Early Intervention in high risk individuals

injured at work

Concord Repatriation General HospitalSydney

2,500 FTE employees (now has 4,500 FTE)Part of Sydney South West Area Health Service which has 17,500 FTE employees

Concord Repatriation General Hospital

We are not a consultant firm. We are not academics or professional researchers I am a F/T medical staff specialist. Andrew McGarity is a F/T Rehabilitation Coordinator

Who are we?

Staff Health• “One Stop Shop”• Workers Compensation• Occupational Health and Safety• Medical management of workers (GP’s 80%)• Compensation injuries• Vaccinations • Needle stick injuries and mucosal splashes• Health monitoring e.g. noise, cytotoxic agents,

etc• Pre-employment assessments

Soft tissue injuries to shoulder, upper limb, wrist and hand 36Soft tissue injuries to back, lower back, knee, foot and ankle 37Soft tissue neck injuries 2Hernias 2Fractures 2Head injuries

2Motor vehicle accidents 7Assaults 6Miscellaneous (bruising, needle stick) 6

Audit of 100 consecutive workers compensation patients through the unit showed the following case-mix:

NSW Health

• Self Insurer – Treasury Managed Fund• Sub-contract to an insurer (EML)

Necessity is often the mother of invention

• 2003-4 we had a huge number of open claims ~ 300• We felt we were failing our injured workers because we were not

meeting their needs despite good medical management and good case management. Something needed to change!

• Spate of very difficult cases who went on to have chronic pain syndromes

• There was no “road map” to tell us what to do!• The following is about 5 years to this presentation.

What we did first Change in Rehabilitation Policy to require worker to attend Staff

Health for initial assessment (unless medically contraindicated).

Database developed to track workers from notification to finalisation.

Development of suitable duties lists for a majority of depts.

Increased role of managers in the rehabilitation process.

Meetings with managers of major depts. with monthly meetings to review claims and provide comparative data.

Regular monthly meetings with the physiotherapists who regularly saw our patients.

Despite these changes our results did not improve significantly

Where to go from here?

• We decided that the first 4 weeks was the answer, – after that you start to lose control!

• We did not need to do anything that is not normally done, only we needed to do it earlier (mainly for the high risk individuals).

• We needed to find these high risk individuals in the first week.• We needed to see people face to face within 48 hours of the injury.• We needed expert help in the two areas that were most influential in a

person’s recovery – the psychological area and the medical area (to assist the GP).

• We needed to ensure that the GP was in control of the whole process through consultation and approval.

• We also did not have the power to do it!.

What else did we decide?• We decided to just use TOTAL COST OF THE CLAIM as the main indicator

of success or not (time lost, treatments by all health professions, legals etc)• We needed an evidence-based intervention.• We needed to spend a significant amount of money upfront.• We needed to consult and convince stakeholders. • We needed the process to be “portable” so it was not just something that

could only be done at Concord Hospital or by a particular medical specialty who had a particular expertise in MSK injuries

• GP’s remained the main doctor involved and the main NTD.

How to do it?

• Literature search – confirmed our understanding about psychosocial issues as the best predictor of a person’s outcome following a W/C injury

• OMPQ: 4 – 6 weeks NSW WorkCover• “Special sort of Psychologist”• Use the IMC Program that NSW WorkCover has in place.• Use WorkCover accredited rehab providers for all high risk

people

◦ Depression◦ Anxiety/ Fear avoidance behaviour◦ Stress◦ Poor pain coping strategies◦ Expectations of recovery◦ Perception of health change◦ Perceived psychological demands at work◦ Perceived confidence in management◦ Perceived high job demands

Yellow Flags

BUT before we could do the intervention we had

to: We needed to change the current OMPQ (Orebro)

26 questionnaire which as designed to be done at 4 – 6 weeks to one that was one page and could be done soon after an injury and in around 10 minutes.

We needed to trial the new form to see if it did what we wanted.

We needed to categorise people into low, medium and high risk according to the new modified questionnaire

We needed to involve and get agreement with all stakeholders.

Pilot: 30 consecutive injured workers – asked if they would fill out the modified questionnaire and followed them through until they returned to work with a final certificate. Reviewed the costs and categorised the groups into high, medium and low. Took a year and a half.

Control Group: We then followed a cohort of 80 injured workers where they received “usual care” (no special intervention). In our institution, they still got seen within 48 hours of notification of the injury, put in a injury notification, received physiotherapy within a few days of the injury and often that occurred before we received a medical workers compensation certificate.

Trial Group: We then followed a cohort of 80 consecutive injured workers with soft tissue injuries and instituted the intervention program.

Took three years to complete the main part of the study

Research

Örebro Musculoskeletal Pain Screening Questionnaire (Modified)(Linton & Hallden, 1998)

1. Please tick the box that reflects you current age2. How many days of work have you missed because of this injury? 3. How long have you had your current pain problem? 4. Is your work heavy or monotonous? 5. How would you rate the pain that you have had during the past week?6. How tense or anxious have you felt in the past week?7. How much have you been bothered by feeling depressed in the past week? 8. In your view, how large is the risk that your current pain may become

persistent? 9. Physical activity makes my pain worse.10.An increase in pain is an indication that I should stop what I’m doing until the

pain decreases.11. I should not do my normal work with my present pain.12.How long have you been employed at Concord Hospital13.In your estimation, what are the chances you will be working your normal

duties in 3 months

•

RISK GROUP NUMBER (%) ($) COST/CLIENT

LOW(<69)

36 (47%) $ 4,878

MEDIUM(70 – 84)

24(31%) $ 6,240

HIGH(> 85)

17(22%) $ 17,178

Results of the Control Group

High Risk (>85) Independent Rehabilitation Provider within 2 weeks Independent psychological assessment and treatment within 2 weeks

at Staff Health Independent Medical Consultation within 2 – 4 weeks Independent Physiotherapy Assessment after 6 weeks. File review by Medical Director if not returned to work within 4 weeks.Medium risk (70 – 84) Psychologist assessment and treatment within 2 weeks of injury plus

“usual care”. Independent Medical Consultation within 1 monthLow risk (<69)

“Usual care”

Intervention strategy

CONTROL GROUP

INTERVENTGROUP

CONTROL GROUP

INTERVENT GROUP

RISK CATEGORY

Number (%)

Number (%)

$ COST $ COST

LOW 36 (47%) 40 (51%) 4878 4898

MEDIUM 24 (31%) 23 (29%) 6240 6752

HIGH 17 (22%) 15 (19%) 17178

$617394

12847Difference $ 4331 or 25%

$531081

Results of the control and intervention arms

1. “Yellow flags” can predict the cost of a workers compensation claim within 48 hours and independently of what or where the injury is.

2. The provision of an early assessment and intervention process can reduce costs in high risk claims.

3. That there is a significant difference between the 20% in the “high risk” category and the other 80% who manage pretty well with “usual care”.

4. There is no further reason to separate low and medium risk patients.

Key Findings

But – what about the longer term – how much difference does it make?

TMF Workers Compensation Claim PerformanceDays Lost/employee at 30 June 2009

4.74

3.042.67

2.25

1.80

0.88

5.74

2.72

1.961.52

0.92

0.41

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

Da

ys

Lo

st/

em

plo

ye

e

SSWAHS

Concord Hospital

SSWAHS 4.74 3.04 2.67 2.25 1.80 0.88

Concord Hospital 5.74 2.72 1.96 1.52 0.92 0.41

2003/2004 2004/2005 2005/2006 2006/2007 2007/2008 2008/2009

Days lost per employee June 2009

SSWAHS Experience Premium Movement from 2007/08 to 2008/09

SSWAHS Experience Premium Movement from 2007/08 to 2008/09

Concord Hospital

Liverpool Hospital

Rozelle

Bankstown Hospital

SSWAHS Laboratory Services

SSWAHS Engineering Services

Community Nursing Service

Fairfield Hospital

Balmain

SSWAHS Supply Services

Population Health

Health Care Interpreters Service

Bowral Hospital

Central & South West Sydney Scarba

Tresillian

Karitane

Lucas St Childcare

Canterbury Hospital

Forensic Medicine

Sydney Dental Hospital

Braeside

SSWAHS Area Services

Queen Victoria

Royal Prince Alfred

Community Health

Camden Hospital

Campbelltown Hospital

Area Mental Health

-$1,500,000.00 -$1,000,000.00 -$500,000.00 $0.00 $500,000.00 $1,000,000.00 $1,500,000.00 $2,000,000.00

Number of claims in fund year

No claims in fund year

0

20

40

60

80

100

120

TOTAL

Cost/employee 2006/2007

TMF Workers Compensation Claim Performance 2006/2007Cost/employee at 31 December 2008

659

774

496

0 100 200 300 400 500 600 700 800 900

NSW HEALTH Average

SSWAHS Average

Concord Hospital

Cost/employee ($)

Cost/employee 2007/2008

TMF Workers Compensation Claim Performance 2007/2008Cost/employee at 31 December 2008

536

492

284

0 100 200 300 400 500 600

NSW HEALTH Average

SSWAHS Average

Concord Hospital

Cost/employee ($)

Cost/employee 2008/2009

TMF Workers Compensation Claim Performance 2008/2009Cost/employee at 31 December 2008

203

164

105

0 50 100 150 200 250

NSW HEALTH Average

SSWAHS Average

Concord Hospital

Cost/employee ($)

Number of open claimsNumbers of Open Rehab Claims

2009-10

2008-9

2007-8

2006-7

2005-6

2004-5

2003-4

2002-3

What do we do now? All W/C injuries are screened at 48 hours High risk clients are referred to an independent

psychologist within 3 weeks and seen at Staff Health.

All high risk clients are seen by IMC within 4 weeks of the injury

Use IPC’s and independent professionals for all treatment areas including massage, chiropractors.

Accredited External Providers are used if people are not back on normal duties within 6 weeks or there are special reasons to use them upfront or injured workers request them.

Yes but! There are no short-term solutions and you need

a longer-term plan You need consistent staff and good leadership If you are geographically diverse, you need to re-

think how you do workers compensation Consider centralising your most experienced W/C

staff Chose carefully your referral base You need to think carefully about a psychologist You need to have Executive/CEO support and

advocacy You need to consult with all stakeholders

Could you do this?

WorkCover NSW and SSWAHS are looking at funding a larger trial over two Area Health Services with one being a “Control” with no change in current practice but doing the early screening and one Area Health Service being an “Intervention” using similar approach.

Where to from here?

Garry Pearce, Medical DirectorConsultant Rehabilitation Medicine PhysicianInjury Research Management Unit Staff Health and OH&S Risk Management UnitConcord Hospital

Steven J. Linton PhDProfessor of Clinical PsychologyDepartment of Behavioral, Social and Legal SciencesÖrebro UniversitySweden

Andrew McGarity, Rehabilitation Coordinator Injury Research Management Unit Staff Health and OH&S Risk Management UnitConcord Hospital

Professor Jennifer K PeatStatistician and Research ConsultantSydney

Michael K Nicholas PhDAssoc Prof. & Director, ADAPT Pain Management ProgrammePain Management & Research CentreUniversity of Sydney at Royal North Shore HospitalSt Leonards NSW 2065  Australia

Daren WilsonBA (Soc Sc) MA (Psych) MAPSPsychologistClearview Psychology Services Pty Ltd