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Vocational Medical Assessments Best practice, what does it look
like?
Written by:
Dr Rob Griffiths MB ChB (Hons), FFOM, FACOEM,
FAFOEM, FAFPHM, FFOMI, FACAsM, MPP, DipAvMed, DIH
Senior Medical Adviser Accident Compensation Corporation
Gillian Anderson
Category Manager, Accident Compensation Corporation
1 – Background
The Value of Vocational Medical Services to ACC
The services are:
• integral to a sustainable return to work outcome for the client and ACC
• supported by robust clinical advice that informs good decision making
ACC primarily purchases medical assessments to:
• determine treatment and rehabilitation interventions
• determine a client’s eligibility for cover and entitlements
• assess a client’s functional capacity to undertake work (vocational independence)
3 Copyright (c) ACC
The Service Philosophy of Vocational Medical Services
• Vocational Medical Services are designed to support our client’s
vocational rehabilitation through:
Providing ongoing support and advice throughout the client’s
rehabilitation
Being flexible
Being responsive
Encourage teamwork
Promote openness and transparency
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Assessments within Vocational Medical Services
• Initial Medical Assessment (IMA)
• Vocational Independent Medical Assessment (VIMA)
• Vocational Medical Review (VMR)
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Key features of the Vocational Medical Services
are:
• encouraging integration
• enabling conversations
• helping to problem solve
• providing clinical leadership
Liaison services and medical review
Vocational Medical Services – key service elements
Copyright (c) ACC
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Client
Provide expert guidance and reassurance on
return to work practices
Improve the likelihood that the client will retain
their job
Encourage participation in 'Better at Work'
culture
GP
Provide expert guidance on safe return to work
practices
Provide confidence in a safe recovery process for
their patient
Assist with the management of their
patient
ACC
Provide expert rehabilitation for ACC
clients
Advance the client’s rehabilitation in the workplace, where
appropriate
Improve rehabilitation rates for clients
VRS Provider
Provide expert guidance on safe return to work
practices
Ensure timely completion of Vocational
Rehabilitation Service programmes
Employer
Improve staff retention and productivity
Provide expert guidance on safe
return to work practices
Encourage 'Better at Work' culture
3 – Best Practice clinical skills
Written by:
Dr Rob Griffiths
MB ChB (Hons), FFOM,
FACOEM, FAFOEM,
FAFPHM,
FFOMI, FACAsM, MPP,
DipAvMed, DIH
Senior Medical Adviser
Accident Compensation
Corporation
Promoting Independence
“Work is good for you”
Harms of not working/participating
50% of long-term dependents are fit to work
“Trajectory of disability”
50% of disability is unrelated to injury; importance of motivation and RTW
“obstacles
The role of pain in disability
Leadership Roles
Clinical
Client-centred
Personal responsibility/autonomy
Confidentiality
Comprehensiveness of information
Maximum Medical Recovery?
Bio-Psychosocial Approach
Process considerations
Consistent use of terminology/measurement
Complex VIMA: History
Age 13
Missed +++ school
Unexplained serious illness
Multiple tests inconclusive
Poor adolescent school performance
Age 19 diagnosed with “chronic colitis”
Age 21 “gravely ill” but video footage swimming on beach days later
Age 21 onset Chronic Lower Back Pain & back brace use
Age 24 fails job pre-placement examination
Several months later passes same examination
Fellow employees note good health while at work
Age 26 permanently unfit for same job
Age 27 failed lumbar disc surgery –
high dose narcotics
Age 29 Endocrinological Diagnosis and Treatment
Age 30 high rate of work absenteeism
Age 34 “unceasing” low back pain trigger point injections for lumbar spasm
Age 37 lumbar fusion; Failed back surgery and depression GP notes “0 degrees flexion or
extension”
Age 42 “exhaustion & trembling at work” Reluctant to work, Asleep during meeting Concerns re performance at work
Age 43
“unbearable back pain” at work
Attends multiple specialists
Age 44
Psychoactive stimulants and anabolic steroid use
Multiple medications for sleep and anxiety
Disrupted sleep: “groggy and fatigued”
What is his fitness to work with these symptoms?
0
No work
1
Minimal
Cognitive
Demands
2
Moderate
Cognitive
Demands
3
Difficult
Cognitive
Demands
4
Hardest
Job
Demands
“Motivation for improvement may be key
factor of an individual's ability to lead a
productive life despite a challenging
impairment ...”
“…motivation is a significant link between
and impairment and resulting disability”
Return To Work Motivation
The Obstacle Question
• What is specifically the obstacle preventing you
from working today?
The Mole Hill Sign
• When an apparently minor health condition having
a major effect on daily life and function, there
maybe a motivational issue.
Jennifer Christian, MD
Pain Behaviour Observation System
Rubbing
Guarding
Bracing
Grimacing
Sighing
Frequency correlates with VAS and 0-10 pain ratings
Keefe & Block Behav Ther. 1982;13: 363–375
Pain Catastrophizing Scale (PCS)
Measures:
• Magnification
• Rumination
• Helplessness
Risk range is total score > 20
sullivan-painresearch.mcgill.ca/pcs.php
Waddell’s Signs
Axial compression
Simulated rotation
Nondermatomal sensory loss
Superficial tenderness to light touch
“Cogwheel” (give-way) weakness
SLR discrepancy between sitting and supine tests
Over-reaction
Non-organic Signs are not...
“Nonorganic signs also correlate with ….disturbed mood, psychological
distress, and dysfunctional beliefs and coping strategies…they are simply
a screening test that should alert the clinician that this patient needs more
careful clinical and possibly psychological assessment”
Spine 2004;29(13): 1393
Assessment of Chronic Pain
ACOEM Practice Guidelines, 3rd ed.
Chronic pain chapter (200+ pages)
• History
• Examination
• Work relatedness
• Diagnostic testing
• Treatment
• Disability durations (MDA)
(ACOEM APG. Hegmann, 2010)
Pain Status
Impairing symptoms
Severity
• Intensity
• Frequency
• Duration
• Precipitants and effects on functioning
Perceived work barriers
Pain Management
• Reduce emotional reactivity and fear response to pain - mindfulness/
relaxation/Cognitive Behavioural Therapy (CBT)
• Promote sleep habit recovery
• Check for psychiatric comorbidities and Substance Use Disorder
• Treat any nociceptive aggravation
• Target approaches for neuropathic pain and Complex Regional Pain
Syndrome (CRPS) - tricyclic antidepressants (TCAs), neuroleptics,
serotonin and norepinephrine reuptake inhibitors (SNRIs)
• Increase physical activity/balance
• Normalise, maintain and enhance social activity and participation
Fatigue and fatigability
• Fatigue limits an individual’s tolerance of tasks
• Fatigue can make some work tasks more risky
• Take a really good history: Fatigue means different things to different people
• Clarify the cause of fatigue
• Find out what makes it better and worse
Mood
• Depression
• Anxiety
• Cognitive dissonance
• Anger
• Resistance
• Malingering?
Know the Job!
• ACC Work Detail Sheets
• O-Net
• University of Calgary site
• Medical fitness guidelines
• Ideally job site visits
• Recovery expectation
• Job satisfaction
• Work relationships and support
• Did work cause the injury?
• Adequate training?
• Disciplinary action pending?
• Fears that work will worsen pain?
• Unusual work absenteeism patterns
Ask about:
Functional Capacity
• Capacity
• Limitations
• Restrictions
• Tolerance
AMA guides to the evaluation of Work Ability & Return to Work 2nd ed.
Tolerance
Ability to sustain work or activity
Not scientifically measurable
Frequently less than capacity
Dependent on the rewards
“Believable” or not?
AMA guides to the evaluation of Work Ability & Return to Work 2nd ed.
Barriers
Diagnosis/severity (red flags)
Environmental (blue/black flags)
Patient responses (yellow flags)
Illness behaviours/perceptions:
• Fear-avoidance
• Catastrophising
• Deconditioning
• Compensation
Factors Associated with Level of Delayed Return to Work
Geographical Organisational Personal
Climate Region Ethnic origin Social insurance Health services Epidemics Unemployment Social attitudes Pension age Taxation
Nature Size Industrial relations Personnel policy Sick pay Supervisory quality Working conditions Environmental hazards Occupational Health Service Labour turnover
Age Gender Occupation Job satisfaction Personality Life crises Medical conditions Alcohol Family responsibility Journey to work Social activities Length of service
Mental Illness and Employment Barriers
• Participation in education
• Cognition
• Type of employment
• Contact with the public
• Need for a support person
• Difficulty in changing jobs
• Need for reduced hours
• Concentration
• Irritability
• Labile mood
• Fatigue/sleep/shift work
• Social
• Medication
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Systemic Issues
• Self esteem
• Career immaturity
• Community Stigma
• Peer stigma
• Employer reluctance
• Health professional expectations
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Elements of Supported Employment
• Job-seeking & resume writing
• Individual Placement & Support
• Disseminate IPS programmes
• Integration of IPS with clinical services
• Improving fidelity of IPS
• Augmenting IPS with education
• Skills training
• Work trials
• Benefits counselling
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When motivation is unclear
Personal
• Rewards of work?
• Depression & anxiety
• Self-assessed competency
Environmental
• Infrastructural effects for work –readiness
• Social supports
• Stigma
• Past experience
Occupational
• Good jobs
• Flexibility
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Motivational Interviewing
• Express empathy
• Develop discrepancy
• Roll with resistance
• Evaluate motivation
• Support self-efficacy
• Support change discussions
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Medical evaluation
• History of mental & behavioural disorder(s)
• Current mental & physical examination findings
• Comorbidities
• Current status/future plans
• Diagnosis
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Analysis
• Effects on normal life activities
• Stability
• Adverse effects of participation?
• Access to work modifications?
• Relate clinical findings to impairment
• Effect of impairment on ability to function
• Severity of impairment
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Assessment
• Motivation
• Activities of Daily Living
• Life Skills Profile
• Occupational Self Assessment
• Specific barriers
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Special considerations
Understanding & memory
Sustained concentration & persistence
Social interaction
Adaptation
Effects of medication
Substance abuse
Personality
Cognition
Pain Malingering
Motivation
Personal & public safety
Severity of impact:
• ADLs
• Social functioning
• Task completion & pace
• Deterioration or decompensation in work settings
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Copyright (c) ACC Author/Unit
Recommendations
• Functional ability
• Further investigations or Rx
• Functional restoration
• Employment suitability
• IRP barriers
• Illness behaviours
Content Guidelines
ID/Assessment Information
Documents reviewed
Introduction & consent
statement
History of the injury &
management
Current situation/function
PMH
Medications
Personal/social history
Previous occupational Hx
Most recent employment
Examination
Diagnosis
Rehabilitation barriers
Recommendations
Restrictions and/or Limitations
Sustainable employment options
Completeness of Rx and Rehab
Specific recommendations/comments
Client comments/feedback
3 – Questions/discussion
• How can you tell if you are doing well?
• Do clients think you are doing well?
• What can we share about what we do well?
Questions
Copyright (c) ACC
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Contact us
Rob Griffiths
Senior Medical Adviser
Phone: 04 816 6075
acc.co.nz
Gillian Anderson
Category Manager, Vocational Assessments and
DHB Relationships
Phone: 04 816 7155
acc.co.nz