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Maximising Capacity: A Functional Approach to Injury Management
Presented by: Marcella Romero MHlth Sc (OT) B.App.Sc (OT) Grad. Cert (Occ Rehab)
Managing Director – Rehab Management [Aust] Pty Ltd
October 2014
SESSION OUTLINE
Introduction
Medical model to a whole person model: paradigm shift
Evidenced-based approach
Using a functional approach and best practice framework to maximise capacity
Case Study: How do we integrate this functional approach into effective case management?
Stakeholder collaboration
Summary / questions
Introduction
International & National Recognition
To improve health outcomes when managing injured persons; we need to adopt a biopsychosocial / ‘whole person’ approach.
The whole person approach is accepted and supported by:World Health Organisation (WHO)Heads of Workers Compensation Authorities (HWCA) and Heads of Compulsory Third Party (HCTP).TIO and NT WorkSafe Federal government agencies including Comcare and DVAInsurers within the life insurance framework
Medical Model to Whole Person Model: Paradigm Shift
Traditional Medical Model
The Biopsychosocial Model“Whole Person”
Individual-centred model considers the whole person, their health problem and their social context:Biological—refers to the physical or mental health condition.Psychological—recognises that personal/psychological factors also influence functioning. Social—recognises the importance of the social context, pressures and constraints on functioning.
Evidence Based ApproachWhat Does the Research Say?
Research-Based ComparisonMedical Model Biopsychosocial (‘whole person’) Model
Too simplistic
Promotes concept that day-to-day functioning and disability is dependent on both personal/psychological and social/occupational factors.
Over emphasises impairment
Preventing incapacity requires framework that addresses all the physical, psychological and social factors
Fails to take sufficient account of the personal and social dimensions of disability.
Fundamental in achieving better outcomes from clinical and occupational rehabilitation management
Focused on illness and fails to promote overall health and wellbeing
Considers the whole person – physical, social, psychosocial and emotional needs of the worker, underpins effective injury management.
Encourages reliance on health care professionals
Effective in improving function, facilitating recovery and maximising independence
Industry Research: Realising the Health Benefits of Work
It’s therapeutic Promotes recovery and rehabilitation Better health outcomes Minimises the harmful physical, mental and social effects Reduces the risk of long-term incapacity Promotes full participation in society, independence and human
rights Reduces poverty
Did You Know?
The longer someone is off work, the less likely they become ever to return.
If the person is off work for:20 days the chance of ever getting back to work is 70%45 days the chance of ever getting back to work is 50%; and70 days the chance of ever getting back to work is 35%.*
*2011 The Royal Australasian College of Physicians, Australian & New Zealand Consensus Statement on the Health Benefits of Work: Position Statement: Realising the Health Benefits of Work
Using a Functional Approach & Best Practice Framework to Maximise
Capacity
Functional Evidence-based Framework
Principles:1.Measure and demonstrate the effectiveness of treatment
2.Adopt a biopsychosocial approach
3.Empower the injured person to manage their injury
4.Goal setting to maximise function, participation and RTW
5.Evidence-based intervention / treatment
Principle 1:Measure and demonstrate the effectiveness of
treatment
Why measure?Information on health statusTrack and monitor progress or any changes in statusContinue, change or cease treatment, Target treatment and improve treatment outcomes.
Principle 1: Measure and demonstrate the effectiveness of treatment
What to Measure?
Outcome measures must be related to the functional goals of therapy and relevant to the person’s injury.
Customised Outcomes - Practical Examples:A change in work status (RTW program)A change in participation at home (ADL functional upgrading program)
Principle: 2Adopting a biopsychosocial approach
Factors affecting function and participation at home, work and in the community.
Early identification and management of risk factors helps to address issues that can impact on an optimal outcome.
Identifying risk factors using the Flags Model
Early identification of risk factors (biological, psychological and social domains) - important during the assessment phase as it informs and guides treatment.
Principle: 2Adopting a Biopsychosocial approach
The Flags Model *
* Based on Main, CJ, Sullivan, MJL and Watson, PJ 2008, Pain Management: practical applications of the biopsychosocial perspective in clinical and occupational settings, Churchill Livingstone, Edinburgh, New York.
Principle 3: Empower the injured person to manage their injury
Empowering the injured person to manage their injury is key:EducationSetting expectationsSelf-managementPromoting independenceHealthcare professionals
Principle 3: Empower the injured person to manage their injury
Education and Setting Expectations
Injured person is empowered when they:Set expectationsKnow respective roles Know nature of their injury, expected recovery timeframes and prognosisActively participate in activities at home, work and the communityKnow risks of prolonged inactivityKnow risks and benefits of the treatment proposedHave collaborative treatment goals Learn to manage their condition as independently as possible
Principle 3: Empower the injured person to manage their injury
Influencing Beliefs:Fear avoidanceCatastrophysingLack of acceptanceBlaming others
Practical Strategies: Education and motivational interviewing
Principle 3: Empower the injured person to manage their injury
Active strategies that support self-management and independence:Collaborative goal settingActivity schedulingPacing strategiesFunctional upgrading programsExercise program
Principle 4: Functional goal setting to maximise function, participation and RTW
Setting GoalsFunctional and SMARTRegularly assessed
SpecificMeasurableAchievableRelevantTimed
Current Evidence – where the injured person has a role in selecting treatment, better health outcomes are achieved.
Principle 4: Functional goal setting to maximise function, participation and RTW
Poor Goals To return to work
To improve driving confidence
To improve activities of daily living
To reduce depression
Good Goals To return to work in two days on
modified duties To be able to drive between home
and work within three weeks. Independently manage preparing
breakfast three mornings per week within four months.
To be able to concentrate on reading for 30 minutes four days per week within one month.
Principle 5: Evidence-based intervention / treatment
Research evidence to inform decision making Referencing MD guidelines in relation to expected recovery and
treatment timeframes Systematic reviews Trials Evidence-based treatments
Case Study:
How do we integrate this functional
approach into effective case management?
Case Study: A Functional Approach
Case Profile
John – 41 year old landcare worker Cervical disc injury Referred for physiotherapy Graded RTW attempted but reports pain
when attempting to upgrade closer to PIDs
Employer unable to provide modified duties on a permanent basis
Social: an active touch football coach
Case Study: A Functional Approach
Case Information
Case referral date February 2014
Case closure date July 2014
Case duration Five Months
Rehab goal Different job, different employer
RTW Pre-injury option? No – employer unable to provide duties on a permanent basis.
Case Study: A Functional Approach
Barriers Identified for John
Employer is not able to provide him with suitable duties in the long term.
Has not been compliant with his exercises, and his progress with recovery has been slow.Work experience has mainly involved manual labour and this may not be possible for him in the future.Worked in the same type of role for most of his adult life and considers this to be part of his identity.Believes that he needs to be ‘100%’ before he can return to any type of work.
Case Study: A Functional Approach
Principle 1: Measure and demonstrate the effectiveness of interventions
Evidence of capacity:Program Start
Evidence of capacity:Program finished
Work Not demonstrated (not at work) Commenced in new job with a new
employer as a traffic controller, working full hours.
Home Limited housework, no gardening Able to mow lawn on fortnightly basis and complete all home maintenance tasks independently.
Community Limited social activity Has re-commenced coaching role with touch football team.
Case Study: A Functional Approach
Principle 2: Adopt a biopsychosocial approach
Interventions designed to consider the individual, injury & circumstances
Use of screening tools: e.g. DASS, OMPQ, VAS
Use of targeted questions for assessment
Case Study: A Functional Approach
Principle 2: Adopt a biopsychosocial approach (Cont.)Flag Type Findings
Red Flags – Medical Nil currently identifiedYellow Flags – Psychosocial
Beliefs about pain and injury (that there is a need for passive physical treatments rather than active self-management).
Psychological distress (bereavement of inability to perform previous role).
Distress that his employer has not been able to provide alternative duties.
Blue Flags – Social/Features of Work
John’s work involves manual handling tasks which he reports will cause him intense pain.
John is distressed that due to his physical restrictions, he is currently unable to meet his commitments as a volunteer coach for a local touch football team.
Black Flags – Other Factors
John’s employer has withdrawn alternate duties. John is concerned about coverage to mortgage payments if he
cannot locate another full time position in a timely manner.
Case Study: A Functional Approach
Principle 3: Empower the injured person to manage their injury
Teaching independence
Use of positive encouragement to develop self-efficacy
Collaborative goal setting
Activity scheduling
Pacing strategies
Functional upgrading program
Case Study: A Functional Approach
Technique (Motivational Interviewing)
Question
Ask Evocative Questions Why would you want to make this change?
Ask for Elaboration How do you see this happening?
Ask for Examples Have you ever had to overcome something like this before?
Query Extremes What would be the worst outcome if you don’t make this change?What would be the best outcome if you do make this change?
Principle 3: Empower the injured person to manage their injury
Case Study: A Functional Approach
Principle 4: Goal setting to maximise function, participation and RTW
Example GoalsTo be able to lift ten kilograms from waist to shoulder height for five repetitions whilst maintaining pain level at no higher than 3/10.To be able to return to all coaching duties with touch football team by [date]. To be able to move the lawn on a fortnightly basis by [date].
Case Study: A Functional Approach
Principle 5: Evidence-based intervention / treatment
Injury Example Recommendation
Findings Consultant Action
Cervical Displacement
Strengthening / Stabilisation Home Exercise Program
Doctor had referred John for home exercise program but John had missed multiple appointments. Physiotherapist indicated John had not been completing agreed exercises.
Confirmed already receiving appropriate treatment: issue identified is compliance.Referenced MD guidelines. Provision of education to John clarifying expectations around recovery and treatment.
Case Study: A Functional Approach
Outcome Domain Success Achieved? Comment
Work John commenced in a new job as a traffic controller, working full hours.
Home John is now able to mow his lawn on a fortnightly basis as well as being able to complete all home maintenance tasks independently.
Community John has successfully recommended his role as a volunteer coach with a local touch football team.
Claims Cost Reduction As John returned to full-time work, his wage
component was reduced to $0 therefore, reducing total claim liability
Stakeholder Collaboration
Stakeholder Collaboration
Collaborative Approach by:Treatment providersClaims managers Rehabilitation providers
Shared Goals:Early intervention and tailored programsUse of a functional approach to case management Work on the premise that ‘work is good for you’Return to pre-injury / pre-accident activities (including work) Active engagement of injured person and working towards a common goal Progress review and management of risk factorsEvidence-based decisions.
THANK YOU
NT Contact
Julie Moore
Regional Manager – Northern Territory0429 936 514 | 1300 762 989 [email protected]
Office Location Unit 2/4 Berrimah Road, Berrimah NT 0828
Rehab Management [Aust] Pty Ltd
www.rehabmanagement.com.au
Ph: 1300 762 989