The role of the occupational medicine physician in the Jones Act/workers compensation systems AUSTAL EXPERIENCE

Transcription

1 The role of the occupational medicine physician in the Jones Act/workers compensation systems AUSTAL EXPERIENCE

2 AUSTAL AWARDS Ship Builders Counsel Of America : Safety award for reduction in injuries and illnesses 4 years in a row American Equity underwriters award : Safety Award 4 years in a row

3 Multi-Team Effort Health Safety and Environmental Insurance Co Supervisors Case managers Employees Administrators Occupational MD Specialists

4 Patient Injury/ Illness Work Flow Work Related injuries Injuries see LPN /MA/EMT Daily wound care Immediate report to supervisor/safety Safety meeting/conference/ recommendations OTX RX available at no cost Dressing supplies Massage Non work related injuries illnesses Also taken care of in same manner Free of charge Prevents crossover

5 Ultimate Goal Go from first date of injury to : Discharged, regular duty, no restrictions MMI : No permanent impairment / zero percent disability No lost time No OSHA recordable Keep the injured employee happy The insurance Co happy The employer happy

6 Major steps to achieving this goal Healthy, safe group of employees to start with. Determine causation. Accurate diagnosis. Control the case. Limit disability.

7 Primary Prevention DO NOT BUY PRE-EXISTING PROBLEMS Pre-employment physical exam Have to make sure you are not aggravating preexisting problems Have to make sure the work force is safe to do their job Satisfy the ADA act

8 Austal pre-employment screen 10 panel rapid Drug screen Medical questionnaire and Vital signs Physical exam by MD depending on answers to questionnaire

9 Pre-employment exams Vital component of your safety program Identify pre-existing conditions that can be aggravated by work Make sure applicant can perform essential functions of the job without endangering himself or others Make sure all illnesses or diseases are well controlled ( diabetes, hypertension) Screen out applicants that can not do the job without endangering their health or the health of their coworkers.

10 Employment exams Periodic exams : DOT ( do these for your heavy equipment operators ), Crane Operator exams Fitness for duty exams: ( reasonable suspicion ) Return to work: ( post op, prolonged absence )

11 Pre-employment Exam Ask questions Explain answers Due diligence Request records X ray Examine the patient Represent the employer, be honest

12 Red Flags Past medical history Lortab, 1-2 a week Multiply this by 7 Prior back surgery Repetitive surgery on the same joint Seeing a Pain doctor Seeing a few other Dr.s in town ( Dr.s Z,D,R )

13 Prescription drugs and safety sensitive work Benzodiazipines Narcotics Half Life 2 half lifes Underlying issue Drug registry

14 Half Life The amount of time it takes for ½ of the drug to be metabolized Example: Lortab T1/2: 3.8 hours Methadone: 28.5 hours Xanax T1/2 : 28 hours Valium T1/2 : hours Suboxone : 37 hours Klonopin : hours

15 Drug screening/ MRO issues MRO : Make sure notification is occurring for safety sensitive drugs Ask for fitness for duty exams on employees taking class 2or 3 controlled substances on a regular basis Verify dosages, get pharmacy records, check dosages, find out who is prescribing MRO can check the state data base see the MDs prescribing/dosages Look at the job

16 Writing restrictions Educated guess Pre-existing problem already symptomatic Easy Pre-existing problem not symptomatic More difficult

17 Causation Critical component of the initial visit Rule out pre-existing non-work related problems Often requires some effort ( reviewing records, reviewing state data base, etc.) Trust your MD to do this ( negative consequences for the provider ) Big issue as work force ages ( arthritis, heart/lung disease )

18 Control of the case Patient has the right to go anywhere Helps to establish a good relationship w the patient from the beginning Office, staff, equipment, cleanliness, professional Spend time w the patient, take a good history Explain the diagnosis, show them the x rays Do as good a job or better than they would get from their personal MD

19 Control Your MD needs to be able to treat a wide variety of problems Comfortable w musculoskeletal issues Handle trauma Know how to conservatively treat without ordering a lot of unnecessary expensive tests Understand the work environment you are in Workers comp vs jones act

20 Referring out Outside referral In house treatment Lose control Leads to lost time More tests Surgery Prescription rx disability Maintain control No lost time No excessive tests No expensive surgery Limited rx Limited disability

21 Knowing when to refer Bad outcome Unable to treat in house Surgery required Expert required

22 When not to refer Case can be managed w optimum result w conservative treatment

23 RX and OSHA recordables Ibuprofen 200 (2 TID w food ) Naproxen 220 (2 BID w food) Acetaminophen 500 ( 2 every 6 hours for pain) Combination of ES tylenol and motrin 200 is just as effective for pain relief as lortab

24 Pain relief without narcotics Motrin, aleve, ES tylenol Package these in prescription bottles w generic names Use them on schedule, not PRN Topical ice, biofreeze, mobisyl Splints activity

25 Avoiding OSHA recordables without restrictions OK to disable a patient on the date of the injury Regular duty as tolerated starting tomorrow Most sprains and strains heal better if they stay active Complete immobilization leads to more stiffness and prolonged recovery

26 My policy regarding disability Medically necessary When patient has to be hospitalized Recovery requires quarantine or bed rest Poses a public or coworker hazard Risks damaging tissues or delaying healing Medically unnecessary Perception that diagnosis alone (without any functional impairment ) justifies work absence Other problems masquerading as job issues ( job dissatisfaction, anger, other psychosocial factors Poor information flow/ communication Administrative or procedural delay

27 Lost time My policy If I have to put you in the hospital then we will take you off work, otherwise you can go back to modified duty Sitting at home, lying in bed or watching TV does nothing but prolong recovery Causes blood clots Tissues heal at incorrect lengths and recovery takes 3 times as long

28 Cost of Disability % of the cost of workers comp is wage replacement % is medical charges By eliminating lost time you should see a % cost saving Disabling patients often prolongs recovery

29 Work Capacity/ Work restrictions Encourage return to work Formal work restrictions often are not necessary Most employees realize their limitations Regular duty as tolerated often is sufficient

30 Communication is key here Phone call Discuss w patient, Co. nurse, safety representative. Jack has a sprain, he can work, may not be able to do all the aspects of his job, no restriction but should be allowed to take it easy for a few days while he is healing and progress as tolerated.

31 Issues to watch out for here Some employers will not do this Old school supervisor 100% work capacity or you should not be here Patient that tries to do too much Requires close follow up and a fair bit of communication comes in very handy here Visit to work site

32 It hurts when I move This is part of the recovery process Not causing damage Pain is not synonymous w damage It is part of the normal recovery process It is expected The more you move, the quicker you will recover It is not damaging anything, it is part of your treatment, you will recover 3 times as quickly if you stay active.

33 Physical therapy Sport / medicine model No improvement in 1-2 weeks start PT Really helps w recovery Instills confidence Keeps the patient active Decreases recovery time Helps maintain control of case

34 On site physical therapy Avoids OSHA recordable Not referring them out Simply a benefit of working at certain sites Gives the patient a break Improves communication Speeds recovery

35 MRI Avoid these if possible 30-40% false positive rate Surgical planning tool Patients often request these Explain it is not a treatment modality, will not make them any better Only reason to do this is if it will change your treatment Usually not indicated for acute back strain Usually not indicated in the 1 st 3 weeks

36 Delayed recovery 90 % of the costs of workers comp costs are caused by only 10 % of the patients These are the patients that fail to recover in the standard time frame Have to have programs to address these situations

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39 Delayed recovery Some individuals need to be challenged in order to improve There is no curative process that occurs at home Individuals can return to work even if symptoms persist

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46 Disability related psychological risk factors Catastrophization Injustice Belief / Expectations Fear

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49 WC- Early screening and risk prediction Evidence for early risk factor identification Impact of early identification on work disability outcomes

50 Risk factors for pain and disability are not identical Risk factors for back pain outcome: Pain severity Duration Somatic focus Coping history Risk factors for back disability Workplace conflict Wkplc inflexibility Fear of injury Pain severity Catastrophic view

51 Risk factors for prolonged disability Individual psychosocial; depresion, fear avoidance, non-organic signs, job stress, RTW expectations, fear of re-injury, Individual physical: radiculopathy, non-organic signs Workplace: physical job demands, modified work, support, satisfaction, job tenure, L-M relations Provider: RTW focus, communication Systemic; employer insurance policies and procedures, litigation

52 Acute Low back pain interventions For the patient that is immobilized, fearful, avoiding work, physically unable to function, poor expectations for resuming activity GRADED ACTIVITY/ PT IMPROVE SELF EFFICACY FOR PHYS FUNCTION

53 Acute LBP risk cluster intervention DISEMPLOYED ( high phys. demands, poor employer response, no modified duty, short job tenure) WORKSITE CONTACT /EVALUATION IMPROVE ACOMADATION AND SUPPORT

54 Acute LBP risk cluster interventions Overwhelmed (mood symptoms, life adversity, work stress, pain catastrophizing) PROBLEM SOLVING SKILLS TRAINING Improve self efficacy for coping with ALBP and overcoming barriers to recovery

55 Delayed recovery / disability Primarily a non-clinical problem, so are the most effective interventions Research evidence for early intervention is encouraging Work disability and delayed recovery risk is predictable.

56 The future of occupational medicine Health care is changing Shift to affordable health care initiative/ organizations Your Occupational MD has a great opportunity here Point person for change Merger between occupational medicine and primary care

57 Health Care Reform Cost effective delivery Better outcomes

58 Accountable care organizations Patient centered medical home Encourage MDs, hospitals, self insured Co.s, Ins. Co.s to coordinate care Develop team based approaches by integrating goals, sharing data Leads to better outcomes/ lower costs

59 PCMH / ACO PCMH ACO Groups of primary care MDs Partner with patients, employers, care givers, hospitals Make MDs and hospitals more accountable by organizing them towards prevention Outcome oriented Rewarded by value

60 Patient centered medical home Will probably begin at the work place Employees screened at work site health clinics Problems identified on a population basis Programs developed for the whole group Idea is prevention Primary care MDs / Occupational MDs will have a much bigger role Try to keep patients from ever having to see a specialist Avoid ER, and admission to hospitals by identifying and treating preexisting conditions and developing problems before they become huge issues Reimbursement is going to be based on value. Compare a unmanaged group to a managed group and pay the primary care MD s a portion of what they save the insurance co. Occupational medicine will most likely be integrated into these worksite clinics

61 Why occupational medicine? Uniquely trained to take care of individuals and populations MPH : includes biostatistics, epidemiology, Public health, preventive medicine We will be able to design programs for your Co. to not only help w Work related issues but also keep your whole employee group healthy Maximizing productivity, minimizing lost time on a much greater scale