Conquering the Barriers in Worker Rehab

Nicole Matoushek, PT, MPH, CSHE, CE

ErgoRehab, Inc.

WORKER REHAB
Worker rehab is a specialized niche of the therapy industry. Because worker rehab deals with return to work, it often involves additional factors that may adversely affect the rehabilitation process. Some of these factors include: clinical complications, return to work, work factors, attorney/legal issues and motivational issues. Thus, frequently in worker rehab, the therapist encounters barriers in the rehabilitation of the injured worker that can affect the treatment planning, progression and outcomes of their services.

BARRIERS IN WORKER REHAB
In order to effectively manage these potential factors, it is important to first define the specific barriers in worker rehab, and how these factors can adversely influence the progression and outcome in worker rehab. Barriers in worker rehab are influencing factors that adversely affect the progress, outcomes and efficiencies of the skilled therapy services. The presence of these barriers can have a negative impact on therapy outcomes. Barriers can result in a decline in:

*Patient satisfaction.
*Functional outcomes.
*Quality of care.
*Progression of rehabilitation.
*Efficiencies of therapy care.
*Return to work status/outcomes.
*Reimbursement for services.

Barriers in Worker Rehab include:

*Subjective Influencing Factors.
*Objective Influencing Factors.
*External Influencing Factors.

By actively managing these influencing factors, the rehabilitation professional can optimize functional outcomes and rehabilitation proficiencies.

CLINICAL MANAGEMENT
Clinical Management in skilled therapy involves actively managing the therapy treatments, goals, and outcomes in accordance with clinical standards of practice. In order to achieve optimal levels of functional outcomes in worker rehab, it is essential that the therapist treating the injured worker, identify and apply the appropriate clinical management strategies to therapy treatments.

The active clinical management of skilled therapy in worker rehab results in:
1.) Cost effective therapy services.
2.) High quality care that is based on the medical necessity of the patient.
3.) Superior functional and return to work outcomes.
4.) High patient satisfaction.
5.) Reduction in re-injury rates upon return to work.
6.) Enhanced opportunities for worker rehab program marketing.
7.) Identification of appropriate candidates for additional work injury management programs and services: FCEs, return to work programs, ergonomics services, gym/fitness programs.

Clinical Management Strategies in Worker Rehab include:

*Provide therapist driven treatment plans.
*Build inherent flexibility in plan of care.
*Ensure patient responsibility and independence.
*Provide home exercise program.
*Provide work-specific treatments.
*Clinically manage surgical protocols.
*Clinically manage complications.
*Focus treatment on functional restoration.
*Do not focus on pain/passive treatments.
*Identify plateau in progress.
*Be proactive with therapy discontinuations and discharges.
*Prepare the patient for discharge.
*Provide effective communication.

When the rehabilitation professional is presented with a challenging case that involves one or more of the barriers in worker rehab, the rehabilitation professional can apply these clinical management strategies in order to control and reduce the influence of these barriers. By applying the appropriate clinical management strategies to the identified barrier in worker rehab, the therapist can provide more efficient and effective therapy care, to even the most challenging cases.

SUBJECTIVE INFLUENCING FACTORS
The first barrier in worker rehab that will be presented is the subjective influencing factor. Subjective influencing factors are barriers to the rehab process which involve the patient's experience, personality, perception and motivations. The presence of any of these subjective influencing factors can limit the patient's ability to tolerate or progress with the rehabilitation process. If the subjective influencing factor is not addressed and controlled, the patient may not be able to progress or achieve optimal functional outcomes in skilled therapy.

"Subjective" is defined as phenomena not directly assessed by the rehab provider, perceptible only to the patient and cannot be perceived by the clinician.

The three Subjective Influencing Factors include:
*Pain Limitations/Pain Focus.
*Behavioral Interferences.
*Poor Motivation.

In order to maximize clinical efficiencies and functional outcomes in worker rehab, the following clinical management strategies for subjective influencing factors can be applied:

*Although pain should not be ignored, treatments should not focus on pain or palliative techniques.
*Keep rehab focus on active, functional activities and abilities: what the patient can do.
*Provide goal-directed therapy.
*Promote patient independence in symptom control and home exercise program.
*Provide patient encouragement.
*Document clinical findings and inconsistencies.
*Communicate findings: physician, insurance adjuster, case manager, patient.
*Recommend functional testing or Functional Capacity Evaluations for appropriate candidates.

The presence of any of these subjective influencing factors can limit the patient's ability to tolerate or progress with the rehabilitation process. If the subjective influencing factor is not addressed and controlled, the patient may not be able to progress or achieve optimal functional outcomes in skilled therapy. By applying active clinical management to the identified barriers in worker rehab, the rehabilitation professional can effectively improve functional outcomes and control the adverse effects of the subjective influencing factors.

OBJECTIVE INFLUENCING FACTORS
The second barrier in worker rehab that will be presented is the objective influencing factor. Objective influencing factors are barriers to the rehab process which involve clinical, physical or physiological factors. The presence of any of these objective influencing factors can limit the patient's ability to tolerate or progress with the rehabilitation process. If the objective influencing factor is not addressed and controlled, the patient may not be able to progress or achieve optimal functional outcomes in skilled therapy. "Objective" is defined as phenomena that exist independently of the patient's perception. Objective measurements must be standardized.

The three Objective Influencing Factors include:
*Clinical Complications.
*Functional Limitations.
*Functional Plateau.

In order to maximize clinical efficiencies in skilled therapy and provide only medically necessary care, the rehabilitation provider should apply clinical management strategies to the treatment planning process.

Active clinical management strategies for the patient with clinical complications include:
*Modify the plan of care and goals on a regular basis to ensure clinical efficiencies.
*Reduce the therapy visit frequency and duration until the clinical complication is addressed, the patient is healing well and can tolerate more aggressive therapy activities.
*Promote independence with home exercise program or home equipment if slow healing is expected.
*Provide goal-directed therapy.
*Discuss the modifications of treatment goals and plan with the patient. This will help to ensure patient remains motivated and goal-oriented in therapy.
*Discuss the clinical findings with the patient in order to ensure high levels of patient responsibility and compliance.
*Communicate clinical findings to the physician, insurance adjuster, case manager.
*Provide documentation of objective findings and plan of care revisions to the physician, insurance adjuster and case manager.

The presence of any of these objective influencing factors can limit the patient's ability to tolerate or progress with the rehabilitation process. If the objective influencing factor is not addressed and controlled, the patient may not be able to progress or achieve optimal functional outcomes in skilled therapy. By applying active clinical management to the identified barriers in worker rehab, the rehabilitation professional can effectively improve functional outcomes and control the adverse effects of the objective influencing factors.


EXTERNAL INFLUENCING FACTORS
The third barrier in worker rehab that will be presented is the external influencing factor. External influencing factors are barriers to the rehab process which involve factors that are typically beyond the scope of therapy and not under the rehabilitation professional's control. The presence of any of these external influencing factors can limit the patient's ability to tolerate or progress with the rehabilitation process. If the external influencing factor is not addressed and controlled, the patient may not be able to progress or achieve optimal functional outcomes in skilled therapy. “External" is defined as a phenomenon that is coming from the outside.

External influencing factors are barriers to the rehab process which involve factors outside the clinic.

The three External Influencing Factors include:
*Attorney/Legal issues.
*Work Issues.
*Re-referral without Medical Necessity.

Clinical management strategies for when the patient appears influenced by an attorney include:
-Keep patient focused on rehabilitation.
-Minimize distractions in therapy by not allowing the patient to discuss legal issues in therapy.
-Provide goal directed therapy.
-Provide work-specific therapy.

The second external influencing factor that can adversely influence functional outcomes and present clinical challenges are work issues. These work issues may become increasingly apparent and challenging if the injured worker has anxiety or apprehension about returning to work, is experiencing challenges performing the work duties, is reporting difficulties with interpersonal relationships at work or is having trouble adjusting to a new position. Specific issues that involve aspects of work, that may adversely affect rehabilitation progression include:
-Ergonomic risk factors.
-Work restrictions.
-Relationships with co-workers.
-Available work duties.
-Work organization factors.

Although the rehabilitation provider may not have any influence over work issues, active clinical management can help the rehabilitation provider to facilitate patient progress despite the presence of the work issues. The presence of any of these external influencing factors can limit the patient's ability to tolerate or progress with the rehabilitation process. If the external influencing factor is not addressed and controlled, the patient may not be able to progress or achieve optimal functional outcomes in skilled therapy. By applying active clinical management to the identified barriers in worker rehab, the rehabilitation professional can effectively improve functional outcomes and control the adverse effects of the external influencing factors.

SUMMARY
The first step in clinically managing the challenging cases in worker rehab is to identify the goals of worker rehab and the potential barriers that may adversely influence therapy outcomes and efficiencies. Once the barriers or influencing factors are identified, the rehabilitation professional can apply the appropriate clinical management strategies to clinical care in order to provide more efficient and effective therapy care, achieve optimal levels of functional outcomes and ensure patient satisfaction, in even the most challenging cases.

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Nicole Matoushek, PT, MPH, CSHE, CEES

ErgoRehab, Inc.

More information about ErgoRehab, Inc. courses

Other articles by Nichole:

Prompt Return to Work

Injury Prevention: The Shoulder Joint

Anthropometrics and Ergonomics

The History of Ergonomics

Why Offer Return-to-Work Programs?

What is Ergonomics?

Work Injury Prevention and Management

The Cost of Work Related Injuries

Ergonomics and Work Efficiency

Functional Outcomes in Worker Rehab

Conquering Barriers in Worker Rehab

Maximizing Reimbursement in Worker Rehab

Clinical Management in Worker Rehab

Work Injury Consultants

Marketing and Selling Ergonomics and Worker Rehab Services

The Economic Burden of Workplace Injuries

Keyboard Design

Health Ergonomic Objectives

Ergonomics: Work Design Principles

Ergonomics and Muscle Fatigue

Work Modifications using Administrative Controls

Ergo Guidelines for Seating Equipment

Office Setting Ergonomics

Ergonomics: Evaluating Mouse Features

Ergonomics: Evaluating Keyboard Features

Ergo Guidelines for Input Devices

Ergo Guidelines for Office Accessories

Ergonomics/Posture Tips for Laptop Users

Laptop/ Computer Keyboard Design

Sports Medicine Approach to Industrial Rehab