Concord Repatriation General Hospital Sydney

Transcription

1 Concord Repatriation General Hospital Sydney

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

3 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

4 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

5 Soft tissue injuries to shoulder, upper limb, wrist and hand 36 Soft tissue injuries to back, lower back, knee, foot and ankle 37 Soft tissue neck injuries 2 Hernias 2 Fractures 2 Head injuries 2 Motor vehicle accidents 7 Assaults 6 Miscellaneous (bruising, needle stick) 6

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

7 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.

8 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

9 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!.

10 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.

11 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

12 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

13 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.

14 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

15 Örebro Musculoskeletal Pain Screening Questionnaire (Modified)(Linton & Hallden, 1998) 1. Please tick the box that reflects you current age 2. 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 Hospital 13.In your estimation, what are the chances you will be working your normal duties in 3 months

16 Results of the Control Group RISK GROUP NUMBER (%) ($) COST/CLIENT LOW (<69) MEDIUM (70 84) HIGH (> 85) 36 (47%) $ 4,878 24(31%) $ 6,240 17(22%) $ 17,178

17 Intervention strategy 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 month Low risk (<69) Usual care

18 Results of the control and intervention arms CONTROL GROUP INTERVENT GROUP CONTROL GROUP INTERVENT GROUP RISK CATEGORY Number (%) Number (%) $ COST $ COST LOW 36 (47%) 40 (51%) MEDIUM 24 (31%) 23 (29%) HIGH 17 (22%) 15 (19%) $ Difference $ 4331 or 25% $531081

19 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.

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21 Days Lost/employee TMF Workers Compensation Claim Performance Days Lost/employee at 30 June SSWAHS Concord Hospital / / / / / /2009 SSWAHS Concord Hospital

22 SSWAHS Experience Premium Movement from 2007/08 to 2008/09 Health Care Interpreters Service Population Health SSWAHS Supply Services Balmain Fairfield Hospital Community Nursing Service SSWAHS Engineering Services SSWAHS Laboratory Services Bankstown Hospital Rozelle Liverpool Hospital Concord Hospital Campbelltown Hospital Camden Hospital Community Health Royal Prince Alfred Queen Victoria SSWAHS Area Services Braeside Sydney Dental Hospital Forensic Medicine Canterbury Hospital Lucas St Childcare Karitane Tresillian Central & South West Sydney Scarba Bowral Hospital Area Mental Health -$1,500, $1,000, $500, $0.00 $500, $1,000, $1,500, $2,000,000.00

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24 TMF Workers Compensation Claim Performance 2006/2007 Cost/employee at 31 December 2008 Concord Hospital 496 SSWAHS Average 774 NSW HEALTH Average Cost/em ployee ($)

25 TMF Workers Compensation Claim Performance 2007/2008 Cost/employee at 31 December 2008 Concord Hospital 284 SSWAHS Average 492 NSW HEALTH Average Cost/em ployee ($)

26 TMF Workers Compensation Claim Performance 2008/2009 Cost/employee at 31 December 2008 Concord Hospital 105 SSWAHS Average 164 NSW HEALTH Average Cost/em ployee ($)

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28 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.

29 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 rethink 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

30 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.

31 Garry Pearce, Medical Director Consultant Rehabilitation Medicine Physician Injury Research Management Unit Staff Health and OH&S Risk Management Unit Concord Hospital Steven J. Linton PhD Professor of Clinical Psychology Department of Behavioral, Social and Legal Sciences Örebro University Sweden Andrew McGarity, Rehabilitation Coordinator Injury Research Management Unit Staff Health and OH&S Risk Management Unit Concord Hospital Michael K Nicholas PhD Assoc Prof. & Director, ADAPT Pain Management Programme Pain Management & Research Centre University of Sydney at Royal North Shore Hospital St Leonards NSW 2065 Australia Professor Jennifer K Peat Statistician and Research Consultant Sydney Daren Wilson BA (Soc Sc) MA (Psych) MAPS Psychologist Clearview Psychology Services Pty Ltd