In many physical therapy practice settings, discharge planning occurs as the initial evaluation is being done. With inpatients recovering from surgery or illness, focus is given to planning for equipment and support that will be needed. Additionally, discharge destination needs to determine whether the home is an appropriate destination or if short-term rehab may be required. In the outpatient setting, discharge goals include return to full play for an athlete, resuming functional activities, and returning to work.
If we broaden the reach of the physical therapist, how can we help employers utilize this planning process to improve their return-to-work process, reduce lost time, decrease employee frustration, and cut costs? Too often, therapists don’t get involved in the care of work-related injuries until weeks or months after the event. The employee is referred to the emergency department or urgent care, and sees an occupational medicine or other specialist or primary care physician. A workup is done, diagnostic tests are ordered, and often the worker is taken out of work. Physical therapy may be ordered at this point, and therapists use their skills to improve motion and strength, remove dysfunction, restore confidence, and return the patient to full activity.
Admittedly, there are many cases where this is the appropriate course of care. The challenge presented in this article, however, is to determine what happens after that process is followed. Do therapists know how the “patient” does resuming life as a worker after discharge from care? Is there a way the therapist can become involved sooner to make the process more efficient—or better yet, to prevent the injury from occurring?
The easiest injury to manage and treat is the one that doesn’t occur. Physical therapists are musculoskeletal experts with knowledge about proper work postures who can correct body mechanics and stressors that lead to soft-tissue injury. Redirecting the therapist’s skills earlier in the process by working directly on-site with an employer can prevent many injuries from occurring or avoid exacerbation of minor issues. Being on-site affords the opportunity to observe and analyze the essential job functions, objectively measure physical demands, and identify and correct stressors.
The job description is a critical tool for the employer, yet the accuracy and applicability of these documents is often questioned. These forms are often filled out with a best estimate of forces and weights, describe the general tasks instead of the essential functions, and are not kept up to date. This tool is the way an employer can introduce the job and required demands to a new-hire candidate or communicate with a medical provider for return-to-work decisions. These important decisions require accurate information. Working with the employer and employees, the on-site therapist is able to collect and organize the information into a usable document. Ergonomic stressors are identified, and suggestions for improvements are made with the input of the worker. Training opportunities for best practice sharing and work process improvements are other benefits to this process, and are the things that prevent injuries from occurring.
Many things can be done on-site that are classified as first aid by the OSHA 1904.7 record keeping standard (www.osha.gov). Working with an employee if they begin to experience fatigue, heaviness, or discomfort to change their technique, use a better tool, or position their work better can prevent an issue from escalating to an injury. The 1904.7 record keeping standard must be followed to stay within first aid guidelines and to not deliver medical treatment. On-site therapists need to be aware of these guidelines and are often the ones who help the employer understand how to best intervene for a positive outcome. Providing instruction in neutral work postures, how to use ice or heat, or providing nonrigid splinting are other examples of interventions within the first aid guidelines to keep a worker performing the essential job functions.
Even with the best efforts, injuries can still happen. Working on-site with employees, safety professionals, and employee health can be a strong partnership for root cause analysis and correction of factors causing possible recurrence or injury to another employee. A good incident report form is critical, and an investigation should occur as soon as possible to review causation and the events surrounding the injury. The employer should have an incident report form and process for the employee and supervisor to follow when an injury occurs. The on-site therapist may not be involved with the investigation but can assist with corrective actions.
The therapist is the specialist in identifying musculoskeletal stressors and can make suggestions to decrease the strain, but also must have help from others to identify the fix. Often the employee has an idea of what would make the task or process safer or more efficient. Additionally, an engineer or purchasing representative may have a correction or tool that would improve the situation. Therapists need to maximize the abilities of everyone on the team, and when the employee is part of the solution, there is better acceptance and use of the new method.
Using the information obtained and organized in the job analysis and job description writing noted earlier, functional tests specific to a job title are developed to assess an individual’s ability to perform essential job functions. These tests are built by the therapist and then validated by the workers. The testing practice matches worker physical capability with physical demands. Physical therapists should obtain appropriate continuing education in this process to assure compliance with the Americans with Disabilities Act Amendment Act (ADAAA). There are many legal caveats that must be considered with this type of testing, and proper training is imperative.
These functional tests can be administered in the post-offer pre-employment hiring process to assure the new-hire can perform and is aware of the required demands, thus preventing injury. If an injury does occur, functional testing performed early in the recovery process shows the worker what he or she can do by performing tasks simulating the job demands. Employees can test their abilities in a safe environment to challenge themselves in lifting, carrying, pushing, pulling, gripping, and pinching. The results of the test are shared with the medical provider, employer, and employee to create a return-to-work plan.
The employee returns to work sooner, performing only those functions they have safely met in testing. The therapist becomes a partner in this interactive process by assisting all parties to understand the types of accommodation that are needed or whether particular aspects of a job cannot be performed safely. Re-testing job components not initially met on regular intervals provides objective information to increase job functions the employee can perform. This gives the employer better control of the return-to-work process. The medical provider does not have to estimate work restrictions, the employee knows exactly what can be done safely, and the therapist has a measure with which to build a functional treatment program.
On course for success
Each working patient seen in the clinic for a musculoskeletal injury has the potential for impairment of his or her job functions. Regardless of injury causation, a lack of strength, decreased range of motion, pain, or dysfunction will have a negative effect on work ability. Building return-to-work planning into discharge goal setting at evaluation sets us on course for success. Using functional testing provides checkpoints to measure progress toward that goal. A therapist’s existing clinic patients are a wonderful bridge to many employer contacts, and thus should be used to expand the reach to other employers.
Help employers keep workers healthy and functional by partnering with them at the workplace. These relationships are a way to create alternative revenue streams into a practice through consulting. When on-site and early intervention is not working, the worker can be referred to the clinic for formal physical therapy treatment. Being viewed as a partner in safety, injury prevention, and management will benefit the therapist, the practice, and the community.PTP
Curt DeWeese, PT, is chief operating officer of DSI Work Solutions, Bowling Green, Ky, and president of Work Injury Solutions, Rochester, NY. DeWeese 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.