Psychosocial Risk Factors That Predict Delayed Recovery: Addressing Risks for Posi:ve Outcomes SESSION TLT 007

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2 Psychosocial Risk Factors That Predict Delayed Recovery: Addressing Risks for Posi:ve Outcomes SESSION TLT 007 Speaker: Geralyn Datz, PhD, President Southern Behavioral Medicine Associates PLLC

3 Agenda Paradigm Shift History Lessons What most influences RTW? What is modifiable? How to Identify Risk at Early Stages of Injury Evidence Based Assessments & Treatments Summary Questions & Answers

4 Disclosures I am a trea6ng provider and researcher The following slides are not opinion We are not yet where we need to be

5 Session Overview Psychosocial risk factors are a strong predictor of delayed recovery that can be iden6fied at early stages of injury/exposure Neglec6ng these risk factors leads to unnecessary surgeries, procedures, medica6ons and extends the life of a claim

6 PSYCHO - SOCIAL

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9 Paradigm Shift Scien6fic findings have led to a new understanding of work injury that differs from a longstanding view that sees work injury (physical) as an isolated problem. Tradi6onally, the mind and the body have been believed to be separate.

10 MRI studies are oqen used to assess objec6ve pathophysiology and quan6fy impairment Several studies shown that + MRI findings are common in people who are symptom free. Physical findings only accounted for 10% of disability in the year following injury Psych assessment was more predic6ve of future disability than MRIs were Psychological diagnoses accounted for 59% of disability Jensen et 1994, Carragee et al 2004, 2005; Burton et al, 1995

11 Cost per Claim MOST injury/pain condi6ons are treatable and resolve quickly. A small number are very expensive. Example: Back injury (Friemoyer & Catz- Baril, 1991) 5% of cases led to 75% of costs 7% of injured pa6ents account for 76% of costs (Spitzer et al, 1987) 14% Medical care 62% Psychosocial complica6ons

12 Anxiety and depression are associated with magnifica6on of medical symptoms Depression treated with medica6on alone is not as effec6ve as psychotherapy + medica6on or even psychotherapy alone Noncompliance is a frequent byproduct Cornwal A, Doncleri DG. The effect of experimental induced anxiety on the experience of pressure pain. Pain 1998; 35: Katon W. The impact of major depression on chronic medical illness. Gen Hosp Psychiatry 1996; 18: Burns J, Johnson B, Mahoney N, Devine J, Pawl R. Cognitive and physical capacity process variables predict long-term outcome after treatment of chronic pain. J Clin Consult Psychiatry 1998; 66:

13 Why do some people get beeer aqer surgery and others don t? Numerous peer- reviewed research studies show the presence of anxiety, depression or personality disorders are strong predictors of poor outcomes of any treatment, including surgery. However, surgeons assess the mental state of their pa6ents less than 10% of the 6me. One study showed that surgeons are able to accurately assess the level of a pa6ent s distress only about 28 percent of the 6me, regardless of how long they ve been in prac6ce.

14 Integrated Approach = Medical + Psychological Goals: To provide good care, At a controlled cost, That is evidence based, Which integrates medicine and psychology

15 Biopsychosocial Laws Regula6ons and guidelines are increasingly recognizing science- based approaches Biopsychosocial laws now populate many evidence- based treatment guidelines Official Disability Guidelines (ODG) Work Loss Data Ins6tute (WLDI) American College of Occupa6onal and Environmental Medicine (ACOEM) The Reed Group (MDA) Colorado Division of Workers Compensa6on Washington State Dept of Labor & Industries Texas Division of Workers Compensa6on

16 Psych as bad, a liability, or to be used only when credibility is called into ques6on Psych as a Pandora s Box Psych as only dealing with pre- exis6ng vulnerabili6es Use of Psych to deal with only pure mental- mental claims Idea that psychological treatment is indefinite PARADIGM SHIFT

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18 What are we doing wrong? A tradi6onal approach is to keep the employee off work un6l she/he is healed. In many cases, this does not help.

19 RTW Likelihood aqer # Days off

20 Worker sa6sfac6on with employer response predicts RTW

21 SOLUTIONS è Educa:on of employees Communica:on with employees Early Interven:on

22 What predicts RTW? Employer factors Employee factors

23 The Golden Key Q. What is the most powerful differen6a6ng variable between those who are employed and those who are not following trauma6c injury? A. Psychological func:oning. These factors are stronger predictors than injury severity / level.

24 Modifiable factors Predic6ve of Higher RTW: High mo6va6on to work Posi6ve expecta6ons about recovery Func6onal beliefs about back pain, injury, and return- to- work Absence of anxiety, insomnia, and depression High self esteem & self efficacy Ac6ve social func6oning Sullivan, & Stanish, 2003; Berglind & Gerner,2002; Schultz et al., 2005; Buchbinder, Jolley, Wyae, 2001

25 What if the pain never stops? What s happening to my body? When it will heal? Will I will ever be the same? What if I get fired? I can t take all this stress! Do I take my medication? Should I really exercise?

26 Sta6c factors Predic6ve of Beeer RTW Outcomes: Younger Age Male Gender More Pre- Injury Educa6on Being Married

27 Schultz et al. (2004) Looked at 253 workers with back injuries. Expecta6ons of recovery were one of the most significant predictors of disability, RTW, and cost. - Correctly classifies who returns to work 85% of the 6me. Nega6ve/adversarial response by employer or WC system to the claim has been clinically observed to prolong disability

28 What can employers do? To facilitate RTW: EARLY interven6on in 6 to 12 weeks post injury Where appropriate, ac6ng quickly and visibly to fix the policies, procedures or machinery whereby injury occurred Asking the worker and their family what can be done to assist them Maintaining regular, suppor6ve contact throughout the recovery period Using a nurse call center reduced ER visits by 300%

29 Promo6ng RTW RTW programs Reduce all or nothing attude (off duty or released for full duty). Promote using temporary assignments which accommodate injuries and work restric6ons. The sooner the employee returns to work, even on a modified basis, the beeer the outcome. Consider keeping a database of modified duty assignments for different restric6ons. Quality Providers Have a list of quality doctors, occupa6onal clinical, physical therapists, and medical facili6es near your worksite.

30 EARLY IDENTITIFCATION Scientific screening tools and treatments exist that can be used to mitigate risk factors, prevent problems from becoming chronic, and promote the wellness of the injured worker

31 Screening tools Depression and Anxiety Pa6ent Health Ques6onnaires (PHQ) Catastrophizing Pain Catastrophizing Scale Injus6ce Perceived Injus6ce Ques6onnaire Fears of Pain Fear Avoidance Beliefs Ques6onnaire Perceived Disability Oswestry, Orebo Magnified responses to injury Psychological Tes6ng

32 Taking the Psycho Out of Psychosocial Understanding of what s happening to body / mind Reducing confusion about instructions Emphasizing work as therapy Teaching stress management

33 Treatment Options Psych related (>50%) CPT series Cognitive Behavioral Therapy w psych diagnosis Non Psych Related (<50%) CPT series Health & Behavioral Treatment w medical diagnosis PGAP Programs (Progressive Goal Attainment Programs) Combination Treatments (Psych & Non Psych) Functional Restoration Programs CPT 97799

34 Getng Unhooked from Opioids Alterna6ve treatment modali6es: 1. Cogni6ve- behavioral therapy 2. Func6onal Restora6on 3. Yoga It s 6me for transi6on away from a medicaliza6on- only mindset Pew (2013) Claims Management

35 Benefits of Interdisciplinary Treatment to Chronic Pain 2 decades of research favors an interdisciplinary approach to chronic pain over standard care (medical/pharmacologic solu6ons) Interdisciplinary pain management treatments are rela6vely low risk compared to standard care (e.g., opioid use, surgery)

36 JOURNAL OF OCCUPATIONAL REHABILITATION (2014)

37 FRP INITIATED EARLY = BIG $AVINGS N = 1,119 pa6ents Group 1 : 4 to 8 months aqer injury Group 2: 9 to 18 months Group 3: 18 months Results: RTW: 88% RTW Work Reten6on: 80% Health care u6liza6on: much reduced Groups did not significantly differ on these domains.

38 Cost $AVINGS Early intervention group (Group 1) had medical cost savings of 64% and productivity loss savings/disability savings of 80% Total economic cost savings of $170,000 per claim If FRP was initiated early on, it cost 56% less than if initiated later on

39 PARADIGM SHIFT At every level of the system, changes need to occur to create a shiq AWAY from: The idea of a quick fix Pills or surgery as the answer One doctor to fix everything Long delays in care Denials of requests for interdisciplinary care Denials of requests for psych / mental health treatment

40 Thank you. Questions? SESSION TLT007

41 Who s Afraid of the Big Bad Wolf? Current attudes towards mental health Current attudes towards risk factors Current understanding of injury as biopsychosocial Trea6ng psychosocial risk factors from an evidence based perspec6ve: methods and op6ons Providing employees with the best standard of care

42 Main Ideas Medical vs biopsychosocial Colorado as example Traditional injury trajectory Injury as example (pain ) What are the tools? Mental health treatment CBT as method Involvement of employer Rehabilitation programs after 3 months

43 Main Ideas Medical vs biopsychosocial Colorado as example Traditional injury trajectory Injury as example (pain ) What are the tools? Mental health treatment CBT as method Involvement of employer Rehabilitation programs after 3 months

44 Main ideas Fear that psych will go on forever Evidence based guidelines now exist Psych is excluded from some claims by law Ignoring behavioral factors is very costly Protracted claims Litigation How to fix this Case managers empower them, lsiten to them Educate adjusters Employer sensitivity Trust as a variable

45 Lost work produc6vity 1 Job dissa6sfac6on & depression beeer predictors than physical injury Surgery Outcomes 2 Psychological assessments predic6ve for spinal surgery response Predicts 80% of response in both invasive & noninvasive procedures 1. Bigos et al. (1992); Carragee (2005); Carragee et al. (2005); Jarvik et al. (2005); Krause et al. (1998) 2. Block et al. (2001); Gatchel et al. (1995); Giordano & Lofland (2005)

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47 PARADIGM SHIFT A shiq towards investment in Recovery Mindset Early Interven6on Emphasize return to work and job accommoda6on De s6gma6ze mental health

48 Modern Psychological Cost-effective Time Limited Treatments (CBT) Problem Focused Medically focused: pain, injury recovery, medication compliance Mentally focused: trauma, depression, anxiety, stress management

49 Do not be afraid of CBT Guest Columnist Michael Gavin for Workcomp central 11/1/2013 CBT can address a wide range of issues, including how we react to pain. We re seeing an increasing emphasis on CBT from our reviewing physicians as an alternabve treatment pathway for chronic pain pabents that are inappropriately ublizing prescripbon drugs Several of [our] physician reviewers feel strongly that CBT offers a compelling opportunity to change the course of a currently intractable claim.

50 Cogni6ve Behavioral Therapy (CBT) Help the pa6ent feel understood, less alone, less maligned ShiQs the pa6ent from Passive à Ac6ve Track the pa6ents progress Teach the pa6ent coping skills Teach how to deal with flare ups of symptoms Emphasize problem solving Reduce isola6on Teach strategies of pacing, adap6ng and delega6ng A psych claim does not always need to be opened.

51 Iden6fying Obstruc6ve Factors Obstruc6ve factors include unhelpful beliefs and behavioral paeerns such as having unduly pessimis6c thoughts I ve tried to cope as much as I can and it just doesn t work If you had this pain, you d be like me If only you could give me something to just take the edge off of it, then I d cope If only I could get my hands on the person that did this to me I just want to be fixed.

52 Spine surgery: The data Deyo and colleagues (JAMA, 2010) recently reported that the rate of complex fusion procedures being performed for lumbar spinal stenosis increased 15- fold from 2002 to Research shows that meaningful pain relief two years aqer a spinal fusion for lower back pain is less than 30 percent. In lumbar fusion, pain may be worse aqer surgery. Even more worrisome is that the re- opera6on rate is around 20% within 11 years. ReoperaBon rates following lumbar spine surgery and the influence of spinal fusion procedures. MarBn B, Mirza et al (2007)