Addressing long term claims; a new approach to improve outcomes

There are many injured workers who follow a relatively straightforward path through the lodgement of a claim to recovery and return to work. Unfortunately, a minority remain off work for extended periods of time at a relatively high cost to the employer, insurer and workers compensation scheme.

There are many injured workers who follow a relatively straightforward path through the lodgement of a claim to recovery and return to work. Unfortunately, a minority remain off work for extended periods of time at a relatively high cost to the employer, insurer and workers compensation scheme. These tend to be claims where there are multiple barriers to return to work, often complex and varied physical and psychological issues, and in many case a long history of treatment and rehabilitation interventions that may or may not have been successful. The long-term nature of these claims is often associated with delays in claims lodgement, and the presence of disputes requiring legal involvement to seek resolution. These claims also tend to incorporate a host of complicating factors including:

  • Permanent impairment
  • Secondary conditions that have resulted from the primary injury or illness
  • Physical deconditioning
  • Extended time away from work and subsequent decline in work related skills
  • Social withdrawal and the stigma of having a work related disability or claim
  • A decline in psychological and emotional wellbeing

Long-term workers compensation claims are defined differently depending on the scheme. In broad terms, these are claims where the injured worker has been off work and in receipt of benefits for an extended period of time, generally greater than two years post claims acceptance. The ‘long tail claim’ is an industry term used synonymously with long-term claims.

Legislation outlines the benefits payable, durations those benefits are paid for and obligations of both the employer and employee. Schemes with generous benefits or the lure of a payout or settlement often create an incentive for injured workers to ‘stay in the system’ and not return to work. These are generally referred to as ‘long tail’ schemes.

At the Commonwealth level, the workers compensation system is a long tail rather than a short tail system in that benefits are paid to the worker without significant step downs in weekly benefit payment for the duration of their incapacity through to the age of retirement with no restriction on medical and hospital expense. In contrast, under the Victorian scheme the injured worker undergoes a work capacity assessment to assist in the review of entitlements before 130 weeks of incapacity. If it is determined that the worker is likely to be able to return to work in the near future, entitlements to weekly benefits cease at 130 weeks.

Several states have introduced recent legislative reforms to address their long term claims and achieve a better balance between the benefits provided to an injured worker and the incentive for the worker to return to work. NSW is an example where prior to recent legislative change which saw the introduction of a cap to injured worker entitlements, the scheme was regarded as a ‘long tail’ scheme.

There are many factors, in addition to the legislation and the nature of the workers’ compensation schemes, that influence the likelihood of a long-term claim and long periods of ‘lost time’ away from work.

The nature of injury or illness is obviously a strong contributing factor to the length of a workers compensation claim and likelihood of return to work. In a statistical report conducted by WorkCover WA (2011), it was suggested that the most common injury resulting in long term claims was sprains and strains. There is also growing evidence to support the fact that psychological injury or illness results in claims that are often long term and costly.

Secondary losses and secondary gains are contributing factors to a longer term recovery from a workplace injury. Secondary losses refer to the loss of social support networks, social relationships at work and the social stigma associated with being the recipient of workers’ compensation. Secondary gains range from receiving financial benefits whilst not having to work, through to the change in family dynamics that result from having to do less at home while injured.1

Research indicates that dysfunction in the return to work (RTW) systems and poor integration between the workplace, healthcare provider, vocational rehabilitation provider, and workers compensation insurer, are significant contributing factors in damaging the likelihood of an injured worker returning to work. Long-term claims are linked to power imbalances among RTW parties, and processes that impeded communication and transparency about RTW situations and problems.2

Limited knowledge of the workers compensation system, conflicting medical information, and confusion about the decision making authority are also contributing factors that lead to frustration, financial and emotional strain, and secondary psychological illness delaying the employees return to work.2

The claims management process is also regarded as an important factor in determining how quickly an injured worker is likely to return to work. Poorly managed claims often contribute to deterioration in communication between the employer and employee leading to long term absence from work and a long-term claim.

Servces and programs designed to assist the long-term injured worker return to work have had varying levels of success, and effective management of these claims remain the focus of regulators, insurers, and self-insurers across Australia.

Services and programs should have a defined end point, and involve the injured worker in setting goals and expectations. Assessing and clearly defining the barriers to a return to work will ensure that interventions are targeted and tailored to the individual.

Developing trust and educating the injured worker about their reasonable expectations of recovery is important in the management of a long-term claim.

Re-engaging with the injured worker through face-to-face contact, rather than phone contact or email communication, is critical to the success of any program. Additionally, it assists in building rapport and developing self-esteem which is integral to being work ready.

Konekt proposes a model of management for the long term ‘tail claim’ underpinned by the following key principles:

  • a strong project management discipline
  • regular stakeholder communication
  • the use of a research based case profiling tool
  • a multidisciplinary initial assessment
  • a strategy meeting with the injured worker and claims agent
  • a suite of tailored interventions to address the identified barriers to the injured worker returning to work

Konekt’s program promotes and rewards employment outcomes without adding additional layers to the already extensive list of interventions that have often been prescribed for these claims.

The program has four stages:

Stage One utilises a research based profiling tool to assess the presence of ‘flags’ and other factors influencing the return to work.

In Stage Two, a comprehensive multidisciplinary assessment ensures that interventions recommended specifically target the barriers to returning to work.

Stage Three involves meeting with the injured worker and claims agent in person to discuss assessment findings, and ensure mutually agreeable recommendations and clear strategies are in place. The meeting also provides an opportunity to engage the stakeholders and establish clear goals and expectations. Throughout each stage, Konekt’s consultants work with participants in the program to engage them, build confidence and build self-esteem which are all integral to being job ready and successful in gaining employment.

In Stage Four Konekt offer a suite of services that can be tailored specifically to align with an agreed strategy and address the barriers to return to work. Konekt believe that tailored intervention is absolutely critical in achieving against the agreed goals for the injured worker.

The interventions can run concurrently or independent of each other; progress will be continuously monitored and regularly communicated back to the key stakeholders.

For further information on Konekt’s Long Term Tail Claims product, please contact your local Konekt office.

References

  1. R. J. Gatchel (2004), Psychosocial factors that can influence the self-assessment of function. Journal of Occupational Rehabilitation; 14(3):197-206.
  2. MacEachen E, Kosny A, Ferrier S, Chambers L. The “toxic dose” of system problems: why some injured workers don’t return to work as expected. J Occup Rehabil. 2010 Sep;20(3):349-66. doi: 10.1007/s10926-010-9229-5. PubMed PMID: 20140752.

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