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Approaches and Interventions
Return to work communication

At a glance:
There are different models for managing the return to work; each requires different interactions between health care providers, employers, and the employee. Ineffective communication causes problems within all of these models. Managing a return to work requires the input of a large number of participants, and it's hard to achieve a good outcome unless everyone involved is communicating effectively. Unfortunately it's rare for all stakeholders to meet at the same time, and communication is usually only between two participants at a time.
Perspectives:
Employee
Good communication improves everyone's understanding of the issues affecting return to work. It allows employers to understand the medical issues, and doctors to understand the workplace issues. Managing a return to work is a cooperative process that needs the input of all the stakeholders, and it's hard to achieve good results unless everyone is communicating.

Encourage everyone involved in your return to work to communicate with each other. This might mean making it clear to your doctor that you want him/her to speak to your employer. Tell your doctor exactly which medical issues you are comfortable with them discussing. Doctors are sometimes hesitant to speak to others because of confidentiality restrictions. You can also encourage your employer to make themselves available to speak to your treater. One way to do this is to give them plenty of notice before your appointment, and ask them to be available for a phone call during the consultation.
Employer
Most approaches to rehabilitation
rehabilitation
The process of helping a person back to their former abilities and quality of life (or as close as possible) after injury or a medical condition.
 can be disrupted by communication problems. Overcoming these problems is very important to achieving a return to work.

You can improve communication by making yourself available to ill/injured employees and to their treaters. Often this is as simple as making the time for a phone call from the doctor while they are consulting with the patient. The more communication you do the better. Outcomes are best when all the stakeholders understand each others' perspectives and requirements.
Treater
Communication takes time, and time is precious in practice. Informing the patient about their condition, dealing with distress,
distress
Severe suffering, pain, anxiety or sorrow
 and coordinating communication between the large number of stakeholders involved are all important challenges for treaters.

It's often worthwhile to encourage meetings, particularly if the patient is comfortable with the case manager or employer attending the consulting rooms. Visiting the worksite takes time, but it's a valuable exercise and should be paid for by the employer. This is a powerful way to understand the job and the return to work issues.
Insurer
Effective communication with all parties is an ongoing challenge. A simple phone call to the person with an injury can make a substantial difference. Good communication takes time, but can reduce the likelihood of problems, and smooth the path forward.

Different people communicate in different ways. In some circumstances electronic communication will achieve the best outcome, and sometimes a face-to-face meeting is best. Communication is usually best when everyone is as flexible and accommodating as possible.
Original Article, Authors & Publication Details:
Pransky G, Shaw W, Franche R-L, Clarke A.

Disability prevention and communication among workers, physicians, employers, and insurers--current models and opportunities for improvement. Disability & Rehabilitation 2004;26(11):625-34.
Background, Study Objectives, How It Was Done:
The authors of this paper investigated communication in the return to work process. The paper identifies four rehabilitation models, and examines the strengths and weaknesses of communication within each.

The four models examined are the:

1. Medical model
2. Physical rehabilitation model
3. Job match model
4. Managed care model
Study Findings:
Medical model

The medical model focuses on the decisions of the doctor and other treating practitioners, who direct care. There is a focus on treatment of the injury rather than return to work rehabilitation. In this model, return to work communication is the responsibility of the treater. Information from this source is valued and has greater credibility than information from other parties.

When rehabilitation is approached this way, communication can be limited. It is often written rather than person-to-person, and interactions usually occur only when the patient visits the doctor.

The authors note that the medical model works well when there is a highly predictable illness such as a fracture.
fracture
A cracked or broken bone.
 In these cases the likely healing timeframe is known and treatment is well defined, meaning that the communication required is usually straightforward.

For non-specific conditions, such as sprains
sprain
Injury to ligaments caused by overstretching or overuse. The ligament is usually stretched but may be torn.
 and strains, the medical model produces variable outcomes. These conditions are less predictable, and the person's perspective on recovery are more important, both of which mean that more complex communication is required.

Studies of the medical model have identified a lack of incentive to:

Conduct work-site evaluations, which are important to employer/treater communication
increase the amount of time spent with the patient
improve communication.

The authors note that most doctors and other treating practitioners
treating practitioner
A health professional that treats patients. In return to work this may include doctors, physiotherapists, chiropractors, osteopaths, psychologists, masseurs, etc.
 have had little training in disability
disability
A condition or function that leaves a person unable to do tasks that most other people can do.
 prevention and management.

Physical rehabilitation model

This approach focuses on reducing disability through physical conditioning. It is based on the assumption that return to work outcomes will be better if the person improves their strength and fitness.

Physical rehabilitation is different from vocational
vocational
Related to work or career. Vocational rehabilitation focuses on the process of returning to the workforce.
 rehabilitation, which includes counselling, retraining, and a focus on re-employment.

There are a number of variations on the physical rehabilitation model, and studies show that some of these approaches produce better return to work results than others. Within this model generally, communication is largely from doctor to others. Any given communication will only be between two of the parties involved. This might mean therapist to employer, physician to patient, or patient to therapist.

The authors indicate that this model works best where physical limitations are well defined and can be improved with physical conditioning. An example would be someone with a knee injury, who needs rehabilitation of weakened thigh muscles.

When return to work barriers are interpersonal, or where the worker's condition is complex or poorly understood, the communication possible under this model may be insufficient.

Job match model

Under this model, rehabilitation is based on a comparison of the person's work capacity and the requirements of work tasks. This allows allocation of duties the person is capable of managing. This approach is suited to larger workplaces with many different jobs, especially if it is easy to define the physical tasks involved in each. Some companies keep a job analysis database,
database
Store of information (e.g. published research articles). Information can be retrieved by searching (e.g. for key words, authors, or titles).
 making it quicker and easier to find a match.

This model does not address interpersonal or psychosocial
psychosocial
Refers to psychological and social factors. Examples of psychosocial factors that affect return to work area include: a person's beliefs about how they will cope with their condition, the attitude of the inured worker's family to their condition and return to work, the employer's return to work policy and the influence of the WorkCover system on a person.
 factors.

Communication under this model is also limited, and is often prescriptive. It is based on definitive statements about capacity and job tasks. The job match model does not necessarily take into account the opinions of the employee or supervisor.

Managed-care model

The managed-care model is based on published “standard' recovery times for particular health conditions. These standards are derived from large numbers of interviews with workers who have a given condition.

The model is based on the idea that return to work can be improved by understanding the expected recovery time and working to that time frame. The approach can be useful to larger organisations when they are trying to appropriately allocate resources to different cases.

This model is generally reactive, since it focuses on people who have already been off work for a longer period than expected. The worker can be inadvertently blamed for a slower than expected return to work, even when the process has been slowed by bureaucratic or treatment delays.

Communication tends to be between two parties, and tends to be authoritative and prescriptive.

This model is used by case managers to determine whether the return to work is taking longer than expected. If so, the case manager can investigate barriers preventing a return.

Communication issues in each model

The authors noted some features common to all four models:

Communication is often “one way' and directive, rather than an attempt to understand the situation
The restrictions applied by treaters are not supported by a solid evidence base, but are treated as scientifically credible.
When communication is authoritative and directive, it cannot always deal effectively with psychosocial factors.
Communication is limited if a return to work manager is following a specific procedure defined by a checklist or similar.

Better communication is associated with greater participant satisfaction and improved return to work outcomes. Communication between treaters and their patients can be improved by helping patients to explain their concerns, preferences and expectations. Patient training may be valuable in certain circumstances.

Programs that focus on communication between the treater, the supervisor, and the employee have been shown to improve outcomes and reduce the number of disputes that occur.

Communication in the health sector is changing. Consumers are more empowered, and patients with access to the internet often do their own research and critically analyse the advice they receive. Patients expect good communication, and are dissatisfied when it is not available.

Improving communication improves return to work outcomes. The authors point out that research on communication is in its early stages, and further study may allow further improvements.
Conclusions:
Return to work communication isn't always productive. Barriers to improved communication include:

Time constraints
Professionals who want to maintain the status quo
Social norms
The need to maintain confidentiality

Making sure that communication is cooperative and respectful can improve outcomes. It's important to focus on finding out where problems lie and avoid making assumptions, or imposing plans without the ill or injured person's input.
References:
PubMed Abstract
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