Managing disability claims effectively requires participation and cooperation from a variety of internal and external stakeholders, including attending physicians, disabled employees, unions and other stakeholders. Their buy-in from the beginning of the process can significantly impact how efficiently disabled employees return to work.

Medical Assessments are used in the workplace to evaluate the medical and physical condition of an individual. Such assessments may be done to assess the suitability of an individual for a particular job, for example a job demanding certain strengths, flexibility, dexterity or other physical characteristics. Assessments are also used to determine progress along a recovery path and its expected duration.

From an insurance perspective and relative to a job, an assessment may be needed to determine the condition of a person who has been injured or has suffered illness in order to determine a recovery plan which will enable them to return to their current line of work, or if that is not possible an alternative type of work.

Assessments may be simple and done quickly by one qualified individual, or may be complex and require a team of professionals with various specializations over an extended period of time, employing different types of examinations and evaluations. As a result, the knowledge and experience required to organize and manage assessments effectively and efficiently has developed into its own specialization.

Medical Assessments – Employer/Employee Advantage:

Many employers have created disability management programs that include most every aspect required to effectively manage absence in the workplace – with the exception of “medically” adjudicating and managing absences.

Employee Perspective:

From an employee’s standpoint, medical adjudication and management is an important step in verifying and managing each aspect of a short or long term absence.  When an absence is managed medically, the employee is provided with the support required to return to the workplace, whether that return be graduated or full-time.

Medical assessments perform a dual function in the return to work process.  A medical assessment will verify a reported disability and provide confirmation to the employer/insurer that the employee is disabled and not able to perform the necessary duties of their pre-disability job.

Employer Perspective:

A medical assessment will also aid in returning the employee to the workplace when they have been absent due to an illness and/or injury.  Identifying return to work options for the disabled employee is not possible when the employer has not been provided with restrictions and limitations with respect to the employee’s disability.  Often employees provide an employer with what they believe to be appropriate return to work data from their treating physician when in fact the employer does not have what is required to ensure a safe and effective return to work.

Medical Assessments in Conjunction with Short/Long-Term Disability:

When an employee is absent from the workplace and receiving short or long-term disability, insurers will on occasion utilize a medical assessment for a variety of reasons including:

• Verification of claim where medical is not clear/available;
• Continuation of claim – to verify disability;
• Return to work – where the employee is experiencing difficulty with a graduated or full time return to work and employee may be falling back to the disability claim repeatedly.

Dual Diagnosis Claims:

The face of disability is changing for both insurers and employers/employees alike.  Insurers are experiencing an insurgence of claims that have both a physical and a mental health component.  Other claims are strictly mental health or physical in nature.

Due to the increase in dual diagnosis claims, insurers and employers are experiencing additional stressors in both adjudicating the initial diagnosis, and providing effective and meaningful return to work plans for employees.  With the changing demographic of claims, and the fact that often the second diagnosis does not come to light until the claim has been initially approved, medical assessments are proving to be an effective means to verify illness or injury and provide essential return to work assistance to both parties.

In short, use of a medical assessment during a casual absence, short or long-term disability situation is often necessary to validate disability and assist both the employee and employer in a return to work situation.  Successful return to work where an employee is able to safely and effectively return to their pre-disability position is key in retaining employees. 

Medical Assessments Available:

• Independent Chiropractic;
• Independent Functional Abilities Evaluation/Functional Capacity Evaluation;
• Physical Demands Analysis/Independent Job Site Analysis;
• Independent Neurology Evaluation;
• Independent Neuropsychology Examination;
• Independent Oral and Maxillofacial Examination;
• Independent Orthopaedic Evaluation;
• Independent Physiatry Evaluation;
• Independent Psychology Evaluation;
• Independent Psychiatry Evaluation;
• Independent Rheumatology Assessment;
• Independent Vocational Evaluations;
• Independent Neuro-psycho-vocational Evaluations;
• Independent Psycho-vocational Evaluations.

 Summary:

A.R.S. understands the importance of effective claim management, adjudication and return to work through the use of medical assessments.  A.R.S. provides a wide variety of medical assessments nationwide to employers, insurers and various Workers Compensation Board(s) across Canada.  A.R.S. specializes in providing services in remote locations where other organizations cannot.

For additional information regarding A.R.S.’ nationwide medical assessment services and all other Employer Services offered by A.R.S. please contact:

Mary Crunkleton – Director of Employer Services
mary@arsi.ca

www.arsi.ca
Telephone: 416-510-2468 or Toll Free: 1-877-304-2239

For instance, psychological tests measuring depression, dementia, or psychosis detect these conditions just as accurately as medical tests such as Magnetic Resonance Imaging (MRI), pap smears, and electrocardiograms detect physical pathology.  Neuropsychological testing for instance has been shown to detect dementia as accurately as MRI (Daw, 2001). However, in order for a psychological assessment to produce accurate and clinically useful findings, the assessment needs to be conducted carefully and comprehensively, which takes time.

I am frequently asked why a psychological assessment under the SABS requires a booking of three to four or sometimes even five hours. The purpose of this article is to provide a more indepth explanation of what a psychological assessment entails, why we ask claimants to sit for several hours collectively between the clinical interview and psychological testing, and why a second appointment is often necessary.

Assessing individuals who have been involved in motor vehicle accidents requires not only that we identify if any psychological impairment exists and the magnitude or severity of these impairments but also whether such impairments result from the motor vehicle accident (i.e., causality). To do so requires that we understand the individual’s background history and in particular, his or her mental health history. Unlike our colleagues who assess physical impairment, psychologists do not have x-rays or MRIs that allow for comment on whether an injury is old or new. We must rely on what the examinee tells us as well, our clinical observations, psychological test results, and a detailed review of a medical file, which might be hundreds if not thousands of pages in length. Some might argue that the heavy weight placed on an examinee’s self-report renders the psychologist impotent or ineffective in obtaining an objective and credible account of the participant’s functioning, especially given that base rates for overreporting of difficulties in litigious populations have been shown to be significant (e.g., Mittenberg et al., 2002).

While it is true that the objective data that we rely on from psychological tests by definition comes from the examinee’s reports, it would be incorrect to conclude that we cannot provide objective and empirically validated evidence of psychological impairment. Interpretation of objective psychometric measures does not involve taking a participant’s endorsement of “I often feel sad and blue” (for instance) at face value. Instead, objective psychometric interpretation requires examination of profile distortion, response patterns, the configuration of clinical scale elevations, and empirically determined correlates of such profile configurations.

While an in-depth discussion of how this interpretive process works is beyond the scope of this article, suffice it to say that an examinee’s response patterns are interpreted by comparing his or her profile with thousands of others who have completed the same measure under standardized administration and examining what scientific studies have shown us to be true about individuals with similar testing profiles, and not by taking the participant’s individual responses at face value. Indeed, these are empirically validated objective measures rather than subjective measures.

The formidable three-part task of identifying psychological impairments, determining the cause of such impairments (e.g., accident-related or not) and determining the credibility of the interviewee’s report is a complex and time consuming undertaking. The process requires a multimodal examination of different sources of information – the participant’s behavioural presentation over the course of the assessment, his or her reports during the interview, a review of the medical brief, and the administration, scoring and interpretation of objective psychometric measures. Psychologists then engage in discrepancy/convergence analysis – that is, we systematically examine whether these sources of data corroborate each other, whether there are discrepancies, and if there are discrepancies, we must reconcile such discrepancies in our conceptualization of the examinee’s clinical picture. For instance, if the participant exhibits a full range of affect and is engaging at interview (e.g., if he or she is observed to joke with the examiner, engage in spontaneous small talk, etc.) and yet reports severe depressive symptomology at interview (two data points that do not corroborate), an examination of objective validity indices on psychometric tests can provide insight into why the discrepancy is present. If objective psychometric validity indices and tests reveal a strong tendency to over-report or embellish psychological symptoms, the psychologist might hypothesize that the examinee was over-reporting at interview and that the credibility of his or her reports is questionable. On the other hand, if objective validity indices reveal a reliable and forthright approach to the completion of psychological tests (i.e., no evidence of underreporting or over-reporting of symptoms), the psychologist might speculate that the claimant’s depression is in fact quite significant but that he or she can “hold it together” at interview. In this case, the psychologist might downgrade the claimant’s depression to “moderate” rather than “severe” (as severely depressed individuals usually do not present as engaging at interview) but still conclude that the participant’s reports are generally credible and that the depression is genuine.

Causality

Determining the degree to which psychological impairments are a result of a motor vehicle accident requires a careful examination of the examinee’s mental health history. Given what we know about base rates of psychological conditions in the population at large (which are in actuality quite significant), it is necessary for the psychologist to explore possible pre-existing conditions and to determine whether the clinical picture identified in the examination represents a continuation of a pre-existing condition, or whether the accident resulted in an exacerbation or aggravation of pre-existing psychological features, or whether the clinical picture represents newly developed symptoms resulting from the accident. Such an examination requires careful interviewing around the participant’s family history of psychopathology, the participant’s past diagnoses, past relationship functioning, history of alcohol and drug use, past mental health service usage (e.g., psychotherapy or use of psychotropic medication), and the participant’s perceptions of how he or she was doing psychologically during the time period just prior to the accident. This section of the interview alone can be very brief in cases where the individual denies pre-existing psychological problems altogether but can also be very extensive in cases where the participant presents a complicated pre-accident mental health history (e.g., multiple diagnoses, hospitalizations, multiple treatments, etc.) When available, the participant’s family physician’s clinical notes and records are examined and compared with the examinee’s reports to corroborate their version of their pre-accident history.

Determining that a psychological symptom developed following a motor vehicle accident does not in and of itself mean that the symptom is a result of the motor vehicle accident. While the temporal relationship is an important clue, a psychologist also needs to understand the mechanism by which the MVA resulted in the development of the symptom. Consider for instance the case of an individual with a history of recurring Major Depressive Episodes over a 20 year period. If this individual becomes depressed following the accident, the psychologist must understand how and why the depression developed. Perhaps the development of
accident-related pains and associated activity limitations and role loss resulting from physical injury triggered the new depressive episode – in which case the psychologist would conclude that the depression results from the subject accident. It is plausible (albeit not as likely) that the depression developed independently – perhaps triggered by a relationship break up or a job transfer. The take home message is that psychologists must understand the mechanism of action that results in the development of psychological impairment in order to understand its pathogenesis (i.e., causal factors).

It is important to keep in mind that the identification of pre-existing psychological conditions and how they affect accident-related psychological conditions is a complex undertaking. It is relatively easy for a psychologist to assess an individual who denies psychological difficulties prior to the motor vehicle accident altogether and then describes a traumatic accident and significant post-traumatic stress symptoms thereafter. It is immensely more complicated to assess an individual with a pre-existing history of abuse or trauma with ongoing post-traumatic stress who then becomes more symptomatic after a motor vehicle accident that most people would not react psychologically to. Psychologists who work with motor vehicle accident claimants must conduct careful interviews in order to effectively entertain crumbling skull and
thin skull scenarios. Stated differently, careful interviewing allows a psychologist to differentiate between 1) an examinee whose psychological impairments are attributable specifically to the subject accident, 2) an examinee whose psychological impairments represent a continuous cycle of peaks and valleys of psychological symptom severity whereby the “peak” would have occurred anyway, regardless of the accident, 3) an examinee whose psychological impairments represent an exacerbation of pre-existing psychopathology or an unusually strong psychological reaction owing to pre-existing vulnerabilities such as past trauma.

Clinical Interview

A carefully executed psychological assessment of motor vehicle accident victims must include a comprehensive interview in regard to current clinical symptoms and functioning. The psychologist must ask (typically in semi-structured interview format) about symptoms of depression, posttraumatic stress, vehicle anxiety/phobia, other forms of anxiety, sleep functioning, cognitive functioning, and use of alcohol and substances. In order to assess posttraumatic stress, the interview must include having the participant recount what happened during the accident and how the participant reacted emotionally at the time. Moreover, the psychologist must understand the claimant’s perceptions of physical pains, their attitudes and beliefs about their pain, and the coping strategies that they use in the face of physical pains. In this regard, assessment of psychological disability or the need for pain management psychotherapy requires a good understanding of the relationship between physical pains and emotional functioning, catastrophizing processes, self-perceived disability, and whether there is an active or a passive-dependent approach to pain management and rehabilitation.

The psychologist must also properly interview the examinee in regard to his or her current every day functioning. This part of the interview requires more than just a survey of what the participant believes he or she can or cannot do as compared with prior to the accident, but must also aim to understand the link between psychological impairment and functional changes – is there evidence of kinesiophobia (i.e., fear of movement) related to pain? Is the examinee simply choosing to avoid certain activities because of expected pain increases or is there evidence of psychological impairments that preclude them from engaging in such activities? Again, this section of the interview can be conducted very briefly in some cases but can also take a considerable amount of time depending on what the examinee conveys in regard to what he or she can or cannot due and why.

The participant’s understanding of his or her injuries and perceptions of the effectiveness of treatments to date and what he or she believes has been lacking is also pertinent information for a psychologist. The clinical interview typically includes other components as well – information is collected in regard to childhood history, past abuse or trauma, educational and occupational history, family and relationship history, social history, if relevant – developmental history, and if culture is a factor – immigration history and acculturation history (i.e., to what degree has the claimant acculturated to Canadian society). The cultural factors are important to consider when interpreting interview and psychometric test data as certain methodologies could be invalid (e.g., psychometric tests normed on North Americans cannot be interpreted in the standard manner when utilized with individuals from different cultural backgrounds. Psychologists must operate with different assumptions and modify their analytical methodologies accordingly.

It is also important to consider that the duration of the clinical interview also varies as a function of the participant’s communication style. Some individuals effectively provide concise and “to the point” responses whereas other individuals are tangential, exhibit psychomotor slowing (such that they do not provide information as quickly) or provide unusually high levels of detail. Some individuals downplay aspects of their personality or psychological functioning due to a lack of self-awareness or stigma-related concerns such that considerable probing at interview can sometimes be required.

If there is a take home message here, it is that the clinical interview portion of a psychological assessment can range from as little as 1.5 hour in an unusually uncomplicated case to as long as several hours, depending on the purpose of the assessment, the complexity of the case, or the participant’s style of communicating.  The interview process will take even longer when an interpreter is used or if there is a closed head injury superimposed on psychological impairment.

Psychometric Testing

Psychologists typically administer a battery of several psychometric tests to corroborate the examinee’s reports at interview with empirically (i.e., scientifically) based objective data. It is not enough to administer “check lists” or basic unidimensional measures of a psychological construct (e.g., such as the Beck Depression Inventory – II to measure depression) without also ensuring that the participant provided valid psychometric test data. Many of the administered tests are self-report inventories whereby the participant might endorse “false” or “true” or choose between “strongly disagree”, “disagree”, “agree” or “strongly agree.” Consider that the examinee could randomly choose different answers if he or she so desired, such that the test scores would be meaningless. Or, consider that the participant might not understand the nuances or meaning of the test items and provide responses that do not actually represent his or her experience. Alternatively, the examinee could deliberately choose extreme responses in order to convey high levels of suffering, such that test scores would overrepresent the severity of his or her actual symptoms. Finally, the examinee could approach the test in a guarded manner and minimize or underreport psychological difficulties due to a lack of self awareness or due to stigma concerns.

Fortunately, there are well validated “validity indices” on commonly used multidimensional inventories that allow the psychologist to measure the degree of inconsistent or idiosyncratic responding or the degree to which he or she provided a forthright and accurate reflection of actual psychological difficulties. As a general rule, psychological assessments of individuals who have been involved in motor vehicle accidents – whether they are carried out to tailor a Treatment Plan and proposed psychotherapy or whether they are carried out as an insurance examination to determine the necessity of psychological treatment or the presence or absence of psychological disability – should include at least one well validated multidimensional measure with built-in validity scales. While there are exceptions to this rule (a discussion of which is beyond the scope of this article), inclusion of such measures is the only way one can be confident in the reliability and validity of self-report psychometric test data. Unfortunately however, these measures are typically lengthy and can take over an hour or sometimes even two hours to administer. Indeed, these measures typically include over 340 items and can include as much as almost 600 test items. When one considers that a typical testing battery in a comprehensive psychological assessment includes several psychological tests (typically including one or more of these longer measures), it is not unusual for 500 test items to be administered during such an assessment.

When one considers issues related to using interpreters, possible reading or comprehension difficulties and a participant’s need to seek clarification from the examiner, and the fact that there is considerable variability in how long people take to respond to self-report inventories, one can see that the psychometric testing component itself can take over two hours and sometimes longer. Psychologists also administer non-verbal performance-based measures and tests of effort to ensure adequate engagement, adding further to the assessment time. While there is variability in test selection (both as a function of assessor preference and of specific examinee needs), it is typically insufficient to administer two or three screening measures coupled with a brief interview.

While I often read reports that describe such truncated assessments as comprehensive psychological assessments, I would submit that more times than not, these are screening assessments at best and cannot properly provide a defensible opinion as to the participant’s psychological functioning, causality, and credibility with confidence.

Summary

There is considerable variability in the amount of time it takes to conduct a thorough psychological assessment. Assessment time varies as a function of the complexity of the case, the purpose of the assessment and specific referral questions, the participant’s communication style (i.e., do they provide concise and effective responses or do they provide insufficient information spontaneously such that the psychologist has to probe for a more complete answer), the examinee’s history, test taking ability and style, or whether there is an interpreter or need for frequent clarification. Psychologists cannot predict the length of the assessment in advance as only some of the variables that affect assessment duration can be known before the participant arrives.

On average, and depending on the type and purpose of the assessment, psychologists should typically meet with the examinee for between three to six hours for a basic psychological assessment, in addition to indirect service time (e.g., time taken to review the medical brief, write up the assessment report, consult with others assessors or providers on an as-needed basis, etc.) When a psychologist is conducting an assessment for treatment planning purposes, it is also required that the psychologist meet with the participant after the assessment for a feedback session to review assessment findings and details of the report, to communicate applicable diagnoses, to discuss treatment planning and if treatment is in fact being proposed, to have the participant sign and consent to the submission of an OCF-18. This, however, is not usually the case when an insurance examination is performed. When specialized assessments such as neuropsychological or psychovocational assessments are carried out, additional time of several hours duration might also be required over and above that which is described above.

While a psychological assessment usually takes a substantial amount of time due to the complexity of the assessment process, a thorough assessment can provide a truly defensible opinion regarding diagnosis, causality, prognosis, treatment needs, and most other issues regarding disability. One should be wary of brief screening assessments which may fail to provide a reliable and accurate account of the examinee’s clinical picture. When conducted properly and comprehensively, psychological assessments are robust diagnostic tools with strong reliability, validity, and clinical utility for the determination of disability and treatment requirements.

References

Daw, J. (2001). Psychological assessments shown to be as valid as medical tests. Monitor on Psychology, 32(6).

Mittenberg, W., Patton, C., Canyock, E. M., & Condit, D. C. (2002). Base rates of malingering and symptom exaggeration. Journal of Clinical Experimental Neuropsychology, 24(8).

Dr. Frank is registered with the College of Psychologists of Ontario as a Clinical and Rehabilitation Psychologist. He is listed with the Canadian Register of Health Service Providers in Psychology. He is a full member of the Association for Scientific Advancement in Psychological Injury (ASAPIL). He is an associate member of the Canadian Society of Medical Evaluators (CSME). He obtained his doctorate in Clinical Psychology from the University of Windsor in 2004. His training includes assessment, diagnosis and treatment of severe mental and behavioural disorders in psychiatric inpatient hospital settings. Dr. Frank’s training and experience to date also includes work in psychological trauma, the treatment of chronic pain, the assessment of disability, and rehabilitation following injuries. Dr. Frank has considerable teaching experience, having taught numerous undergraduate courses, and having taught and supervised numerous Masters-level clinicians, doctoral students and PhD-level psychologists in supervised practice in clinical and rehabilitation assessment and treatment. Dr. Frank has conducted research on the use of the Personality Assessment Inventory for the psychological assessment of claimants who have been involved in motor vehicle accidents and has coauthored a book chapter with newly developed norms for this population in 2010. Dr. Frank served on the Board of Directors of the Ontario Psychological Association from 2007 to 2010 and has been on the Board of Directors of CAPDA since 2009. He currently serves as Chair of the CAPDA Membership Committee and is involved in the development of the CAPDA board certification/diplomate program. A significant portion of Dr. Frank’s work involves the assessment and treatment of individuals who have been involved in motor vehicle accidents. He has performed hundreds of psychological disability assessments both at the request of plaintiff and defence, largely for individuals who have been involved in motor vehicle accidents (including Catastrophic, Post-104 disability, and assessment of treatment necessity and other specified benefits), for individuals with WSIB claims, and for individuals in other personal injury contexts (e.g., slip and fall, medical malpractice suits). He also has considerable experience providing psychotherapy (with a rehabilitation focus) to automobile accident victims and victims of work-related injuries. Dr. Frank also maintains an active private psychotherapy practice where he sees individuals with a range of psychological difficulties and couples with marital problems.

To schedule an Independent Psychological Examination or Independent Psychological File
Review with Dr. Frank, please contact A.R.S. at 1 (877) 304-2239 or info@arsi.ca.

The RTW Program is a collaborative process involving departments within each employer’s office, unions (where necessary) and staff. Most programs provide a planned approach to returning or remaining at work following an injury or illness, whether occupational or non-occupational.

Employers can develop a personalized RTW plan utilizing a member of the RTW staff in consultation with the staff, union representative, their physician and/or other health service providers, and their department head or manager.

Purpose of the Return to Work Program

The purpose of the RTW Program is to facilitate the safe and earliest possible return to work from absence due to injury, illness or a medical condition for each eligible employee. The program should be designed to meet the requirements of each province’s Human Rights Code.

An employee’s return to work may involve temporary or permanent modifications or adjustments in job duties or workplace arrangements in order to accommodate a disability of an individual staff member.

Privacy and Confidentiality

The RTW Program must respect the individual employee’s dignity, privacy of personal information and confidentiality of personal health information. Data should be collected for the purpose of a safe return to work plan for the employee and his/her department in compliance with the Freedom of Information and Protection of Privacy Act and the Personal Information Protection Act. Further, outside agencies, such as any Workers Compensation Board across Canada or a group insurer, should not share their information with the employer’s RTW program.

Who can access the Return to Work Program?

• All staff who are eligible under all sick day/sick plans within the organization’s internal policies or any staff member the organization deems eligible
• Staff should self-refer to the program through information provided by the organization on paper or electronically on the organization’s website
• With the knowledge of the staff, individual departments can certainly refer employees to the RTW Program
• With the knowledge of the staff, bargaining unit members may also refer employees to the RTW Program 

Roles and Responsibilities of all Stakeholders in the Return to Work Process

Some or all of the following parties may be involved in return to work planning in the following capacity:

• Organization: Must comply with the Human Rights Code in their province of residence together with all other relevant legislation including the Freedom of Information and Protection of Privacy Act. Compliance includes the duty to accommodate to the point of undue hardship for employees who meet the definition of disability as provided for in human rights law.
• Departments: Must identify and provide reasonable, meaningful and productive job adaptations or accommodations that assist the employee during the return to work process. Must ensure that each employee is returning to work following safe work practices, which have been agreed to and outlined by the department.
• Unions: Must advocate on behalf of employees returning to work and ensure collective agreements are not compromised except as required by human rights legislation.  Unions should also work in harmony with the employer to ensure the return to work process for each employee is coordinated and fully integrated.
• Return to Work Specialists/Health Promotion Programs: Must act as an expert resource for all parties involved if an employee is experiencing health related issues to remain in the workplace, or the employee is absent and returning to work. Must liaise with the medical community and interpret medical information. Coordinates with all stakeholders involved in the planning, implementation and monitoring of safe and timely returns to work. Encourages appropriate accommodation as medically recommended, monitoring the progress of the disabled employee. Responsible for ensuring privacy and security of medical information.
• The Employee: Provides objective medical documentation of restrictions and limitations to the Health Promotion Office. Participates in treatment as prescribed by his or her medical team. Communicates regularly with his/her supervisor and all internal RTW Specialists.

Return to Work Process

For accepted referrals to the RTW program, the RTW Process should begin once the employee signs an informed consent/medical release document.  Once the informed consent/medical release document is signed, a Return to Work Specialist is assigned to the absence.

The process should be flexible depending on the individual and the medical case requirements however; the Return to Work Process generally proceeds in the following manner:

• Program description, interview and consent/medical release document
• Collection of medical documentation for the purpose of RTW
• Communication on a need to know basis with stakeholders (specifically with respect to diagnosis/prognosis if in fact this information has been provided)
• Exploration and delineation of options for accommodation
• RTW plan implementation
• Follow up and monitoring

In Summary:

All internal policies relating to return to work for a disabled employee are crucial to the internal working of any organization.

A.R.S. understands the costs involved in managing absence and returning employees to the workplace at the earliest and safest opportunity.  Effective creation of return to work policies and procedures are essential to managing absence in the workplace.

For additional information regarding all functions related to return to work and all other Employer Services offered by A.R.S. please contact:

Mary Crunkleton – Director of Employer Services
mary@arsi.ca
Telephone: 416-510-2468 or Toll Free: 1-877-304-2239

Ineffective or dated Absence Management policies are often the culprit where excessive casual absence is concerned.  If employees are either not aware of the policies or the policies are out of date and not effective an organization’s bottom line suffers.  Some employers will also not have formal policies in place, for a variety of reasons.  This will also negatively affect their bottom line.

Employers need to ensure that they have current and relevant Absence policies and procedures in place to address employees who are away from the workplace due to illness.  When absence is not managed properly problems such as loss of production or a reduction in services can arise and staff morale can be adversely affective.

Current policies created specifically for your organization will allow you to illustrate to employees that they are being treated fairly, equally and reasonably, which is crucial if employees need to be disciplined or eventually dismissed for poor attendance.

Creation/Amendment of Policies:

The larger the organization, the more difficult it can be to control sickness or other absences and their associated costs.  Many employers find it useful to have a current written Human Resources policy and procedure that informs employees the exact process for a variety of absences.

Sickness related absences can be casual (less than 3 days consecutive absence) to short or long-term in nature.

When employees know that their absences are being captured and reviewed or documented, their level of absence tends to decline as a matter of course.  The same can be said about the processes an employer puts into place regarding meeting and speaking with employees.  Some employers publish anonymous statistics that indicate the difficulties created by unacceptable absence levels.  This will reinforce your policies and employees will remain aware of the most current absence levels for the organization.

Best Practices:

• Absence management should always be conducted in an environment of mutual trust and confidence, as well as safety and a healthy workplace;

• Managers who develop a relationship including mutual trust and respect with their staff enable open discussion and support which encourages employees to honour internal corporate policies;

• Incorporate fair and understandable processes and policies for sickness and absence and develop these with your corporate culture in mind;

• All contracts of employment should include a clause referring to a specific procedure or policy which should also include an overview of the processes;

• Contracts of employment should also include a clause requiring employees to agree on request, to undergo a medical examination by an occupational health or other medical professional and to grant release of the related medical report to the disability management department/specialist at the employer.  All such requests for medical must be tied in to absence and disability management policies;

• Employers must take reasonable steps to remedy the cause of illness/injury to employees and prevent recurrence when sickness absence is due to a workplace problem;

• Policies should include a statement ensuring employees are not expected to attend work while unfit medically, regardless of the inconvenience their absence may cause the employer.

Types of Absence:

Employees will be away from the workplace for a variety of reasons:

• Casual absence (less than a specific number of consecutive days), certified or uncertified;
• Short-term sickness absence (up to and including a specified number of days or weeks absence);
• Long-term sickness absence (usually paid for by an insurer through an employer sponsored program);
• Unauthorized absences or persistent lateness;
• All other authorized absences including unpaid leaves, maternity, paternity, educational and all other authorized absences.

Measurement of Absence:

Why would an employer want to measure any or all forms of absence by employees?  A key element of managing absence is accurate measurement and monitoring of all absence.  When an organization assesses the difficulties they experience with absence, they are able to look at its extent and the best way to work through the absence related issues at hand.

The data should be collected to identify particular patterns of absence and underlying causes, for example, the management style of a particular manager or an increase in workloads. It can also provide evidence of how absence impacts on the bottom line and why it is worth investing in an effective absence management programme or Human Resources database.

Accurate records should be kept of the employee’s absence and the different reasons for the absence, e.g. sickness, holiday, etc. It is best to record the specific reasons for the sickness where this information is available such as colds or flu in order that your organization can see repeated reasons for absence. Regular patterns that emerge should as regular absences on Mondays or Fridays may indicate that the sickness absence is not genuine.

Measurement of Time Lost:

There are a number of measures that can be used to assess absence, each of which gives information about different aspects of absence. 

Lost Time Rate –

This is most common measure of absence. It expresses the percentage of total time available which has been lost due to absence.  It can be calculated separately for individual departments of groups of employees to reveal particular absence problems.

Frequency Rate –

The method shows the average number of absences per employee, expressed as a percentage. It does not provide any indication of the length of each absence period, or any indication of employees who take by counting the number of employees who take at least one spell of absence in the period, rather than to total number of spells of absence, the calculation gives an individual frequency rate.

Causes of Absence:

Various causes of absence must be measured and analyzed when an organization reviews its absence policies or is in the process of developing such policies.

• Minor illnesses (including colds, flu, etc.)

• Back pain

• Stress

• Skeletal injuries

• Recurring medical conditions

• Mental health

• Home/family responsibilities

• Other absences not due to genuine ill health

The Basics:

Absence policies should contain clear provisions supporting your organization’s business objectives and culture.  Various forms of government legislation must be taken into account when formulating your organization’s internal policies.

Effective absence policies must include employees’ rights and obligations when taking time away from the workplace due to sickness.

The policy should include the following:

• Details of contractual sick pay terms and their relationship with statutory sick pay;
• Outline the processes employees must follow if taking time away from the workplace due to sickness.  Who should employees notify and under what time restraints must these notifications take place;
• After how many consecutive days of absence must employees complete a sick day certificate;
• Make note that the organization reserves the right to require employees to attend an independent third party medical assessment and under what conditions
• Include various provisions for return to work initiatives as well as early intervention;
• State clearly those employees who fail to follow procedures regarding notification of absence or who fail to provide medical certificates where required will be subject to disciplinary action.

Managing Long-Term Absence:

Various interventions are useful and possible at the workplace when managing longer term absences.

• Involving Occupational Health can be helpful when managing absences that are longer term in nature (but have not reached the “long-term disability” stage);
• Supervisor involvement must form part and parcel of the absence policy;
• Sick pay can be developed in a fashion that will pay a percentage of actual wages after a specified number of days absence;
• A formal rehabilitation program should form part of the absence policy;
• Return to work interviews and management also form an integral part of all absence policies.

Elements of Recovery and Return to Work:

• Staying in touch with sick employees – contact should be maintained on a regular basis using a non-intrusive approach.  All contact should be agreed to by the employee and management including direct supervisors and where appropriate a union representative;
• A risk assessment will identify measures or adjustments to assist a disabled employee return to the workplace and stay at work;
• Graduated return to work plans are crucial in bringing employees back to the workplace and must include input from the employee, treating physician, management, direct supervisor and where appropriate a union representative;
• A structured return to work committee should be in place to coordinate all return to work efforts including detailed graduated return to work planning.

Confidentiality – PIPEDA:

Employers must be aware of requirements under legislation regarding obtaining, storing and use of employee personal information.  “Personal information” will also include medical documentation obtained throughout the course of a short or longer term absence.

All internal policies must include statements about confidential information obtained from employees and employers must review these policies annually to ensure they are being adhered to as well as to ensure policies remain relevant.

In Summary:

All internal policies and procedures promoting effective absence management are crucial to the internal working of any organization.  Effective absence management is also about creating work environments and cultures where employees are less likely to want to be absent from the workplace.

A.R.S. understands that the costs involved in managing absence and creating appropriate internal policies and procedures.  Effective creation of policies and adjustment to current policies is essential in managing absence in the workplace.

For additional information regarding formal absence policy creation and all other Employer Services offered by A.R.S. please contact:

Mary Crunkleton – Director of Employer Services
mary@arsi.ca
Telephone: 416-510-2468 or Toll Free: 1-877-304-2239

On December 23, 2011, the Ontario Court of Appeal overturned the trial judge’s decision in Kusnierz v. The Economical Mutual Insurance Co. that psychological impairments should be combined with physical impairments to determine whether a motor vehicle accident victim has sustained a catastrophic impairment. This decision will likely impact the current definition of “catastrophic” impairment under the SABS and could lead to potential modifications to the definition.

This article will review the current definition of a catastrophic impairment as well as some relevant judgments pertaining to combining physical and psychological impairments using the AMA Guides to the Evaluation of Permanent Impairment, 4th Edition.

Current definition of a “Catastrophic” impairment under the SABS

Under section 2 (1.2)(f) and(g) of Bill 198 of the SABS (section 3(2)(e) and (f) of the current SABS), a person meets the definition of “catastrophic” where they sustained:
(f) . . . an impairment or combination of impairments that, in accordance with the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, 1993, results in 55 per cent or more impairment of the whole person; or
(g) . . . an impairment that, in accordance with the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, 1993, results in a class 4 impairment (marked impairment) or class 5 impairment (extreme impairment) due to mental or behavioural disorder.

The AMA Guides to the Evaluation of Permanent Impairment, 4th Edition (the “Guides”)

The Guides provide a method by which medical practitioners may assess impairment and assign a percentage rating to the impairment. In circumstances where an individual is suffering from two or more impairments, the impairments are combined under a “Combined Values Chart” in the Guides. If the combined value of the impairments reaches a total of 55% or more, the individual meets the SABS definitions of a catastrophic impairment.

Chapters 3 to 13 of the Guides deal with physical impairment. Chapter 14 deals with mental or behavioural impairment. Mental or behavioural impairment is not assessed on a percentage scale. Rather, it is assessed on a scale that ranks impairment from class 1 to class 5. If the individual is suffering from a class 4 (marked impairment) or a class 5 (extreme impairment) impairment, then the individual is suffering from a catastrophic impairment. This is assessed in four domains of function: activities of daily living, social functioning, work adaptation and concentration, persistence and pace.

As previously mentioned, the 4th Edition does not include percentage measures of impairment for mental or behavioural impairment under chapter 14. However, the chapter does reference percentage levels used in earlier editions under Table #3 “Emotional or Behavioural Impairment”. This table describes a five category rating system of No, Mild, Moderate, Marked, and Severe Impairment with associated percentage ranges in which Mild Limitation = 0 -14%, Moderate Limitation = 15% -29%, Marked Limitations = 30% – 49%, and Severe Limitation (of almost all functions)= 50% – 70%.

Whether in fact the Guides was intended to allow for combining of physical and psychological impairment has been argued in the courts and has been a contentious topic of debate.

Previous Judgments

Below are two notable cases where the issue of combining physical and psychological impairments was considered.

Desbiens v. Mordini

In this case, Superior Court Justice Spiegel concluded that a mental impairment could be assigned a whole body impairment percentage for the purpose of (f).

In 1986 Mr. Desbiens fell off a roof and was rendered paraplegic at T11-12. In November 1, 1999 a car struck him while he was wheeling down a sidewalk. The main issue at the trial before Justice Spiegel was whether as a result of additional injuries sustained in the car accident, Mr. Desbiens was entitled to Catastrophic designation under Sections 5 (1) f) and g) of the SABS regulation.

Justice Spiegel found that without taking into consideration Desbien’s paraplegia he had suffered a 40% whole body impairment as a result of the motor vehicle accident. The injuries included a spiral fracture of the femur. Justice Spiegel agreed with the plaintiff’s assertion that Mr. Desbien’s MVA related impairments must be considered in the context of his paraplegia and that a 40% impairment to a paraplegic is “qualitatively much worse than to an able bodied person”. He found Desbiens catastrophically impaired under Subsection f) for this reason. In addition, he found that Desbiens also met the 55% threshold under subsection f) when his psychological impairments (25%) were combined with his musculoskeletal impairments (40%) in the appropriate manner.

Justice Spiegel in Desbiens felt it appropriate to use the percent measures in the earlier editions, to allow the combination of physical impairment with mental or behavioural impairment. In doing so, the courts allowed experts to provide clinical judgment in the assessment of the level of mental or behavioural impairment in percentage terms.

Kusnierz v. The Economical Mutual Insurance Co.

In the case, Robert Kusnierz was a passenger in a vehicle involved in an accident on December 24, 2001. As a result of the accident, Mr. Kusnierz suffered numerous injuries, including a below knee amputation of the left leg. He also suffered from psychological problems including depression.

The main question argued in this case was whether assigning of percentage ratings for Mr. Kusnierz’s psychological impairments was permissible and if these ratings could be combined with the percentage ratings for the physical impairments.

Secondly, the court assessed Mr. Kusnierz’s impairments alone, to determine if he had met the threshold for a catastrophic impairment.

Justice Lauwers noted that in Chapter 14 of the Guides, mental or behavioural impairments are not expressed in percentages, as there is no empirical evidence to support any method for assigning a percentage of psychiatric impairment of the whole person. He rejected that the reference to percentages in previous editions gives assessors permission to use them in the assessment of catastrophic impairment. He argued that the Guides are based on the assessment of objective and verifiable impairment and does not permit the introduction of clinical judgment in the assessment of a percentage level of impairment for a mental or behavioural disorder.

The judge made the following conclusions:
I find that it is not permissible under the SABS to assign percentage values to mental and behavioural disorders under Chapter 14 of the Guides (which is referred to in clause 2(1.1)(g) of the SABS), and then combine them with the percentage values derived from impairments assessed under the other chapters of the Guides (referred to in clause 2(1.1)(f) of the SABS) in determining whether an individual meets the catastrophic impairment threshold of “55 per cent or more impairment of the whole person” prescribed by clause 2(1.1)(f) of the SABS.

Kusnierz v. The Economical Mutual Insurance Co. Ontario Court of Appeal Decision (December 23, 2011)
On Dec. 23, 2011, the Ontario Court of Appeal ruled in Kusnierz v. The Economical Mutual Insurance Co. that psychological impairments should be combined with physical impairments to determine whether a car accident victim has suffered a catastrophic impairment. Therefore, the Court reversed the decision of Mr. Justice Lauwers, who had held that assessors could not combine psychological and physical impairment scores to determine an injured person’s Whole Person Impairment (WPI) score.

The Court of Appeal disagreed with the trial judge for a number of reasons, notably adopting the judge’s reasons in Desbiens:

Firstly, as has been noted, the definition of “impairment” as meaning “a loss or abnormality of a psychological, physiological or anatomical structure or function” is extremely broad. Indeed it is difficult to conceive of a more inclusive definition.

Secondly, clause (f) ensures that persons who do not suffer any of the specific injuries or conditions described in the other clauses of ss. 5(1), but nevertheless have an impairment, or a combination of impairments, that is so severe that they are among those with the greatest need for health care are able to recover the expenses of that health care. In effect the legislature, with clause (f), included a catch-all provision for the benefit of those who were likely in the greatest need of health care.

Thirdly, in order to ensure that no impairments were overlooked in determining whether the requirements of clause (f) and (g) were met, the analogous impairment provision, ss. 5(3) was included. This provision comes into play where an impairment is sustained that is not listed in the Guides.

Fourthly, there is nothing in the text of the Regulation that suggests that a combination of physiological and psychological impairments is not permitted. Indeed clause (f) permits any combination of impairments, both physical and psychological. The only requirement is that these impairments must result in a 55% WPI “in accordance with” the Guides. While the definition in clause (g) does not include mild or moderate psychological impairments there is nothing in the Regulation that prohibits such impairments from being considered under clause (f). If the intention were to exclude psychological impairments from clause (f), the insertion of the word “physiological” before the word “impairment[s]” would easily have achieved that purpose. [Emphasis in original.]

Justice MacPherson concluded the following:
[I]t seems unfair to deny to persons with combined physical and psychiatric impairments the enhanced benefits that are available to persons with similarly extensive impairments that fall entirely into one category or another.

Commentary

This recent decision will no doubt be a catalyst for the government to consider potential modification to the catastrophic definition. In an advisory report in April 2011, it was suggested that physical and psychological impairments should not be combined. The Kusnierz decision has no doubt created uncertainty for accident victims, health care professionals and insurers with respect to the interpretation of the catastrophic definition. Despite this uncertainty, the intent of catastrophic benefits is to assist the most seriously injured accident victims and this should remain the primary focus of any legislative reform. This is increasingly important today given that the benefits for non-catastrophic victims were reduced post September 2010. Of further interest is that more recent editions of the AMA Guides do allow for combining impairment rating but do not follow the approach taken in Desbiens. The percentages for psychological impairments reference by Desbiens in the 4th Edition of the Guides are significantly higher than the percentages used in the newer editions.

Catastrophic impairment continues be an interesting area of the SABS and the recent ruling by the Ontario Court of Appeal will likely lead to many new developments.

How many employers have taken the time to survey their employee population on any given issue?  Most employers would not know where to start in terms of the questions to pose to employees, as well as how to collect and process the data that is returned from survey participants.

Importance of Surveying Employees

Employee surveys are an important tool that organizations use to solicit employee feedback.  Surveys can be morale boosting for those who may not have or may not feel that they have other opportunities to confidentially express their views.  Surveys provide a way to improve levels of productivity and commitment by identifying the root causes of workplace attitudes and issues.  Employee satisfaction surveys allow for increased productivity, job satisfaction, and loyalty through their reporting by identifying root causes of employee satisfaction and targeting specific areas.  Engagement surveys measure the extent to which employees are passionate about the work that they do and how emotionally committed to their organization and their coworkers they may be.

The organization itself may also benefit by conducting a more comprehensive organizational assessment survey.  Listening to employees’ insights and suggestions for improvement provides the organization with valuable information that can be acted upon to increase satisfaction in the workplace.  Employees leaving the organization can also provide valuable feedback through employee exit interviews.

Survey Types

Employee Attitude Surveys – Assess the feelings or emotions of employees within the workplace on a variety of topics specific to your organization.

Employee Engagement Surveys – Analyze passion and commitment about employees’ work, company, and coworkers with an employee engagement survey.

Employee Opinion Surveys – Uncover the beliefs or conclusions held by employees thorough an employee opinion survey.

Employee Satisfaction Survey – Most commonly used by employers, this survey provides access to employees’ needs and wants within the workplace and provides employees an opportunity to express feedback on specific situations unique to their workplace.

Absence and Disability Management Survey – Measuring the true cost of absence through a calculation of average days lost for your organization, including a myriad of other casual absence, short and long term disability calculations.

Back to Basics – In-House vs. Outsourced Surveys

Organizations often make an attempt at surveying employees and developing surveys in-house.  There can be significant hazards associated with unprofessional attempts to conduct surveys in-house.

Few organizations have experience creating and reporting back on data from employee surveys.  Surprisingly, few organizations run surveys at all and those that do often outsource to other companies in order to avoid handling the project in-house.

Benefits of Outsourcing

Confidentiality/Quality of Data –

The quality of survey data is crucial if an organization hopes to make any definitive judgments with the data.  It really does not matter how large the data sample is – if the responses you are receiving do not accurately reflect the feelings of your employees, the data you have will not be usable.

Some studies have illustrated that employees may be less likely to answer truthfully when they know the information is being gathered by their employer.  If this is accurate, data collected in-house may be far less relevant, if relevant at all to your organization.  At the very least, you may have to change the way you look at “good results” considerably, which could harm the integrity of your data.

Experience –

Organizations experienced in creating, conducting, and reporting on survey data are the best suited to providing a comprehensive report.  Such organizations have researchers on staff that are able to analyze data to determine if there is something relevant that can be used from survey data.

When an organization does not have someone trained in conducting surveys, they run the risk of conducting the survey, analyzing and reporting incorrectly thus providing no useful information.

Staff Burden –

Finally, your organization may not have someone on staff that can handle an additional amount of work.  That is yet another reason that it may be in your organization’s best interest to outsource the survey project to a professional organization that is best suited to assist.

The best run surveys are those that are able to collect relevant data in a confidential manner, and report this data back to the organization in a useful format.

A.R.S. understands that operating a professional, confidential survey is crucial to a healthy productive workplace.  Effective reporting is key to organizational change.

For additional information regarding A.R.S.’ professional employee survey consulting and all other Employer Services offered by A.R.S. please contact:

Mary Crunkleton – Director of Employer Services
mary@arsi.ca
Telephone: 416-510-2468 or Toll Free: 1-877-304-2239

Shoulder impingement (or sub-acromial impingement) occurs when the space between the acromion process (bony extension of the shoulder blade that extends laterally, over the shoulder joint) and the rotator cuff tendons becomes narrowed. At such a time, the acromion can rub against, or ‘impinge’, the underlying soft tissue structures, causing irritation, injury and pain.

This condition commonly occurs with sports and/or jobs that involve overhead activities, though pain may also occur as the result of an injury whereby the arm is jolted upwards. In this case, the head of the humerus (arm) pushes upward, against the acromion, ‘pinching’ the overlying soft tissue structures.

Pain is usually felt towards the front of the shoulder, and movements become painful, especially elevation of the shoulder.

Neer Impingement Stages =

Stage 1: Involves Edema and/or Hemorrhage
Stage 2: Involves Pathological changes such as Fibrosis and Irreversible changes to the Tendon
Stage 3: Involves Tendon Rupture or Tear with presence of degeneration

Basic Phases of Rehab

1) Pain Control, Reduction of Inflammation (first 24-72 hours) and Activity Modification
— RICE (rest, ice, compression, elevation)
— Modalities (electrical therapy, ice, etc.)
— Massage

2) Restore Normal Motion after Pain and Inflammation are managed

— Stretches for shoulder and joint capsule

— Codman’s Pendulum Exercises: patient adopts a prone position on a bench, or stands bent forward with the good arm used as a support, while the injured arm hangs freely and perpendicular to the floor. Start with small circles, clockwise and counter-clockwise. Graduate to holding a light weight.

— Figure 8′s: same position as above, but perform figure 8′s with affected arm.

3) Strength Exercises (aim for 15-20 reps, 2-3 sets/day, 3 -5 days/week; stop if painful)

= ISOMETRICS (performed statically, as opposed to dynamically, such that joint angle and muscle length do not change during contraction) are performed through the shoulder’s ranges of movement

= ISOTONICS (performed dynamically such that the muscle length changes, though tension remains constant)

— Supraspinatus: the shoulder is flexed 90o, then horizontally abducted 45o. Then the patient lowers and raises the arm in this diagonal plane with the thumb pointing up and elbow pointing down. The patient is instructed to raise through to about 45o, not to 90o.

— External Rotation: patient lies on the unaffected side with a rolled-up towel under the armpit of the affected arm. The Up arm (affected arm) is bent to 90o at the elbow and the forearm is resting across chest. The patient keeps their UP arm at their side while slowly raising the forearm (via external rotation) to shoulder level. The forearm is slowly lowered and the movement is repeated for sets of repetitions.

— Internal Rotation: patient lies on the affected side with DOWN arm (affected arm) bent to 90o at the elbow. The patient then roll the shoulder inward, raising the DOWN forearm up to the chest (via internal rotation). The forearm is slowly lowered and the movement is repeated for sets of repetitions.

— Posterior Rotator Cuff: patient lies prone, on a bench, with arms straight out in a thumb up position. The arms are lowered until perpendicular with the floor, then elevated until nearly parallel to the floor. The movement is repeated for sets of repetitions.

— Supine Protraction: patient lies supine, on a bench, with arms perpendicular to body. The patient then makes a small ‘reaching’ motion while keeping the back flat on the bench. The reaching position is held for a few seconds and then released. The movement is repeated for sets of repetitions.

The above ISOTONIC exercises are performed against gravity and then the patient may be graduated to similar activities with the use of rubber bands and/or small weights. Such activities may also be performed while standing.

4) Proprioception (ability to sense where your own body parts are in space)

— PNF (Proprioceptive Neuromuscular Facilitation) helps stimulate the muscle/tendon stretch receptors for muscle length-tension re-education. The tissue is stretched to end-point or until ‘pain’ is beginning, then the patient contracts. The contraction aids in producing further relaxation for a brief time after contraction that is used to facilitate an increased stretch (provided by practitioner). Proprioceptive exercises vary, and they often also include use of an exercise ball, such as with having the patient move a ball to form letters of the alphabet, against the wall, with the hand of the affected side (eyes open/eyes closed).

Prognosis = Excellent for young individuals with acute, early stage impingement.

Expected recovery times may vary, though typically, inflammation subsides within 7-10 days, and complete recovery is expected within 12 weeks. If full recovery has not been achieved in such a timeframe, further investigation and/or non-conservative treatments may be required.

References

Belzer, J. and Durkin, R. Common Disorders of the Shoulder. Primary Care (1996);
23 (2): 365-388.
Fongemie, A., Buss, D., and Rolnick, S. Management of Shoulder Impingement Syndrome and Rotator Cuff Tears. American Family Physician (February, 1998); 57 (4).
Lally, S. Soothe Your Shoulder and Knee Pain. Prevention (1990); 4 (7): 33-43.
Nelson, L. Exercise and Fitness: Rehabilitation Protocols for the Shoulder. Chiropractic Journal (!992); 6 (5): 34.
Unidentified Author. Four Exercises to Strengthen the Muscles of Your Rotator Cuff. American Family Physician (February, 1998); 57 (4): 680.
Wolin, P. and Tarbet, J. Rotator Cuff Injury: Addressing Overhead Overuse. The Physician and Sportsmedicine (1997); 25 (6).

Written by Dr. Swain, B.Sc.(Hons), D.C., CICE
Certified Functional Abilities Evaluator
Certified Training in Impairment Rating (AMA Guides, 6th Edition)
Certified Independent Chiropractic Examiner

There is an elusive connection between an individual experiencing workplace stress and the occurrence of anxiety related illnesses including depression.

Psychologically Safe Workplaces

Canadian employers have been required by law to protect their employees’ physical health and safety in the workplace.  For the first time in Canadian history, employers are obligated to create and maintain not only a physically safe workplace, but also a psychologically safe work environment.

What is a Psychologically Safe Workplace?

A psychologically safe workplace is one that does not permit harm to an employee’s mental health in careless, negligent, reckless or intentional ways.  This kind of workplace is one in which every practical effort has been made to avoid reasonably foreseeable injury to the mental health of employees.

A report prepared for the Mental Health Commission of Canada – “Stress at Work” explains that a growing number of case law precedents, legislation changes and tribunal deliberations support a trend toward envisioning the duty to provide a psychologically safe workplace as an implicit term of the employment contract.

The law has imposed an increasingly restrictive limitation on management rights by requiring that the employer and management of work must lead to no lasting harm to employee mental health, which may impact an employee’s ability to function at work or outside of the workplace.  Interestingly, the overall implications are similar in both union and non-union workplaces.

In the not too distant past, acts of harassment and bullying resulting in psychological harm could give rise to legal actions for mental injury; we have now arrived at a point where even the negligent and chronic infliction of excessive work demands can certainly be the subject of such claims, under certain conditions.

Navigating the Workplace

In a rapidly transforming and uncertain environment, understanding the process and results of this change will be a manager’s key to responding effectively.

Managers and supervisors alike must pay be aware of the fact that making positive changes to the workplace will not only protect their employees, but will also enhance the competitiveness and overall workplace environment as a whole.

Recognizing anxiety and depression and the effects of each in the workplace are crucial.  The following illustrates both anxiety and depression:

Anxiety

Stress itself is not an illness, and in and of itself is not even necessarily harmful.  Because every person experiences stress differently, each individual’s reaction to stress can vary widely and can result in crippling anxiety for some. More than one quarter of the population will suffer from some type of anxiety disorder during their lifetime. Anxiety disorders are the most treatable of all mental disorders with 80% who undergo cognitive behaviour therapy report recovering after just one year.

There are a variety of anxiety disorders including:

• Generalized anxiety disorder which is characterized by chronic worrying, nervousness and exaggerated fears. This disorder is usually accompanied by physical symptoms that may include headaches, shaking, twitching, hot flushes, breathlessness, dizziness, nausea or insomnia;
• Social Anxiety Disorder is often noted by an extreme fear of being humiliated or ‘shown up’ in front of others;
• Obsessive Compulsive Disorder results in continual unwanted thoughts and rituals that the sufferer has no control over.

Depression

More than one million Canadians suffer from some form of a depressive illness. Over a lifetime as many as 12% of men and 24% of women experience at least one major depressive episode. Unfortunately less than one third of these individuals seek assistance from a doctor, despite the fact that treatment is successful in 70-80% of people who seek help. Depression is caused by a variety of issues, including traumatic life events, the impact of their own personal style (often introverted, dependent, high worriers, untrusting or inflexible), genetics, the absence of social support or often an imbalance of brain chemistry which comes on without a preceding traumatic event.

Symptoms of depression may include: reduced interest or pleasure in activities, changes in appetite, weight and sleep patterns, sad, dark mood, a feeling of lethargy, fatigue or restlessness, difficulty concentrating, feeling that life is purposeless and empty, irrational feelings of guilt, and thoughts of death or suicide.

Additional Support

Where an employer has a number of employees on extended absences related to anxiety and depression related illnesses, there is a high cost involved in continuing to operate the business profitably.

In workplaces where there is a combination of high stress activity and unresolved employee relation problems there seems to be an increased number of employees on medical leave for depression and anxiety. Workplace stress is rarely the only factor in an individual’s illness. Usually there is a combination of home life issues, coupled with a highly stressful work environment and together the situation is more than some individuals are able to manage.

Time Away vs. Staying at Work

As a percentage, how many employees are taking time away from the workplace when they experience anxiety or depression symptoms?  It has been found that most employees do not take extended sick leave absences; continuing to work during this time.

What kind of productivity can be expected from employees who stay in the workplace, ignoring anxiety and depression symptoms?  Low productivity is often exhibited together with less than optimal relations between affected employees, their co-workers and management.

The Workplace as a Source of Support

What can an employer do in terms of supporting vulnerable employees?

Employee Assistance Plans (EAPs) have increased in popularity and have become an invaluable tool in assisting employees experiencing a variety of workplace and personal issues.  Providing support to employees is crucial as there is statistical evidence that shows for each extended absence from work due to depression, there is an exponential increase in the likelihood of the illness reoccurring. This means that each time an employee is away from the workplace on sick leave for a depressive type illness, the chance of the employee leaving the workplace for the same illness increases by approximately 20%. Returning to work after such an absence is emotionally traumatic, and so the duration of the absence may increase each time the employee is away from the workplace.

• Talk to your employee.  Describing your observations and expressing your concern for their health is a good first step;
• Share information about the your internal EAP and discuss the benefits of this program;
• Assess the level of stress within your operation, are their unresolved issues contributing to a high stress environment?
• Take action to resolve the issues at play at your workplace.

A.R.S. understands that the costs involved in managing absence and offering appropriate support is crucial to healthy productive workplace.  Effective counselling and Employee Assistance Plans (EAP) are essential.

For additional information regarding A.R.S.’ EAP – Optimal Health Solutions and all other Employer Services offered by A.R.S. please contact:

Mary Crunkleton – Director of Employer Services
mary@arsi.ca
Telephone: 416-510-2468 or Toll Free: 1-877-304-2239

What some employers neglect to take into consideration is the home or “away from work” life of their employees.  While a healthy work environment is a good first step to ensuring optimal productivity and balance for employees, a healthy home life is just as important.

Healthy, productive employees are essential to every workplace.  It is important to recognize that situations and issues in an employee’s personal life will affect their ability to perform in the workplace.  Likewise, unresolved issues and stressors in the workplace can carry over to an employee’s home life.  The end result of this cycle is decreased overall health for the employee, and a decreased ability to perform in the workplace.

Employees today are managing a variety of personal situations while attempting to perform at the workplace.  Day care, elder care, addiction, financial and a variety of other stressors are affecting your employees and in some cases may be contributing to casual absenteeism in the workplace, which can ultimately develop into long-term absence.

As an employer you are not able to manage a healthy home life for employees, but you can offer tools that will encourage the best management of this home life as possible.

Psychological Healthcare

As Canadians we are accustomed to publicly funded provincial hospital insurance plans that provide excellent physical healthcare through a network of doctors and hospitals. Employer-sponsored extended healthcare insurance policies reimburse employees for some expenses not covered by the provincial plan.

Unfortunately, when we face emotional, interpersonal or psychological problems, the traditional healthcare delivery system can be of little assistance.  It can be difficult to locate a qualified professional, and often the accessibility and cost prevent us from getting the help we need.

Healthy Human Resources 

Personal problems can and ultimately do become personnel problems.  Investment in corporate wellness is likely to be the most significant factor that will influence the quality of work, productivity, attendance and retention of your staff.  By addressing the personal needs of your employees, you can create a healthier corporate environment.

Employee Assistance Plans (EAP)

EAPs have been in existence for many years, with varying degrees of success.  With some very good intentions employers have adopted EAPs for their employees, usually in combination with some sort of group insurance plan.

An EAP will help both your employees and your corporation reach their potentials. The increasing popularity of EAPs shows that corporations are beginning to realize the need to invest in healthy human resources.

The purpose of an EAP is to improve the psychological health of your employees and to provide the information and supports needed by all family members.   An EAP will assist employees in resolving their individual, marital, family and job performance situations.   As a result, their productivity and attendance will show improvement.

A.R.S.’ EAP –“Optimal Health Solutions”

As a national provider of Absence and Disability Management services across Canada, A.R.S. is pleased to offer a unique EAP solution to both employers and employees alike.  Optimal Health Solutions provides our employer clients and their valued employees with the dedicated personal attention and service required to meet the various needs in the workplace, and at home.

The A.R.S. Optimal Health Solutions plan specializes in providing counselling services to employees and family members with the intention of improving their overall health, productivity in the workplace, and quality of life.

The A.R.S. Optimal Health Solutions plan will provide access to qualified professionals who are trained to assist in the resolution of personal and work related situations.

The A.R.S. Optimal Health Solutions plan is unique in that we are able to deliver EAP services from PhD level Psychologists only.  These Psychologists are professionals with the highest qualification in the field of human behaviour and personal situational resolution.

Effective counselling focuses on assisting the employee deal effectively with change and stress in their personal, career and family lives.

As an employer, your managers, supervisors and human resource staff will be able to focus on work performance. They will no longer feel the need to struggle with the personal problems of their staff.

Optimal Health Solutions Provides:

• Direct Access:  Upon assigning a Registered Psychologist to an individual, he or she may contact this professional directly;
• Quick Response:  The first counselling session will take place as soon as possible;
• Direct Treatment:  If supplementary or long-term care are required, we are pleased to offer appropriate referrals;
• Availability:  Our staff is available to take referrals 24 hours per day, 7 days per week.

About A.R.S.

A.R.S. understands that the costs involved in ineffective management of employees’ personal situations are crucial to employers. Effective counselling and Employee Assistance Plans (EAP) are essential.

For additional information regarding Optimal Health Solutions and all other Employer Services offered by A.R.S. please contact:

Mary Crunkleton – Director of Employer Services
mary@arsi.ca
Telephone: 416-510-2468 or Toll Free: 1-877-304-2239

On first blush, this makes sense.  An employer pays premium for a short-term disability benefit regardless of whether employees use or do not use the benefit itself.  Premiums increase year to year regardless of use, although with extensive use they can certainly increase at alarming rates.

In the last ten to fifteen years in Canada it has become popular to switch from fully to self-insured short-term disability plans, mainly for perceived financial gain.  Making a change is fine, but it also makes sense to analyze the costs of a self-insured short-term disability program.

Many employers consider self-insuring because they feel their claims have not been substantial enough to warrant paying the premium for a fully-insured program.  Before any employer can make this decision it is important to analyze the following factors:

1. Actual short-term disability claims paid:  Has your organization tracked and accurately recorded the cost of these claims?  Most organizations are unaware of what they have paid out in short-term disability claims dollars.
2. Proof of Loss:  Most employers require some form of proof of loss (burden of proof) before an employee can access a casual absence or short-term disability plan.  How does this differ from what an insurer may require?  The differences are staggering.  An insurer will require supporting medical data, together with completion of a short-term disability claim form.  Most employers who self-insure have virtually no way to accurately manage the length or medical component of a claim.
3. Sick Days/Sick Time:  A number of employers offer some sort of sick pay that is utilized prior to a short-term disability claim, and they often allow employees to access this service in the days/weeks prior to a claim.  Medical management of this sick time is crucial, and this is often an area where employers lose track of a claim before it ever even begins.  Will you allow employees to utilize vacation days prior to a medical claim?  What are the ramifications of this action and what policies do you have in place to manage this process?

A “Hybrid” Approach – Third-Party Case Management

The objective of any short-term disability plan is to ensure that disabled employees receive pay and/or benefits during the period they are unable to work and that any return to work program is managed effectively returning the employee to their pre-disability job.

The “hybrid” approach involves the introduction of an independent third-party case management service that would accurately and effectively manage all short-term disability claims, according to a predetermined set of criteria.

Third-party case management provides considerable savings as fees are only paid when a claim is incurred, as opposed to a fully-insured plan where premiums are paid regardless of the number of claims submitted and paid.  As the employer managing a third-party plan you are also responsible for the dollars paid for each claim paid in accordance with the terms of your contract.

Third-party case management is also attractive in that it provides accurate and expert adjudication, medical management, and full supports for all graduated return to work programs.

The Right Choice

The right choice for your organization can be determined by studying and auditing claim dollars paid out versus the cost of the premiums to insure this liability.

The following questions are important when considering a truly self-insured program:

• What functions do you want your internal HR department performing?
• Are you following all of the current legislation in terms of privacy with regard to claims payment?
• The risks involved in a bad claims year – can your organization continue to support a program in a year where your claims may double or triple in cost?
• What liability is involved in making an incorrect decision?
• What are your internal processes where a contentious claim is concerned?  Do you have staff internally capable of defending a claim decision?

About A.R.S.

A.R.S. understands that the costs involved in managing and adjudicating short-term disability claims are important to employers.  Effective adjudication, claims management and accurate claims payments are crucial.

A.R.S. offers a comprehensive third-party claims management program that can assist employers both in managing cost and claims management.

For additional information regarding third-party claims management and all other Employer Services offered by A.R.S. please contact:

Mary Crunkleton – Director of Employer Services
mary@arsi.ca
Telephone: 416-510-2468 or Toll Free: 1-877-304-2239