Creating More Effective Return-to-Work Pathways

Heather Grimshaw

How can employers create an environment that encourages employees to return to work when possible? Kerri Wizner, MPH, Assistant Director of Epidemiology for MDGuidelines, and Dr. Keemia Vaghef, PhD, Director of Analytics Consulting for Alight Leave Solutions, share insights and recommendations in this episode, which elaborates on concepts discussed in their @Work magazine article “The ROI of Shifting the Curve Toward Optimum Durations.“ Listeners will also hear from W. Shane Journeay PhD, MPH, MD, FRCPC, BC-Occ Med, Physical Medicine & Rehabilitation & Occupational Medicine, who shares a valuable provider perspective. 

Related DMEC Resources


Heather Grimshaw: Hi, we're glad you're with us. I'm Heather Grimshaw, communications manager for DMEC, and today we're talking about the optimum duration for returning employees to work. This conversation ties into the @Work magazine article “The ROI of Shifting the Curve Toward Optimum Durations” that was written by Kerri Wizner, MPH, assistant director for Epidemiology, MD Guidelines, and Dr. Keemia Vaghef, PhD, director of analytics consulting, Alight Leave Solutions. We are also joined today by Dr. Shane Journeay, a physician who specializes in occupational medicine and rehabilitation medicine at the University of Toronto. He regularly sees workers and assists employers with return to work. So, to kick us off, Kerri, will you talk about how employers identify when interventions make the most sense?

Kerri Wizner: Yeah, I would love to get it started. Thanks for having us, Heather. This was a great opportunity. So my background is in public health and analytics, so I'm always going to recommend that people go and look at their own data or in the published literature. So, for example, for this podcast, I found an article in the Journal of Occupational Environmental Medicine that was just published in June, and it found that people at elevated risk for cardiovascular disease were four times more likely to develop musculoskeletal disorders and also 17 times more likely to develop four specific disorders, including carpal tunnel and rotator cuff tendonitis. So employers can look to the research to go see what is happening and what's new and cutting edge, and they can take these findings and either review their own data to see if their employees also face this issue, or they can proactively create a process linking people at higher risk to more resources. So if you start with either leisure or your own data, you really can't go wrong. So, as you mentioned in our @Work article, we talk about shifting the duration curve, and we talk about reviewing data and finding places where you can make the most impact. So, sure, you can look at your longest claims on the books, but those are probably outliers. More impactful would be to look at your more common claim types and see how well your population is doing compared to a benchmark. Heather, do you want to give, like, a quick overview of the article?

Heather Grimshaw: Yes, thank you. Our authors talk about the fact that each year, U.S. employees are absent from work 1.4 billion days, including sick time, disability days leave that falls under the Family and Medical Leave Act, and health-related impaired performance. I'm quoting from the article here. So beyond diagnosis, there are many nonmedical factors that affect how long an employee is away from work, including clinical recommendations, disability plan constraints, and workplace culture. There is evidence, the authors write, that returning to normal activities, including work when people are physically able after an illness or injury, is beneficial for overall well-being, mental health, and financial stability. And the question they pose in this article and that we're going to be talking about today is how many people return to work as soon as they are able to do so. And more specifically for our conversation today, how do employers influence that?

Kerri Wizner: So, yeah, going back to your question about how do employers identify where interventions make the most sense. So your next question should be, how do I find benchmarks? How do I look for places that I can make an impact? So there's commercially available benchmarking, like my company MD Guidelines offers best case scenario benchmarks and population level benchmarks. But it's also available through government agencies, nonprofit groups, or back in the medical literature. You can even create your own benchmarks if you have a lot of data. You can go look at past years, past groups, measure your impact of implementing a new program, see where your data is. That can be a great benchmarks. So once you have a benchmark, then you want to see where you can make the most impact. So I would recommend don't start at places where conditions are consistent across all types of people. For example, for cataract surgery, it's usually pretty straightforward, and most people recover in less than a week. There's a few outliers, but everybody's kind of recovering in a normal time frame, so you're not going to have a lot of impact on that. But conditions that have a wide range of recovery, like low back pain, where about a third of people return to work in one to two weeks, but two thirds is longer than that. Or hip osteoarthritis, where half the people return in two months, that's a long range of recovery. Those are places where employers can make the most impact. If you can return people to work more quickly or closer to that best case scenario, then you're going to be able to build programs that shift those remaining people one or two days shorter. But because they're so common, that one to two days across a lot of people makes more impact than maybe five days for only a handful of people that have very long claims and science. I'm going to talk about public health all the time. Don't forget to evaluate those changes. See where your benchmark is, see where you initially started, and then implement your program. And then check on it maybe six months down the road, a year down the road. See how the program is doing. See how much change you've made and where you can make continuing impact.

Heather Grimshaw: That's really helpful, thank you Kerri so Dr. Vaghef, would you share some examples of ways that employers can help employees focus on recovery goals?

Dr. Keemia Vaghef: Absolutely. Employers actually play a crucial role in supporting employees recovery goals. They can provide assistance in creating an environment that really facilitates employee recovery through a variety of means. The goal is that the solutions employers put in place should really be tailored to encourage healthy employees to want to return to work. Some examples are the obvious employee assistance programs that offer access to EAP, services that provide that confidential counseling and mental health support. Especially during those stressful times where employees need to learn how to manage stress and gain coping mechanisms that help them with their disability, specifically focus on their recovery goals as a whole. Speaking of a whole wellness program, we've heard a lot about wellness programs in the past. However, implementing wellness initiatives are really there to support employees in the recovery journey and enhance their overall wellbeing. Things like stress management workshops, mindfulness training, or physical fitness programs or incentives are often things that employers can put in place to help encourage employees return to activity. In addition to those employee assistance programs and wellness programs, it's important to highlight benefit coordination because employers really assist employees in understanding their benefits, such as the short-term disability insurance, their paid leave policies, or even medical coverage. To be able to help them navigate those administrative processes is key in helping shorten those durations to enhance those administrative inefficiencies and make things like the user interface tools more user friendly for those folks who are implementing or putting in lead requests and needing to put in extra information or provide additional documentation. Oftentimes I'm sure all of us have come across a website where we can't find a certain function and we have to put off maybe putting a call into the organization till tomorrow that extends durations collectively. So the more administrative efficiencies that an organization can provide can really enhance that duration experience.

Kerri Wizner: And can I jump in real quick? I love what Dr. Vaghef said. With return to activity, we really focus on that. It's returning to all of your normal activities that also includes work. So not specifically it doesn't have to be returned to work all the time, but returning to your normal life, whether it's picking up your kid or picking up boxes at work, it's returning to that activity. Absolutely.

[08:47] Dr. Keemia Vaghef: Kerri? Yeah, thanks for expanding on that. That actually leads to my next point, which is employers can provide that flexible work arrangement that really manages or helps manage that transition period for the employees. Employers should really aim to allow employees to gradually return to work when applicable by offering flexible work hours or part-time schedules. Because like you said, Kerri, it's sometimes about just returning to activity to encourage those employees who will eventually be returning full time to work. This flexibility really helps employees balance their recovery needs while easing back into their regular workloads. This shows that an organization understands that gray area between the employee transitioning back to work from that disability, and it really shows that the employer is willing to support them throughout this transition. So I think that highlighting those flexible work arrangements, those reasonable accommodations that employers can put into place, really provides the necessary accommodations and highlights to the employee that the employer is willing to bend and accommodate to their needs because they value the employee and they're wanting to keep that employee within the organization. In addition to those workplace accommodations and flexible work arrangements, it's important for an employer to have a strong return to work plan for the employees. This is where the employer can really collaborate with the employee, the healthcare professionals, human resources, to develop that personalized return to work plan. It really allows for that gradual reintegration that I mentioned, as well as allowing those modified tasks if needed, such as those accommodations, to allow for a more realistic timeline for successful transition into the workplace. Is that something you come across often, Dr. Journeay, as a physician, seeing employees return with a strong return to workplace?

Dr. Shane Journeay: When a worker is injured or has a new medical illness, whether it's related to their work or not, the data actually supports the value that the worker or the employee places on a timely diagnosis, a treatment plan, reassurance about their work. So many workers who present for the first time that's the first question they ask is what about my work? And so having a strong plan and a supported plan in place is really quite important. Having trained and worked on both sides of the border, one of the biggest barriers I see on the employer side, as we all know, is lack of available modified work. It's also a bit of a red flag for me in some occupations if there's zero modified duties available. And so if I take my school teachers, for example, recovering from concussions and other such injuries, the degree to which they can support a gradual return to work makes all the difference in the world in that individual progressing. If it's way too fast or way too slow, things can get away on people, if you will. And so certainly that supportive approach is the way to go in my mind.

Dr. Keemia Vaghef: Yeah, that's a great point, because one of the topics that I think employers, as you just mentioned, really need to enhance or dive deeper into, at least like you were saying, based on job titles, why not really ask themselves, why not make this available modified duty for this job role? Why not allow these accommodations for these employees? Of course, there are certain job roles that the essential functions might not still be able to be completed if those certain accommodations are done. But there are jobs like you were mentioning there doctor journey, that there are jobs like the teachers with concussions that are returning to work, that there's definitely things the employers could do to allow for that modified duty. Things like you mentioned gradual transition, but it might even be reducing physical demands, accommodating key tasks, maybe making certain other, maybe coworkers available during key times or even workplace adaptations for a temporary period to allow them to reintegrate fully. I think those are really important points that availability of modified duty is important for employers to consider.

Kerri Wizner: I did hear a good example of a utility company. So a power company only had more heavy or very heavy job roles. So they partnered with a nonprofit in their community and said, while you're on modified duty, you can go work at this nonprofit, and we'll count that as your time. And he made his full salary. And I thought that was a great idea.

Dr. Keemia Vaghef: Wow, that's really interesting. And that offers that employee a sense of community, a sense of they feel reintegrated in society and useful after a stressful time going through a disability and things like that.

Kerri Wizner: For sure.

Heather Grimshaw: That's a great example, Kerri, thank you. And really helpful context there. It does seem like this is an area that employers struggle with. And so I'd love to hear more about recommendations for applying recovery expectations in clinical care to help an employee return to work when it is safe to do so, and kind of what that looks like in practice.

Dr. Shane Journeay: Sure. So this is essentially my daily practice, whether it be in a worker's compensation setting or outside of this. And as alluded to earlier, the data actually backs up how much the patient values a timely diagnosis, a treatment plan, reassurance about their work and a pathway back to work or return to function. As Kerri alluded to earlier, where things get off track is when there's uncertainty. So, for example, if we have a patient with a shoulder injury or a back injury and we reassure them that we'll manage their pain and provide them education about their diagnosis, the role of rehab in supporting their return to work, really, the importance of having a solid diagnosis really sets the stage for everything that comes after that. Because if the diagnosis is wrong, the treatments thereafter and perhaps the recovery trajectory will be wrong. And certainly people will end up sort of lingering with symptoms for something that they don't actually have in some cases. So the way I see guidelines and recovery expectations and how I counsel my patients is really to set not a deadline, but some parameters around one's injury or medical illness. If we say an average individual with this diagnosis will be better in ten to 14 days, we want to be careful that the patients don't interpret that as a deadline, but certainly something that sets up for goal setting. And so we say, on average, you can probably return to work in the next one to two weeks, maybe sooner. If there's modified duties, it just sort of sets a goal for the patient in parallel with any treatments that have been put in place. And so setting recovery expectations I use on a clinical basis to educate my patients about what to expect going forward, and I link that to their work, which many of them are often worried about. And so if we can align recovery expectations with approximate timelines, support them with appropriate treatments and recovery pathways, also education around the role of modified duties, patients do really well, the other big thing here is that we all know is that returning to work or returning to function is really part of the recovery process. And patients usually are quite rewarded, if you will, when they can see that connection between the two items. So, in summary, on the expectations setting front, I think we can use things like guidelines and data to reassure patients and set them on a pathway forward so they can envision their recovery and also be reassured that their work working life will also be supported.

Heather Grimshaw: I really appreciate the way that you said that too, not setting a deadline but providing parameters and the language that you used here are the parameters you may be able to return to work sooner if kind of that dot, dot, dot inserted there. In the article, Dr. Vaghef and Kerri do a really nice job of setting up or providing an overview of when that return to activity should occur and how employers know when that activity should occur. So it helps them detect if treatments are working. And I think it would be helpful to hear your insights there as well.

Dr. Shane Journeay: What I think you're touching on is that oftentimes there's a bit of a disconnect or perhaps a room for improvement around communication between providers and employers. And I believe that for larger organizations, perhaps they have preferred providers or even internal healthcare providers to provide these treatments and return to work recommendations. If those are solidly aligned with that specific organization, it can only expedite people's recovery and treatment plans. And so what I mean by that is, if I am an independent provider in the community and I have an injured worker, but I don't know if an employer has modified duties, I don't really understand what this individual does in their work. My recommendations tend to default to no work or less work or different levels of function than are probable. Now in my world as a rehab doctor and an occupational medicine physician, those are the first questions I ask, “Are there modified duties and what do you do in your daily working life?” And so a lot of this, I would say the vast majority of this, when things fall off that expected recovery time, it often comes down to a disconnect between the provider's recommendations and what is actually available or not available within the employer. Furthermore, for the patients who are on track, so to speak, sometimes guidelines or setting recovery expectations and goal setting can really serve as a clue. So when patients fall off that expected trajectory, it's a clue that other factors might be involved. These might be employer factors, provider factors, or things like mental health outside of a musculoskeletal injury, for example, that are starting to creep into the picture and need to be managed as well. And so I think having a plan up front, having good lines of communication about what's available from the provider side, employer side, and really understanding what an average timeline might look like really helps us navigate the complex cases.

Kerri Wizner: Yeah, I would totally echo what Dr. Journeay said. I work with a lot of occupational physicians who have this training to focus on return to work and activity and are more aware of that, but that's not the average physician or clinician. A lot of times that conversation might not be happening at the point of care or that awareness is not there to have that discussion. And so patients might be getting just advice, I'll see you in six weeks at your appointment, and might not even touch on that conversation. So employers or case managers can kind of fill that role to start talking about information or talking with the patient about what is your return to work expectation. And it would be better if there was more communication across all of the care spectrum so that patients are aware of what the expectations are, can set those expectations early because it can come as a shock at you. Don't expect to go back to work until six weeks and then all of a sudden your employer is like, you should be back to work next week. A patient's not going to understand the difference of that. And so if we have more clinicians talking about those pieces, benchmarks and guidelines can kind of fill that role to provide that information. It's kind of a shortcut for all the occupational training that occupational physicians get. You can quickly look up by diagnosis how long people should be out of work or what is the expected recovery time, and also both returning to work quickly. And like Shane said, if you're not returning to work or not returning to your activity level, what's going on? Let's talk about that. Let's fix something, because we want everybody to be returning to their normal life.

Heather Grimshaw: I think that's really helpful, Kerri, thank you for that. Because it does seem as though there's a lot of unknown and potentially anxiety of what role employers can and should play when they're reaching out to and helping support employees, as well as communicating with providers and how they can support that recovery in an appropriate way. And I think that there are references to the modified duties and Dr. Vaghef mentioned the flexibility on the side of employers to really reassess. And I think the way she phrased it is, why not? Why not consider a different approach here so that we can support the employee and return that person to activity and to work when possible? So this has been such a wonderful conversation. I really appreciate all of your input and perspectives here. Thank you all for joining us for the conversation today.

Kerri Wizner: Thanks so much. It was great to be here.

Dr. Keemia Vaghef: Thank you.

Dr. Shane Journeay: Thank you for having me.