* Portions of this article have been adapted from Shrey and Lacerte (1995) and Shrey (1995).
Employers are faced with increasing societal and legislative pressure to integrate and accommodate people with disabilities. Increasing workers’ compensation and health care costs are threatening the survival of business and draining resources otherwise allocated to future economic development. Trends suggest that employers can be successful in the effective management of injury and disability problems. Impressive disability management programme models are prominent among employers that assume control and responsibility for injury prevention, early intervention, injured worker reintegration and worksite accommodation. Current disability management practice in industry reflects a paradigm shift from services provided in the community to interventions occurring at the worksite.
This article offers an operational definition of disability management. A model is presented to illustrate the structural components of an optimal worksite-based disability management programme. Effective disability management strategies and interventions are outlined, including key organizational concepts that strengthen service delivery and successful outcome. This article also includes a focus on joint labour-management collaboration and the use of interdisciplinary services, which are considered by many to be essential to the implementation of optimal disability management programmes in industry. Promoting respect and dignity between workers with disabilities and the professionals who serve them is emphasized.
Definition of Disability Management
Disability management is operationally defined as an active process of minimizing the impact of an impairment (resulting from injury, illness or disease) on the individual’s capacity to participate competitively in the work environment (Shrey and Lacerte 1995). The basic principles of disability management are as follows:
- It is a proactive (not passive or reactive) process.
- It is a process that enables labour and management to assume joint responsibility as proactive decision-makers, planners and coordinators of workplace-based interventions and services.
- It promotes disability prevention strategies, rehabilitation treatment concepts, and safe work return programmes designed to control the personal and economic costs of workplace injury and disability.
Successfully managing the consequences of illness, injury and chronic disease in the workforce requires:
- an accurate understanding of the types of injury and illness that occur
- the employer’s timely response to the injury or illness
- clear administrative policies and procedures
- the effective utilization of health care and rehabilitation services.
Disability management practices are based on a comprehensive, cohesive and progressive employer-based approach to managing the complex needs of people with disabilities within a given work and socio-economic environment. Despite rapidly escalating costs of injury and disability, rehabilitation technologies and disability management resources are available to facilitate immediate and recurrent savings among business and industry. Disability management policies, procedures and strategies, when properly integrated within the employer’s organization, provide the infrastructure which enables employers to effectively manage disability and continue to compete in a global environment.
Controlling the cost of disability in business and industry and its ultimate impact on employee productivity is not a simple task. Complex and conflicting relationships exist between employer goals, resources and expectations; the needs and self-interests of workers, health care providers, labour unions and attorneys; and the services available in the community. The ability of the employer to participate actively and effectively in this relationship will contribute to the control of costs, as well as to the protection of the worker’s sustained and productive employment.
Disability Management Objectives
Employer policy and procedure, as well as disability management strategies and interventions, should be designed to accomplish realistic and attainable objectives. Disability management programmes at the worksite should enable the employer to:
- facilitate control of disability issues
- improve corporate competitiveness
- reduce work disruptions and unacceptable lost time
- decrease incidence of accidents and magnitude of disability
- reduce illness and disability duration (and costs)
- promote early involvement and preventive interventions
- maximize use of internal (employer) resources
- improve coordination and accountability, with respect to external service providers
- reduce human cost of disability
- enhance morale by valuing employee physical and cultural diversity
- protect the employability of the worker
- ensure compliance with reintegration and employer equity legislation (e.g., Americans with Disabilities Act of 1990)
- reduce adversarial nature of disability and litigation
- improve labour relations
- promote joint labour-management collaboration
- facilitate direct worker involvement in planning
Essential Disability Management Conceptsand Strategies
Both labour and management have vested interests in protecting the employability of workers while controlling industry’s injury and disability costs. Labour unions want to protect the employability of the workers they represent. Management wants to avoid costly worker turnover, while retaining productive, reliable and experienced employees. Research suggests that the following concepts and strategies are important when developing and implementing effective worksite-based disability management programmes:
Joint labour-management involvement
Disability management requires employer and union involvement, support and accountability. Both are key contributors in the disability management process, participating actively as decision-makers, planners and coordinators of interventions and services. It is important for both labour and management to assess their joint capacities for responding to injury and disability. This often requires an initial analysis of joint strengths and weaknesses, as well as an assessment of the resources available to properly manage accommodation and return-to-work activities among workers with disabilities. Many unionized employers have successfully developed and implemented on-site disability management programmes under the guidance and support of joint labour- management committees (Bruyere and Shrey 1991).
Organizational structures, worker attitudes, management intentions and historical precedents contribute to the corporate culture. Prior to developing a disability management programme in industry, it is important to understand the corporate culture, including the motivations and self-interests of labour and management regarding injury prevention, worksite accommodation and injured worker rehabilitation.
Injury and disability patterns
Disability management programmes in industry must be customized to address the unique patterns of injury and disability in the employer’s workforce, including types of impairments, ages of workers, lost-time statistics, accident data and costs associated with disability claims.
Interdisciplinary disability management team
Disability management requires an interdisciplinary disability management team. Members of this team often include employer representatives (e.g., safety managers, occupational health nurses, risk managers, human resources personnel, operations managers), labour union representatives, the worker’s treating physician, a rehabilitation case manager, an onsite physical or occupational therapist and the worker with a disability.
Perhaps the most important principle of disability management is early intervention. Rehabilitation policy and practice among most disability benefit systems recognizes the value of early intervention, in light of compelling empirical evidence resulting from disability management research over the past decade. Employers have substantially reduced disability costs by promoting early intervention concepts, including the systematic monitoring of workers with work restrictions. Early intervention strategies and programmes for an early return to work result in decreased lost time, increased employer productivity and decreased workers’ compensation and disability costs. Whether the disability is work related or not, early intervention is considered to be the primary factor upon which the foundation of medical, psychosocial and vocational rehabilitation is established (Lucas 1987; Pati 1985; Scheer 1990; Wright 1980). However, the successful management of disability also requires early return to work opportunities, accommodations and supports (Shrey and Olshesky 1992; Habeck et al. 1991). Typical early-return-to-work programmes in industry include a combination of disability management interventions, facilitated by an employer-based multidisciplinary team and coordinated by a skilled case manager.
Proactive interventions at individual and work environment levels
Disability management interventions must be directed at both the individual and the work environment. The traditional approach to rehabilitation often ignores the fact that occupational disability may originate as much from environmental barriers as from the worker’s personal traits. Workers dissatisfied with their jobs, supervisor-worker conflicts and poorly designed workstations rank high among the many environmental barriers to disability management. In short, to maximize rehabilitation outcomes among injured workers, an equally balanced focus on the individual and the work environment is needed. Job accommodations, as required under the Americans with Disabilities Act and other employment equity legislation, often expand the range of transitional work options for an injured worker. Redesigned tools, ergonomically correct workstations, adaptive devices, and work-schedule modifications are all effective disability management methods that enable the worker to perform essential job tasks (Gross 1988). These same interventions can be utilized in a preventive manner to identify and redesign jobs which are likely to cause future injuries.
Benefit plan design
Employee benefit plans often reward workers for remaining disabled. One of the strongest negative forces impacting on unacceptable lost time and associated costs is economic disincentives. Benefit plans should not create an economic disincentive to work, but should reward workers who have disabilities for returning to work and remaining healthy and productive.
There are two basic ways to reduce disability costs in industry: (1)prevent accidents and injuries; and (2) reduce unnecessary lost time. Traditional light duty programmes in industry have been less than fully effective in returning injured workers to their jobs. Employers are increasingly using flexible and creative work return transition options and reasonable accommodations for workers with restrictions. The transitional work approach enables employees with disabilities to return to work before they fully recover from their injuries. Transitional work typically includes a combination of temporary assignment to modified work, physical conditioning, safe work practices education and work adjustment. Reduced lost time through transitional work translates into lower costs. The injured worker is enabled to perform temporary alternative productive work while gradually transitioning back to the original job.
Promotion of positive labour relations
Relationships between workers and work environments are dynamic and complex. Compatible relationships often lead to job satisfaction, enhanced productivity and positive labour relations, all of which are mutually rewarding for the worker and the employer. However, relationships characterized by unresolved conflicts can lead to mutually destructive consequences for workers and employers. Understanding the dynamics of person-environmental interactions in the workplace is an important first step in resolving injury and disability claims. The responsible employer is one that supports positive labour relations and promotes job satisfaction and worker involvement in decision making.
Psychological and social aspects of disability
Employers need to be sensitive to the psychological and social consequences of injury and disability and the overall impact of work disruption on the worker’s family. Psychosocial problems that are secondary to the initial physical injury typically emerge as lost work time increases. Relationships with family members often deteriorate rapidly, under the strain of excessive drinking and learned helplessness. Maladaptive behaviours resulting from work disruption are common. However, when other family members become adversely affected by the consequences of a worker’s injuries, pathological relationships within the family emerge. The disabled worker undergoes role changes. Family members experience “role change reactions”. The once independent, self-supporting worker now takes on a role of passive dependency. Resentment abounds when the family is disrupted by the presence of an ever-demanding, sometimes angry and often depressed individual. This is the typical outcome of unresolved labour relations problems, fuelled by stress and ignited by litigation activity and intense adversarial proceedings. Although the relationship among these forces is not always understood, the damage is usually profound.
Accident prevention and occupational ergonomics programmes
Many employers have experienced significant reductions in accidents by establishing formal safety and ergonomics committees. Such committees are typically responsible for safety surveillance and monitoring risk factors such as exposures to dangerous chemicals and fumes, and establishing controls to reduce the incidence and magnitude of accidents. More frequently, joint labour-management safety and ergonomics committees are addressing problems such as repetitive motion injuries and cumulative trauma disorders (e.g., carpal tunnel syndrome). Ergonomics is the application of technology to assist the human element in manual work. The overall objective of ergonomics is to fit the task to humans in order to enhance their effectiveness in the workplace. This means that ergonomics aims at:
- eliminating or minimizing injuries, strains and sprains
- minimizing fatigue and overexertion
- minimizing absenteeism and labour turnover
- improving quality and quantity of output
- minimizing lost time and costs associated with injuries and accidents
- maximizing safety, efficiency, comfort and productivity.
Ergonomic interventions can be considered preventive as well as rehabilitative. As a preventive approach, it is important to analyse ergonomically jobs that cause injuries and to develop effective ergonomic modifications that prevent future work disabilities. From a rehabilitation viewpoint, ergonomic principles can be applied to the jobsite accommodation process for workers with restrictions. This may involve exerting ergonomic administrative controls (e.g., rest periods, job task rotation, reduced work hours) or by ergonomically engineering the job tasks to eliminate re-injury risk factors (e.g., changing the table height, increasing illumination, repackaging to reduce lift loads).
Employer responsibility, accountability and empowerment
Employer empowerment is a basic principle of disability management. Except for the worker with a disability, the employer is the central figure in the disability management process. It is the employer who takes the first step in initiating early intervention strategies subsequent to an industrial accident and injury. The employer, being intimately familiar with work processes, is in the best position to implement effective safety and injury prevention programmes. Likewise, the employer is best positioned to create work return options for persons with lost-time injuries. Unfortunately, history has revealed that many employers have relinquished control and responsibility for disability management to parties external to the work environment. Decision making and problem solving, as relates to the resolution of work disability, have been assumed by insurance carriers, claims managers, workers’ compensation boards, physicians, therapists, case managers, rehabilitation professionals and even attorneys. It is only when employers become empowered in disability management that the lost-time trends and associated costs of workplace injury are reversed. However, employer empowerment over disability costs does not occur by chance. Not unlike persons with disabilities, employers often become empowered upon recognition of their internal resources and potentials. It is only with a new awareness, confidence and guidance that many employers are able to escape the relentless forces and consequences of workplace disability.
Case management and return-to-work coordination
Case management services are necessary to facilitate the development and implementation of disability management strategies and return-to-work plans for workers with disabilities. The case manager serves as a central disability management team member by functioning as a liaison between employers, labour representatives, injured workers, community health care providers and others. The case manager may facilitate the development, implementation and evaluation of an on-site transitional work or worker retention programme. It may be desirable for an employer to develop and implement such programmes, in order to: (1)prevent work disruptions among employees with medical impairments that effect work performance; and (2) promote a safe and timely return to work among impaired workers on medical leave, workers’ compensation or long-term disability. In the administration of an on-site transitional work programme, the case manager may take on direct rehabilitative responsibilities, such as: (1)objective worker evaluations; (2) classification of the physical job demands; (3) medical surveillance and follow-up; and (4) planning for placement in an acceptable permanent modified-duty option.
Disability management policy and procedure: creating expec-tations among supervisors, labour representatives and workers
It is important for employers to maintain a balance between worker and union expectations and the intentions of managers and supervisors. This requires joint labour-management involvement in the development of formal disability management policies and procedures. Mature disability management programmes have written policy and procedure manuals that include mission statements reflecting the interests and commitments of labour and management. Written procedures often delineate the roles and functions of internal disability management committee members, as well as the step-by-step activities from the point of injury to the safe and timely return to work. Disability management policies often define the relationships between the employer, health care providers and rehabilitation services in the community. A written policy and procedures manual serves as an effective communication vehicle among the various stakeholders, including physicians, insurance carriers, unions, managers, employees and service providers.
Enhancement of physician awareness of jobs and work environments
A universal problem in work injury management involves the lack of employer influence over the physician’s return-to-work determination. Treating physicians are often reluctant to release an injured employee to work with no restrictions prior to a full recovery. Physicians are often asked to make return-to-work judgements without adequate knowledge of the worker’s physical job demands. Disability management programmes have been successful in communicating with doctors regarding the employer’s willingness to accommodate workers with restrictions through transitional work programmes and the availability of temporary alternate duty assignments. It is essential for employers to develop functional job descriptions that quantify the exertional demands of job tasks. These tasks can then be reviewed by the treating physician to make a determination of the compatibility of the worker’s physical abilities and the functional demands of the job. Many employers have adopted the practice of inviting doctors to visit production sites and work areas to increase their familiarity with job demands and work environments.
Selection, utilization and evaluation of community services
Employers have realized substantial savings and improved work return outcomes by identifying, utilizing and evaluating effective medical and rehabilitation services in the community. Workers who become ill or injured are influenced by someone to make treatment provider choices. Poor advice often leads to extended or unnecessary treatment, higher medical costs and inferior results. In effective disability management systems, the employer takes an active role in identifying quality services that are responsive to the needs of workers with disabilities. When the employer “internalizes” these external resources, they become a vital partner in the overall disability management infrastructure. Workers with disabilities can then be guided to responsible service providers that share mutual return-to-work goals.
Utilization of independent medical evaluators
Occasionally an injured worker’s medical report fails to substantiate objectively the worker’s alleged impairments and medical restrictions. Employers often feel that they are held hostage to the treating physician’s opinions, particularly when the doctor’s rationale for determining the employee’s work restrictions are unsubstantiated by objective medical tests and measurable assessments. Employers need to exercise their right to independent medical and/or physical capacity evaluations when evaluating questionable disability claims. This approach requires that the employer take the initiative to explore objective and qualified medical and rehabilitation evaluators in the community.
Essential Components of an Optimal Disability Management System
An employer’s foundation for an optimal disability management system has three major components (Shrey 1995, 1996). First, a worksite-based disability management programme requires a human resource component. A major part of this component is the development of the employer’s internal disability management team. Joint worker-management teams are preferred, and they often include members representing the interests of labour unions, risk management, occupational health and safety, employer operations and financial management. Important criteria for the selection of disability management-team membership may include:
- resourcefulness—familiar with employer’s operations, labour relations, internal/external resources and corporate culture
- influence—able to initiate change within management decision-making process
- leadership—earns respect among workers, supervisors and senior management
- creativity—ability to design proactive interventions that work, despite obstacles
- commitment—professional views that are consistent with disability management mission and principles
- motivation—both self-motivated and able to motivate others towards programme goals and objectives
Gaps often exist with respect to the assignment and delegation of responsibilities for resolving disability problems. New tasks must be assigned to ensure that the steps from injury to work return are properly orchestrated. The human resource component includes knowledge and skill supports or training which enable managers and supervisors to perform their designated roles and functions. Accountability is essential, and it must be built into the organizational structure of the employer’s disability management programme.
The second component of an optimal disability management system is the operations component. This component includes activities, services and interventions which are implemented at the pre-injury, during injury and post-injury levels. Pre-injury operations components include effective safety programmes, ergonomic services, pre-placement screening mechanisms, loss prevention programmes and the development of joint labour-management committees. A strong pre-injury operations component is oriented towards injury prevention, and it may include health promotion and wellness services such as weight loss programmes, smoking cessation groups and aerobic conditioning classes.
The during-injury level of an optimal disability management system includes early intervention strategies, case management services, formalized transitional work programmes, worksite accommodations, employee assistance programmes and other health services. These activities are designed to resolve the disabilities that are not prevented at the pre-injury level.
The post-injury level of an optimal disability management system includes worker retention services. Worker retention services and interventions are designed to facilitate the worker’s adjustment to work performance within the context of the worker’s physical or mental restrictions and environmental demands. The post-injury level of a disability management system should also include programme evaluation, financial management for cost-effectiveness, and programme enhancements.
The third component of an optimal disability management system is the communications component. This includes internal and external communications. Internally, the operational aspects of the employer’s disability management programme must be consistently and accurately communicated among employees, managers, supervisors and labour representatives. The policies, procedures and protocols for return-to-work activities should be communicated through labour and management orientations.
External communications enhance the employer’s relationship with treating physicians, claims managers, rehabilitation service providers and workers’ compensation administrators. The employer can influence an earlier return to work by providing treating physicians with functional job descriptions, job safety procedures and transitional work options for injured workers.
Workplace disability management and transitional work programmes represent a new paradigm in the rehabilitation of workers with illnesses and injuries. Trends reflect a shift in rehabilitative interventions from medical institutions to the worksite. Joint labour-management initiatives in disability management are commonplace, creating new challenges and opportunities for employers, unions and rehabilitation professionals in the community.
The interdisciplinary members of the worksite-based disability management team are learning to harness existing technologies and resources within the work environment. The demands on employers are essentially limited to their creativity, imagination and flexibility to adapt disability management interventions to the work environment. Job accommodations and temporary non-traditional job options expand the range of transitional work alternatives for workers with restrictions. Redesigned tools, ergonomically correct workstations, adaptive devices and work schedule modifications are all effective disability management methods that enable the worker to perform essential job tasks. These same interventions can be utilized in a preventive manner to identify and redesign jobs which are likely to cause future injuries.
Protecting the rights of injured workers is an important component of disability management. Every year thousands of workers become disabled through industrial accidents and occupational diseases. Without transitional work options and accommodations, workers with disabilities risk discrimination similar to that faced by other individuals with disabilities. Thus, disability management is an effective advocate tool, whether advocating for the employer or the person with a disability. Disability management interventions protect the employability of the worker as well as the economic interests of the employer.
The profound impact of rapidly escalating workers’ compensation costs will be experienced worldwide by business and industry throughout the next decade. Just as this crisis offers a challenge to industry, disability management interventions and transitional work programmes create an opportunity. With a decreasing labour pool, an ageing workforce and increased worldwide competition, employers in industrialized societies must seize the opportunities to control the personal and economic costs of injury and disability. An employer’s success will be determined by the extent to which he is able to shape positive attitudes among labour and management representatives, while creating an infrastructure supportive of disability management systems.