Improving vocational rehabilitation services for injured workers in Washington State

Appraisal of Washington State workers' compensation-based return-to-work programs and suggested system improvements: A survey of workers with permanent impairments

BACKGROUND

Following a work-related permanent impairment, injured workers commonly face barriers to safe and successful return to work (RTW). Examining workers' experiences with the workers' compensation (WC) system could highlight opportunities to improve RTW outcomes. Objectives included summarizing workers': (1) appraisal of several WC-based RTW programs, and (2) suggestions for vocational rehabilitation and WC system improvements to promote safe and sustained RTW.

METHODS

In telephone interviews, 582 Washington State workers with work-related permanent impairments were asked whether participation in specified WC-based RTW programs helped them RTW and/or stay at work. Suggestions for program and system improvements were solicited using open-ended questions; qualitative content analysis methods were used to inductively code responses.

RESULTS

Most respondents reported positive impacts from RTW program participation; for example, 62.5% of vocational rehabilitation participants reported it helped them RTW, and 51.7% reported it helped them stay at work. Among 582 respondents, 28.0% reported that no change was needed to the WC system, while 57.6% provided suggestions or critiques. Reduce delays/simplify process/improve efficiency was the most frequent WC system theme-mentioned by 34.9%. Among 120 vocational rehabilitation participants, 35.8% reported that no change was needed to vocational rehabilitation, while 46.7% (N = 56) provided suggestions or critiques. More worker choice/input into the vocational retraining plan was the most frequent vocational rehabilitation theme-mentioned by 33.9%.

CONCLUSIONS

This study's findings suggest that there is substantial room for improvement in workers' experience with the WC system. In addition, injured workers' feedback may reflect opportunities to reduce administrative burden and to improve worker health and RTW outcomes.

The role of nonstandard and precarious jobs in the well-being of disabled workers during workforce reintegration

BACKGROUND

Nonstandard employment arrangements are becoming increasingly common and could provide needed flexibility for workers living with disabilities. However, these arrangements may indicate precarious employment, that is, employment characterized by instability, powerlessness, and limited worker rights and benefits. Little is known about the role of nonstandard and precarious jobs in the well-being of disabled persons during workforce reintegration after permanent impairment from work-related injuries or illnesses.

METHODS

We used linked survey and administrative data for a sample of 442 Washington State workers who recently returned to work and received a workers' compensation permanent partial disability award after permanent impairment from a work-related injury. Multivariable logistic regression models were used to examine associations between nonstandard employment and outcomes related to worker well-being and sustained employment. We also examined associations between a multidimensional measure of precarious employment and these outcomes. Secondarily, qualitative content analysis methods were used to code worker suggestions on how workplaces could support sustained return to work (RTW).

RESULTS

Workers in: (1) nonstandard jobs (compared with full-time, permanent jobs), and (2) precarious jobs (compared with less precarious jobs) had higher adjusted odds of low expectations for sustained RTW. Additionally, workers in precarious jobs had higher odds of reporting fair or poor health and unmet need for disability accommodation. Workers in nonstandard and precarious jobs frequently reported wanting safer and adequately staffed workplaces to ensure safety and maintain sustained employment.

CONCLUSIONS

Ensuring safe, secure employment for disabled workers could play an important role in their well-being and sustained RTW.

Initial return to work and long-term employment patterns: Associations with work-related permanent impairment and with participation in workers' compensation-based return-to-work programs

BACKGROUND

Roughly 10% of injured workers experience work injuries that result in permanent impairment and a permanent partial disability (PPD) award. This study aimed to characterize and quantify long-term employment outcomes for injured workers, by the degree of whole body impairment (WBI) and by participation in several workers' compensation (WC)-based return-to-work (RTW) programs.

METHODS

A retrospective cohort of 43,968 Washington State workers were followed for up to 10 years after WC claim closure (2009-2017). Degree of impairment was classified as: (1) no PPD award, (2) PPD award with WBI < 10%, or (3) PPD award with WBI ≥ 10%. State wage files were used to construct employment outcomes for regression, modeling: (1) time to first RTW, (2) time to first RTW interruption, (3) RTW volatility, and (4) employment gaps.

RESULTS

Wage patterns and employment outcomes differed significantly by the degree of impairment. Compared to other workers, workers with WBI ≥ 10% had delayed RTW, shorter average times to first RTW interruption, and higher rates of both RTW interruptions and quarters without wages. Time to first RTW averaged over a year, increasing with the degree of impairment. About 9% overall-and 27% of workers with ≥10% WBI-had no observed wages after claim closure. In adjusted models, workers with WBI ≥ 10% had significantly poorer employment outcomes, compared to workers with no PPD award (p < 0.001).

CONCLUSIONS

State wage files provide an efficient approach to identifying RTW patterns. Workers with permanent impairment were at substantially higher risk of poor employment outcomes. WC-based RTW programs may promote better employment outcomes.

Workforce Reintegration After Work-Related Permanent Impairment: A Look at the First Year After Workers' Compensation Claim Closure

Purpose The purpose of this study was to descriptively quantify experiences of injured workers with permanent impairment during their first year of work reintegration. Methods A representative survey was conducted to characterize health, disability, pain, employment, reinjury, and economic outcomes for 598 workers with permanent impairment who had returned to work during the year after workers' compensation claim closure. Survey responses were summarized by degree of whole body impairment (< 10% vs. ≥ 10%). Results Injured workers who had returned to work reported that permanent impairment made it difficult to get a job (47%) and to keep their job (58%). A year after claim closure, 66% reported moderate to very severe pain; 40% reported pain interference with work. About 13% reported new work injuries; over half thought permanent impairment increased their reinjury risk. Asked to compare current to pre-injury work status, workers with a higher degree of impairment more frequently reported working fewer hours (OR 1.60; 95% CI 1.06, 2.42), earning less (OR 1.56; 95% CI 1.04, 2.36), and being at higher risk of losing their current job due to their impairment (OR 1.66; 95% CI 1.01, 2.71). Conclusions Injured workers with permanent impairment face long-term challenges related to health limitations, chronic pain, work reintegration, and economic impacts. Workers with a higher degree of impairment more frequently reported several economic and job security challenges. Developing workplace and workers' compensation-based interventions that reduce return-to-work interruption and reinjury for workers with permanent impairment should be prioritized as an important public health and societal goal.

Estimating time to reinjury among Washington State injured workers by degree of permanent impairment: Using state wage data to adjust for time at risk

BACKGROUND

Many injured workers are reinjured, but reinjury risk is challenging to quantify. Because many injured workers face delayed return-to-work, or return to part-time or intermittent jobs, a calendar timescale may overestimate actual work-time at risk, yielding underestimated reinjury rates. Objectives included determining: (1) reinjury risk by degree of permanent impairment and other factors, and (2) how choice of timescale affects reinjury estimates.

METHODS

This retrospective cohort study included Washington State workers' compensation (WC) claims for 43,114 injured workers, linked to state wage files (2003-2018). Three timescales were used to define at-risk denominators: (1) calendar quarters; (2) quarters with any wages; and (3) full-time equivalent (FTE) quarters, defined as cumulative work hours ÷ 520. Associations between reinjury outcomes and worker, injury, job, and WC vocational rehabilitation program participation characteristics were assessed using Cox proportional hazards regression.

RESULTS

Overall reinjury rates were 5.9 per 100 worker-years using a calendar timescale (95% confidence interval [CI]: 5.8-6.0), 10.0 using any-wage quarters (95% CI: 9.9-10.2), and 12.5 using FTE quarters (95% CI: 12.3-12.7). Reinjury rates were highest in the first two quarters after initial injury, remaining elevated for about 4 years. Using FTE quarters, workers with ≥10% whole body impairment had a 34% higher risk of reinjury relative to workers with no permanent partial disability award (95% CI: 1.25-1.44); no difference was detected using calendar time.

CONCLUSIONS

Timescale substantially affects reinjury estimates and comparisons between groups with differential return-to-work patterns. Linking wage data to WC claims facilitates measurement of long-term employment, yielding more accurate reinjury estimates.

A Review of a Workers' Compensation Database 2003 to 2013: Patient Factors Influencing Return to Work and Cumulative Financial Claims After Rotator Cuff Repair in Geriatric Workers' Compensation Cases

Background

Workers' compensation status is associated with poor outcomes after rotator cuff repair surgery. The purpose of this study was to analyze a database of geriatric workers' compensation patients after surgical repair of the rotator cuff and identify both medical and nonmedical patient factors that influence the time it takes for them to return to work at full duty, including a comparison of arthroscopic and open techniques.

Methods

An all workers' compensation database was queried for rotator cuff claims that were surgically managed using arthroscopic, open, or both approaches from 2003 to 2013 in patients aged ≥60. Primary outcomes were the number of days for return to full work (RTW) following surgery and the total reimbursement for health care. Multivariate analysis was performed, and data are presented as average ± standard deviation.

Results

The database yielded 1903 claims for surgically treated rotator cuff conditions (arthroscopic n = 935; open n = 926; both n = 42). In multivariate RTW analyses, we did not find a significant difference between groups (RTW in days was 153 ± 134 for arthroscopy [P = .81], 160 ± 160 for open [Ref], and 140 ± 82 days for both [P = .75]). However, multivariate analysis of reimbursement claims found arthroscopic surgery claims to be 13% higher compared to claims for open surgery only (US $29 986 ± 16 259 for arthroscopy vs US $26 495 ± 13 186 for open, P < .001). Patients aged ≥65 had more medical expenses than patients aged 60 to 64 (P = .03). Potentially modifiable variables that significantly prolonged RTW timing and higher health-care claims included need for vocational rehabilitation services and filing of a legal suit.

Conclusions

Return to full-duty work in geriatric workers' compensation patients after rotator cuff repair takes about 5 months regardless of surgical approach and costs significantly more in patients aged ≥65. Arthroscopic repairs generated 13% more cumulative health-care costs than open surgery alone. More efficient vocational rehabilitation services and minimizing legal suits may help get patients back to work sooner and reduce overall costs.

Expanding vocational retraining options for injured workers: An experiment in worker choice

BACKGROUND

An innovative self-directed vocational retraining alternative (Option 2) has been offered to eligible Washington State injured workers since 2008.

OBJECTIVE

We aimed to describe: (1) how frequently Option 2 was selected and by whom, (2) the extent to which Option 2 workers used their reserved retraining funds, and (3) how worker satisfaction and employment outcomes for Option 2 workers compared with those of workers undergoing traditional vocational retraining.

METHODS

Five-year cohort study involving workers' compensation data, state wage files, and two worker surveys.

RESULTS

Fewer than 25% of Option 2 workers used their retraining funds. Retraining fund use was associated with better employment outcomes. Workers who were older, whose preferred language was not English, or who had lower pre-injury wages or less education, were least likely to use Option 2 retraining funds. Many workers chose Option 2 because they thought the approved traditional retraining plan was not a good fit for them.

CONCLUSIONS

Self-directed retraining may benefit workers who have the ability, resources, and motivation to independently identify and complete retraining. Additional efforts may be needed to ensure that traditional retraining plans are well-suited to workers' circumstances, and to identify and remove barriers to use of reserved retraining funds.

Vocational rehabilitation program evaluation: comparison group challenges and the role of unmeasured return-to-work expectations

PURPOSE

Despite the importance and cost of workers' compensation (WC)-based vocational rehabilitation (VR) programs, outcome evaluations are rare, in part due to the scarcity of suitable comparison groups. The aims of this study were to assess (1) the adequacy of a commonly recommended internal comparison group, i.e., workers who were eligible for but did not receive services, and (2) return-to-work (RTW) expectations as a potential source of bias.

METHODS

In this prospective cohort study, we used WC claims data and worker-reported RTW expectations to compare workers who received vocational retraining services to eligible workers who did not receive such services. Workers were surveyed after retraining eligibility determination, prior to the initiation of retraining activities. VR progress and RTW wage outcomes were followed for 3 years. The magnitude of confounding contributed by RTW expectations and other covariates was quantified.

RESULTS

Workers who were somewhat or very certain they would RTW had significantly better outcomes. RTW expectations played a strong confounding role, reducing the retraining plan effect estimate by about 23 %, while education and physical capacity each changed the effect estimate by <5 %.

CONCLUSIONS

RTW expectations predicted long-term RTW outcomes and can play a strong confounding role if unmeasured. We found that the internal comparison group approach, commonly recommended for VR program evaluation, is inappropriate for WC-based VR evaluations. Ultimately, there is no simple solution to the challenge of identifying a comparison group; however, measurement of RTW expectations, an easily-measured multi-dimensional construct, may be a useful addition to the VR evaluation toolbox.

Occupational injury trends derived from trauma registry and hospital discharge records: lessons for surveillance and research

OBJECTIVE

The suitability of the Washington State Trauma Registry (WTR) for occupational injury surveillance was assessed via comparing estimated rates and trends with those derived from state hospital discharge data.

METHODS

Descriptive methods and negative binomial regression were used to model occupational injury trends (1998 to 2009).

RESULTS

Nonlinear trends based on WTR data closely tracked those based on hospital discharge data, beginning about 2002. Rate estimates differed somewhat by data source and were most similar when a severity threshold was applied. Conclusions regarding temporal trends in work-related injury rates were the same using either data source.

CONCLUSIONS

This study found substantial similarity between occupational injury trends estimated using either WTR or hospital discharge data. We conclude that a mature state trauma registry with mandatory reporting requirements can be used for surveillance of severe work-related traumatic injuries.