, and other Off work and pre-return illnesses such as diabetes, mellitus, asthma and ulcer

Human resources

Education of workplace staff or case managers

Short-Term Disability Management Program

Scope

Access to alternative placements

Tailored condition

Preventative strategies to avoid disability occurrence

Program

Revision of workplace roles

WPDM Program features and constituent components

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8

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9

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6

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A classification of work disability management policy and practice A WPDM can potentialy score 0 and 9

Modified from Gensby et al. 2014

Progression in RTW

Results  Consistent knowledge base (Akabas et al. 1992; Shrey & Lacerte 1995; Williams & Westmorland 2002; Hunt 2009)

 The benefits of programs and their conceptualization  Design and components that employers may consider

 Few robust WPDM outcome evaluations in the international peerreview literature (no Nordic examples identified)  Based on the Campbell systematic review approach adopted, it was not possible to determine if specific programs or some set of components are more related to positive outcome  Primarily large company program evaluations  Primarily targeting MSK conditions  Limited attention to long term program effects (at work)

 So in general do WPDM programs promote RTW? - Evidence currently is small but the field is research active…..  Choice of guiding evaluative framework a consideration  It seems that research has not kept pace with practical needs

Conclusions  No unambiguous conclusions on the effect of WPDM programs promoting RTW could be reached, with few program evaluations conducted  Identified continuous weakness in RTW policy and practice, focusing on initial RTW, with limited attention to the period when back at work  Propose a taxonomy for WPDM program evaluation and RTW system analysis 

Efforts are still needed to conduct company intervention studies to inform collaborative action !

Implications for research  Knowledge on mechanisms that determines sustainable maintenence at work, beyond initial return-to-work  Mixed method approaches would increase our understanding of underlying mechanisms driving WPDM program outcomes  A potential for designing and testing WPDM programs in Nordic contexts

Implications for practice  Initializing WPDM programs in organizational contexts  How to balance productivity loss and costs, while ensuring sustainable practice in the long run  Interplay between primary and secondary preventive initiatives  Those smaller companies with little knowledge and resources to set up a full WPDM program to guide return-to-work policy and practice?

Translating WPDM to a Nordic occupational rehabilitation context  Balance betweem job security vs. employment security (i.e. Flexicurity)

 Could enlarge the role of employers and tie in occupational rehabilitation activities to workplace contexts  Represents a supportive framework to inform company resources and timing of RTW activities  Fits well with existing partnership models between unions and employer associations in RTW (i.e. the Norwegian IA-avtale)  May enlarge RTW counseling practices provided by occupational rehabilitation services (i.e. primary and secondary prevention in SMVs)

 Potential synergy with OHS audits and work environment inspection at the workplace (i.e Arbejdstilsyn)

WPDM support model for occupational rehabilitation: A Nordic perspective Maintenance at work

Off work phase Health and safety organization

Specialist Social insurance (NAV)

Physician Rehab clinic DM

Labor management commitee

HRM department

Employer WPDM

RTW coordinator placement and responsibility?

Social insurance (NAV)

Pre return phase Occupational health service

Systematic, participatory and coordinated action

Local collective agreement

Unions and employer associations

Post return phase Working environment authority

Thanks for your attention!  Sources of support:  The National Centre for Social Research, SFI Campbell (DK)  Department of Environmental, Social and Spatial Change, Roskilde University (DK)  Institute for Work and Health, Toronto (CA)  References: Gensby U, Lund T, Kowalski K, Saidj M, Jørgensen AMK, Filges T, Amick BC III, Labriola M. (2010). Workplace Disability Management Programs promoting return-to-work: A protocol. Campbell Systematic Reviews Gensby U, Lund T, Kowalski K, Saidj M, Jørgensen AMK, Filges T, Irvin E, Amick BC III, Labriola M. (2012). Workplace Disability Management Programs promoting return-to-work: A systematic review. Campbell Systematic Reviews

Gensby U, Labriola M, Irvin E, Amick BC III, Lund T. (2014). A classification of components of workplace disability management programs: Results from a systematic review. Journal of Occupational Rehabilitation 24 (2) 220-241