Advice sheet 5: Treatment using work related activity Improving outcomes: Integrated, active management of workers with soft tissue injury

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1 Advice sheet 5: Treatment using work related activity Improving outcomes: Integrated, active management of workers with soft tissue injury When does this information apply? WorkCover has developed this information sheet to provide more detail about work related activity, as treatment during secondary intervention for some workers with soft tissue injuries. You should use this information to understand the principles and practice of using work related activity as one strategy to prevent onset of chronic disability and work loss in these workers. This information has not been written to apply to workers when their injury has resulted in chronic disability and work loss. More information about managing workers with soft tissue injury Read the document Improving Outcomes: Integrated, active management of workers with soft tissue injury to obtain an overview of the approach recommended for the management of workers during the first 12 weeks after injury. Key terms are also listed and explained in the document. Refer to Advice Sheet 3: Review and transition process for more information about assessing psychosocial risk factors and recovery and implementing transition of care. Refer to Advice Sheet 4: Secondary intervention for more information about integrating work related activity with other secondary interventions and alternate strategies during this period. Treatment providers can obtain more information about designing and delivering work related activity by attending the WorkCover NSW course Management of Soft Tissue Injuries Using Work Related Activity. Contact Provider Services Group on for more information. 1

2 Early return to work promotes recovery and prevents long term disability and work loss 1. Consequently, work (suitable duties) is the treatment strategy of choice for workers with a soft tissue injury. Treatment using work related activity may be indicated where there are insufficient suitable duties available in the workplace. Treatment using work related activity is: one way of promoting activity and recovery in some workers with soft tissue injuries a progression of treatment for workers with soft tissue injury during the sub acute period (usually 4-12 weeks after injury) an individual structured, functional activity routine to encourage activity and independence, using a cognitive behavioural and educative approach collaborative treatment that is directed toward improving and therefore is integrated with the worker s return to work activity (suitable duties) complementary to the biopsychosocial nature of work injury delivered one on one, in a group and/ or is done independently by the worker (e.g at work or home), usually a combination of methods. The treatment is to be cost effective and based on the needs of the individual worker. Usually, it would be unlikely for workers with sub acute soft tissue injuries to have developed significant de-conditioning. Treatment using work related activity is not: to take priority over return to work necessary for all workers with soft tissue injuries when recovery is delayed solely a physical conditioning program, without emphasis on addressing psychosocial issues, self management and integrating suitable duties performed predominantly in a gym setting a standard product delivered to workers with soft tissue injury. Indicators treatment using work related activity may be needed (When more indicators are present it is more likely the treatment is needed) there is insufficient suitable activity available in the workplace to meet the worker s total activity needs through the return to work plan the worker s injury has been appropriately assessed and managed in the acute period acute treatment methods are no longer resulting in significant functional improvement the worker s injury is now in the sub acute period and they are not working pre injury duties and hours the worker s injury is not yet chronic and disabling (usually less than 12 weeks after injury) the worker has psychosocial risk factors and/ or delayed recovery activity levels are not progressing and/ or fluctuate widely the worker requires a high level of supervision, instruction and reinforcement. 1 Foreman P, Murphy G and Swerissen H. Barriers and facilitators to return to work. A literature review. Australian Institute for Primary Care, La Trobe University: Melbourne

3 Who delivers treatment? Work related activity can be provided by a single treatment provider collaborating with key parties outside their service or more than one provider working within a multidisciplinary service. Single provider A single treatment provider assesses the worker s needs, designs and delivers the treatment and monitors the worker s progress. The treatment provider may be: The acute treatment provider (physiotherapist, chiropractor or osteopath), or A medical practitioner, or A treatment provider with suitable skills and experience in the delivery of work related activity treatment (such as a physiotherapist, chiropractor or osteopath other than the acute treatment provider, occupational therapist or WorkCover approved exercise physiologist). The treatment provider works with key parties outside their service such as the nominated treating doctor (NTD), rehabilitation provider, employer or psychologist, as needed. The treatment provider may work within a single or multidisciplinary service. Multidisciplinary service It may be considered reasonably necessary that the treatment be delivered by more than one provider working within a multidisciplinary service. The multidisciplinary service works with key parties outside their service such as the nominated treating doctor, rehabilitation provider or employer, as needed. Duplication of service is to be avoided. 3

4 Treatment using work related activity Remember that work related activity is just one treatment strategy to prevent onset of chronic disability and work loss in some workers with soft tissue injuries. This information has not been written to apply to workers when their injury has already resulted in chronic disability and work loss. In this case, more complex physical and vocational strategies will probably be needed. Practices to avoid The treatment hinders or delays return to work. Standard treatment programs in a standard setting for all workers. Continue treatment which is no longer effective in progressing recovery. General physical conditioning in a gym setting, for the purpose of improving general health and fitness. Work in isolation from others who are assisting return to work; ineffective communication strategies. Pre and post program reports. Focus solely on the reduction of symptoms, such as pain. Alarming the worker; not providing an explanation of their ongoing symptoms/delayed recovery. Design treatment to stand alone from and/or delay other necessary interventions. Deliver treatment sessions without regard to the expected progress of recovery and the goals. Promote dependence on the provider to solve problems. Commence treatment without firstly setting goals and expectations with the worker. Continue treatment without reviewing progress against goals and expectations. Improved practices Incorporate return to work, activity and independence and encourage the worker to participate Collaborate with key parties to work toward return to work. Provide treatment specifically to address the identified needs of the worker, including preferred style of activity. Consider ceasing ineffective treatment When indicated, transition to work related activity and incorporate a cognitive behavioural approach Consider alternate strategies/providers. Review the workplace assessment and match the prescribed work related activity to the critical job demands. Use a setting that promotes specificity of work related activity, transferability to the workplace and independence. Communicate effectively with key parties outside the service about return to work Report barriers outside the treatment setting so they can be addressed e.g. in the workplace. Use treatment provider/multidisciplinary plans to request approval. Focus on work related and functional outcomes. Reassure the worker that this type of treatment is common at this time and recovery is expected. Explain the likely cause of the ongoing symptoms and the way to continue improving. Integrate with other secondary interventions: return to work, psychological. Gradually increase the interval between treatments and progress style of delivery (such as reduced supervision/ group) to encourage self management. Progress the worker to self management. Designate the goals and the end point. Regularly review progress during the treatment. 4

5 Treatment proposals, approvals, fees and completion Treatment provider tips Review the workplace assessment, suitable duties plan and discuss with the rehabilitation provider. Highlight on the management plan the workplace barriers to be investigated/ actioned by the insurer or other key parties. Allow adequate time for case conferencing on the plan, if this will facilitate communication. Acute treatment providers may use standard consultations already approved for the worker on a management plan. Ensure the type of treatment proposed and the case for intervention is clear on the management plan. This will avoid delays in decision making by the insurer. Initial consultation and treatment The worker s current treatment provider/ practice simply progresses treatment when indicated. Providers use a standard consultation already approved on a management plan. With insurer approval, a new treatment provider/ practice provides an initial consultation and treatment. This includes history taking, assessment, goal setting, planning, treatment, clinical recording, communication with the referrer/key parties and preparation of a management plan. Subsequent consultations The design of consultations is to meet the needs of the individual worker, the goals of treatment and be reasonably necessary. Treatment providers can propose different consultation types within the management plan, for example, a combination of individual, reduced supervision and group consultations. Reducing the frequency and level of supervision of treatment will assist the worker to achieve self management. 5

6 Management Plans There is no need to provide the insurer with a written pre program report, unless this is requested in writing. A WorkCover treatment provider management plan is used when the treatment is to be delivered by a single discipline of provider, regardless of whether the practice is single or multidisciplinary. Use the template provided in WorkCover guides for service providers. A multidisciplinary management plan is used when the treatment is to be delivered by more than a single discipline within the same practice. WorkCover does not provide a template for multidisciplinary programs but the individual treatment provider plan can be adapted for this purpose. WorkCover suggests the multidisciplinary team develop and submit a plan, including the following information: worker details return to work goal and current work status insurer details details of all providers of treatment details of the provider co-ordinating the worker's treatment presenting problem, as written on the WorkCover medical certificate functional measures used to assess and monitor progress barriers to return to work and strategies to address these proposed treatment content and design - number of sessions, format (for example group/individual) and provider/s, completion date, cost. The insurer makes the decision regarding the treatment and communicates this to the treatment provider within five days of receipt of a properly formulated plan. Prompt decision making assists recovery and reduces risk of onset of long term disability and work loss. An alternative strategy should be discussed if the plan is not approved. This might include referral to an independent consultant. 6

7 Fees No separate fee is payable for completion of the management plan, as it is completed during a treatment session and developed in consultation with the worker. WorkCover recognises that: workers who have risk factors and/ or have not progressed as expected are likely to have additional needs collaboration and communication is essential to successful outcomes the worker may be managed by a different treatment provider in the sub acute period. WorkCover has updated the gazetted fees orders from 1 January 2008 for physical treatment providers to include a code for work related activity treatment delivered to a new patient by a provider, allowing up to one hour for assessment and treatment. It is advisable that treatment providers consider the potential need for case conferencing to discuss the worker s return to work with key parties. Case conference time can be requested on the management plan and is then available to be used if necessary during the course of treatment. When treatment is delivered by a single provider, maximum fees payable for the services (including equipment and facilities) should be in accordance with the gazetted fees order and WorkCover guidelines applicable to the provider delivering that service. Single provider treatment is billed using the relevant consultation code, not OTT003. When treatment is delivered by a multidisciplinary service, maximum fees payable (including equipment and facilities) should be in accordance with the gazetted fees orders and WorkCover guidelines applicable to the providers delivering services under the proposed treatment, where available. Multidisciplinary work related activity treatment is billed under the code OTT003. Subsequent management plans Treatment providers may submit a new management plan to propose further treatment. However, it is advisable to review the progress to date against goals and ensure that the treatment proposed is the most appropriate strategy to progress recovery and return to work. The insurer will determine whether the treatment is reasonably necessary based on information provided by the treatment provider and other available information. If there is difficulty determining an effective treatment strategy, it may be helpful to involve an independent consultant. There is no need to provide the insurer with a written post program report, unless this is requested in writing. 7

8 Disclaimer This publication may contain occupational health and safety and workers compensation information. It may include some of your obligations under the various legislations that WorkCover NSW administers. To ensure you comply with your legal obligations you must refer to the appropriate legislation. Information on the latest laws can be checked by visiting the NSW legislation website This publication does not represent a comprehensive statement of the law as it applies to particular problems or to individuals or as a substitute for legal advice. You should seek independent legal advice if you need assistance on the application of the law to your situation. Catalogue No. WC05369 WorkCover Publications Hotline WorkCover NSW Donnison St Gosford NSW 2250 Locked Bag 2906 Lisarow NSW 2252 WorkCover Assistance Service Website Copyright WorkCover NSW 0710