Curt DeWeese, PT, meets with Elaine Spagnola, RN, COHN, to review information about a lost-time employee injury case.
This is the story of an important job that “everybody” was sure “somebody” was doing. “Anybody” could have done it, but “nobody” did it. “Everybody” thought “anybody” could do it, but “nobody” realized that “somebody” hadn’t done it. The job was getting an injured worker back to work, and that employee may still be out.
Why do injured workers who are out of work end up missing so much time? Part of the answer to that question is that the process to assess the injury, get authorization for treatment, arrange and provide that treatment, and bring the worker back to work can be very complex. It requires action from the employee, the employee’s supervisor, the employee health office, the human resources or benefits office, the medical providers, and third-party payor.
Each of these distinct and different parties has a keen understanding of their role and what they need to do. The problem is that these parties do not have a consistent method of communication to share what constitutes their plan and needs. An on-site physical therapist can be the central link to assist with gathering and sharing information and facilitating the effective use of that knowledge to expedite return to work.
Dennis Isernhagen, PT, has worked with many employers to reduce lost time related to injury claims and decrease the resulting costs of that lost time. In 2012, Isernhagen made a presentation titled “Avoiding the ‘Silo’ Effect.” He compared the management of a work-related injury to individuals working separately from one another. He described these as functional silos where individual people, departments, or companies conduct business in a vacuum, without taking into effect the impact their actions have on the entire organization.
He went on to say that functional silos are a result of a lack of systems thinking and questionable management theory, or barriers to communication and cooperation. When individuals don’t have common goals, when incentives are not aligned, silos are the natural response by people who head the silos and the people who work within them.
A 42-year-old female assembler reports to the employee health nurse that she has been experiencing difficulty with work tasks, weakness in her right hand, and being awakened with numbness and pain in her thumb and index finger. She has had these symptoms off and on over the past year but did not want to be taken out of work and, therefore, did not report the issue sooner.
A report is made to her supervisor, and an accident report is filed. Because of the severity and duration of symptoms, a referral is made to an occupational medicine provider for evaluation. This provider takes the employee out of work pending consult with a specialist. After 4 weeks of time away, the nurse seeks input from the new on-site physical therapist regarding how long to expect this person to be out of work. This is the inquiry that identifies how the silo effect is contributing to the ongoing lost time.
The therapist asks some simple questions, such as, “What is the course of treatment,” and “Has therapy been ordered?” The nurse responds that she doesn’t know, as she has not had contact with the employee. We check with the supervisor, who also has not received any new information. We call the employee to ascertain what is happening. What we discover is that the nurse is waiting to have an appointment scheduled for a nerve conduction study the specialist has ordered. The specialist also agreed the employee should stay out of work at this time.
The nurse and therapist contact the workers’ compensation carrier and learn that they have not received the request from the specialist for the nerve study. Subsequently, a call is placed to the specialist’s office, and it is confirmed that they did order the nerve conduction study, submitted the request, and are awaiting approval. This appears to be where the breakdown occurred.
The nurse asks the specialist’s office to fax her the request; she then communicates with the carrier that the case is work-related and forwards the nerve study order. Within an hour, the authorization is obtained, the employee is notified, and the nerve study is scheduled. More than 2 weeks of time was wasted because everyone involved assumed that someone was addressing the needs of the case. In reality, no one was doing anything to move along the process. There was no communication.
The people on the “business side” of the claim often have little to no understanding of how the medical process works. The people involved with the medical side of the claim are frequently not aware of or concerned about the issues of lost time and the associated costs related to a claim. The worker commonly is waiting for direction about the next step. The workers’ compensation system may not be understood by the employee, or that person’s physician may have explained what is being ordered but not how it will be accomplished. If no one gives the injured worker the next step, that person simply waits, without knowing or understanding how to advocate for themselves.
There are many components of the care process. Appropriate care begins with the employer completing the incident report and referring the employee for care. Medical evaluation and treatment is the responsibility of the provider but relies on the authorization of the carrier or payor. The approval of payment is tied to the proper information about the claim getting from the employer and medical provider to the carrier. This is where the concept of the silo infiltrates the process. Because each part of the process operates independently from the other, there is not enough exchange of information between parties to move things along.
How the On-Site Physical Therapist Can Help
Physical therapists are experts in caring for musculoskeletal disorders (MSDs) and can assist in preventing them from occurring in the first place. Being on-site provides the opportunity to observe the work being performed, identifying the stressors leading to MSDs, and working with safety and engineering professionals to decrease these stressors. In the realm of first aid intervention, the on-site therapist can help with job coaching for neutral work postures, instruction in the use of cold or heat, and nonrigid splinting.
Assisting with workstation setup, tool selection, and workflow are other contributions an on-site presence will afford. There is additional training therapists should obtain to be proficient in on-site work. This includes knowledge about job analysis, ergonomics for industrial and office settings, and understanding of OSHA’s record keeping requirements and other regulations.
Connecting the Silos
Our background and training as physical therapists positions us perfectly to assist employers in preventing work-related injuries. We can work with early intervention within the OSHA first aid guidelines to prevent small problems from escalating to injuries that require medical treatment. We understand the diagnostic and treatment programs for MSDs and can assist with asking questions about how a case is being managed to help move it forward.
On-site presence interacting with professionals in departments such as human resources, safety, engineering, ergonomics, and purchasing brings all the expertise together. Interviewing and watching the employee and supervisor provide valuable insight missed if we are only treating a problem in a clinical setting. We may have a primary role in identifying ergonomic stressors and can contribute to solutions for those stressors, but often the collective knowledge of a group creates more robust and sustainable corrections.
When we bring our knowledge of how physicians evaluate a condition and the tests they order, and how insurance carriers work to authorize treatment, we open up the medical treatment “silo” so these other professionals gain a better understanding of that part of the process. Working on-site provides the understanding about employer’s needs and concerns in the return-to-work process. Communicating with the employee and supervisor builds trust and allows us to consider their needs as well.
It is improving the understanding of what each party does and bridging the gaps that will break down these communication barriers. We become the connecting link between each of the “functional silos” of information, the right “body” to get this important job done, and get the worker back to the job. RM
Curt DeWeese, PT, is president of Work Injury Solutions & PT, PC in Rochester, NY, and COO of DSI Work Solutions in Bowling Green, Ky. He works with many employers using Job Function Matching for workplace injury prevention and management. He also provides education and training for therapists in working on-site with industry. For more information,