WORK A Journal of Prevention, Assessment & Rehabilitation
ELSEVIER
Work 5 (1995) 115-122
An integrated program for the prevention and management of musculoskeletal work injuries Sue Rhomberg*\ Laurie Wolfb, Bradley Evanoff c a Rehabilitation
Services, BamesCare Corporate Health Services, 5000 Manchester, St. Louis, MO 63110, USA bErgonomics, BamesCare Corporate Health Services, 5000 Manchester, St. Louis, MO 63110, USA C Section of Occupational and Environmental Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
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Abstract With rising health care costs and a dynamic health care structure in the USA, many medical and rehabilitation professionals are seeking cost effective strategies to assist employers in preventing and managing musculoskeletal work injuries. An integrated approach based on the classic three component model of preventive medicine which includes primary, secondary and tertiary prevention is discussed. This approach includes ergonomics, medical injury treatment and rehabilitation services to provide a comprehensive occupational health program. The manner in which these services are packaged for purchase by industry is shifting from a fee-for-service system to a capitated program with the provider coordinating service delivery at risk. The incentives for successful outcomes are tremendous. Challenges in carrying out this program are presented as well as discussion of approaches to overcome these barriers. Ergonomics; Occupational health; Injury prevention; Musculoskeletal work injury; Return-to-work; Industrial rehabilitation; Model prevention program _._--_._----._-------------Keywords:
1. Introduction
The health care system of the USA is undergoing enormous transition, with even greater changes anticipated in the near future. Health care costs are an obstacle to global economic competitiveness. Private business spent $205.4 billion on health care for employees in 1991 (Cowan
* Corresponding author, Fax: + 314531 8773.
and McDonnell, 1993). Employers are becoming much more sophisticated as active purchasers of health care rather than remaining passive payors (Loeppke, 1993). There is a growing consensus that costs may outweigh consumer value. These changes have created a climate of uncertainty among deliverers and purchasers of health care, but enormous opportunities are emerging for providers to create new service delivery models for medical treatment and health promotion. This article will discuss an integrated program
1051-9815/95/$09.50 © 1995 Elsevier Science Ireland Ltd. All rights reserved. SSD11051-9815(95)00113-Y
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s. Rhombergetal. /Work5 (1995) 115-122
for managing patients with work-related musculoskeletal disorders (WRMSDs), including both acute injuries and the group of chronic conditions referred to as cumulative trauma disorders (CTDs) or repetitive strain injuries (RSIs). We will present the regulatory and reimbursement environments that guide the concepts of this integrative approach and the program components which include elements of prevention, treatment, and rehabilitation. We also want to share some of the experiences that have challenged us as we establish this program within a comprehensive occupational health clinic setting and a larger health system. 2. Regulatory and reimbursement environments
National trends in health care delivery seem to favor the integration of prevention, acute injury treatment, and rehabilitation. We are moving away from a system which reimburses most handsomely for procedure-oriented treatment interventions and pays little, if at all, for consultationbased prevention services such as ergonomics. One type of shift from the traditional fee-forservice model is capitation, in which a health-care delivery organization agrees to provide all necessary treatment services to a population for a flat fee. This form of reimbursement encourages health care providers to take two important positive perspectives. The first is to actively promote wellness and injury prevention in the covered population. The second is to monitor and carefully examine the expense and efficiency of service delivery to the covered population. In order to take on the financial risk of providing comprehensive care to a group of workers at a fixed cost, a health care organization must: be able to direct and control preventive measures aimed at keeping the work force healthy; (2) oversee the provision of care to injured workers in order to assure that high-quality care is provided without incurring unnecessary expenses, and (3) direct the rehabilitation of injured workers so that they are assisted in returning to their (1)
jobs and to their maximum functional abilities in a timely and efficient manner. Capitation and other changes in health care financing have been driven in part by the demands of purchasers and users of health care to demonstrate the value of the health care received. Rather than merely pay for health care based on volume, purchasers are asking for measures of value received. Such measures of value (or outcomes) include: patient satisfaction, demonstrated medical appropriateness and effectiveness of treatment, and ultimately improvements in the health of the population. Crucial to both the purchasers and providers of health care are improvements in our measures of health outcomes and wide-scale implementation of healthoutcome databases. Current health-care databases are almost entirely based on billing or other administrative data, and often do not contain the types of data which are necessary to measure the effectiveness of preventive, treatment, or rehabilitative services. Outcome measures need to be implemented not only for individual episodes of care or treatment, but also for measuring changes in the health of whole populations. Additionally, as medical and rehabilitation professional groups, it is imperative that we utilize outcomes to prove the value of our services in terms of effectiveness and cost containment. Another force which favors the integration of health services is the increasing governmental regulation of monitoring and controlling workplace physical exposures and WRMSDs. Both the federal and some state governments currently have ergonomic guidelines and regulations for governing allowable exposures (Military Handbook, 1975; American National Standard Institute/Human Factors Society, 1988; Military Standard, 1989; Occupational Safety and Health Administration, 1991). As merely guidelines, these are not enforceable. The Occupational Health and Safety Administration (OSHA) is expected to release draft ergonomic regulations for general industry this fall. It is widely believed that these regulations will require employers to institute programs for hazard assessment, hazard preven-
s. Rhombergetal. /Work5 (1995) 115-122 tion, and surveillance of WRMSDs. Guidelines for medical management will also be an important component of these draft regulations. It is apparent that many companies lack the needed expertise to develop programs meeting all provisions of the anticipated federal regulations, and therefore, will rely on consultants such as occupational health groups to guide them. Many employers are still struggling to comply with the Americans with Disabilities Act (ADA), which requires employers to reasonably accommodate workers with disabilities who have the qualifications for a specific job. Integrated prevention and treatment programs are uniquely suited to help employers comply with these new regulations. Both workers and employers will benefit from the lower rates of injury and disease which are expected to occur as a result of better surveillance and hazard assessment. 3. An integrated prevention and treatment program
The successful integrated program for WRMSDs can be modelled after the classic three-component model of preventive medicine: primary, secondary, and tertiary prevention «Last and Wallace, 1992) See Fig. 1). Primary prevention is the pro-active approach to preventing the occurrence of disease or injury. Secondary prevention stops the progression of a disease or illness in the early stages. Tertiary prevention attempts to minimize the effects of an injury and disability once an injury or disease has occurred. A comprehensive ergonomics program focused on primary prevention, includes: risk assessment, injury/illness file review, workstation evaluation and redesign, pro-active on-the-job injury prevention education and training, ergonomic task force development and follow-up to assure long term effectiveness. Pre-placement screenings of musculoskeletal function, upper extremity CID signs and symptoms, and functional capacity for job specific tasks will assist in identifying high risk individuals and will also guide job placement. These screenings should identify needs for accommodation as well as disqualify those individu-
117
als who cannot safely perform a job (with or without accommodation). Ongoing surveillance of an individual's or work group's health status will be essential for promoting optimal employee health and long term cost effectiveness. Results of the assessment assist companies in prioritizing interventions and corporate spending to focus on the most important ergonomic issues. Secondary prevention is the early detection and treatment of the disease or injury in order to prevent its progression. Acute injury medical treatment and occupational and physical therapy facilitate quick recovery, maintain work status and prevent lost work time. With corporate compliance in encouraging early reporting, many CIDs can be recognized early after onset, when treatment is less costly and symptoms can be effectively managed with a conservative approach. Many employers struggle with adopting this early reporting approach, however, in fear of epidemic and exaggerated responses and with little insight toward the tremendous potential for long term savings. Having in-house access to the results of the risk assessments, the occupational health providers will be able to optimally manage the case immediately following injury and be able to make accurate return-to-work decisions. In this setting, treatment of WRMSDs can occur with minimal interference with work performance. Sharing of information facilitates good quality treatment while maximizing productivity, preventing lost work time and facilitating recovery to the preinjury status. Tertiary prevention means minimizing the effects of disease or injury after it has occurred. At this level, the priority is to minimize functional disability through appropriate evaluations of work capacity and treatment models such as work conditioning and work hardening to manage the more severe and chronic cases. Emphasis is placed on capacities and accommodations to maximize employment potential rather than identifying work limitations. Education to prevent reinjury or worsening of a condition is an important component of rehabilitation in a tertiary prevention program.
118
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4. The BarnesCare integrated approach
BamesCare Corporate Health Services assists approximately 1500 client companies in the St. Louis metropolitan area in managing employee health and work-related injuries. BamesCare has five occupational health clinics, is affiliated with the Washington University School of Medicine and operates as an entity within the BamesJewish-Christian Health System. This large health system has developed as a result of several corporate mergers in recent years and currently includes 14 hospitals and over 20000 employees. Its member organizations extend throughout the St. Louis metropolitan area and to outstate Missouri. The comprehensive model that BamesCare has adopted has evolved over the past 5 years as our services have interrelated with and expanded from departments within the Washington University School of Medicine. Clinical research studies have been conducted jointly between BamesCare and the Departments of Plastic Surgery, the Program in Occupational Therapy and the section of Occupational and Environmental Medicine. One line of comparative research has been to determine measures for detecting upper extremity CTDs at different stages of the illness. The research has focused primarily on workers within the food processing, manufacturing and clerical occupations, however, a variety of industries have adopted one of the clinical measures developed, the upper extremity screening, as a component of post-offer testing. During the past 7 years, the upper extremity battery of tests has been refined and become the basis for the development of the BamesCare Carpal Tunnel Carepath. This carepath is a guideline for in-house medical management, hand therapy, and ergonomic workstation intervention. BamesCare is committed to evaluating the prevalence of cumulative trauma problems within identified work units or a company as a whole, as well as to implement cost-effective treatment.
4.1. The comprehensive BamesCare team The BamesCare interdisciplinary team combines the expertise of the occupational medicine physicians, rehabilitation therapists in physical
Work 5 (I995) 115-122
therapy, occupational therapy, and exercise physiology and our ergonomist who has a degree in human factors engineering. Roles of each team member are based on the expertise of each individual. The inevitable overlap in roles gives us a broad perspective of the risks, treatment approaches and effective injury prevention strategies to offer a comprehensive package. Proper team structure and interaction is important to carry out a project efficiently and to maximize, yet not over utilize, the input from each expert. Consistent with the classic preventive model, an integrated program has been developed at BarnesCare which is illustrated in Fig. 1. Risk assessment in our system is primarily coordinated by the ergonomist. Injury management is provided by the medical staff, the acute physical therapists and occupational therapists. Minimizing functional disability has become the role of the physician, occupational therapist and the rest of the work-hardening staff who work closely with the injured worker and employer. Below we will discuss the functions in the BamesCare system that are associated with each of these prevention areas.
4.2. Primary prevention: assessing risk and controlling hazards
The objective of the risk assessment component of the model is to provide pro-active ergonomic interventions to prevent injury whenever possible. Our ergonomist conducts workstation evaluations and designs solutions for hazard prevention and control. Whether a company is in the phase of planning a new site or modifying an old one, it is important to investigate the risks and recommend optimal job and workstation layout that will resolve any existing or potential problem. The risk assessment involves identifying, quantifying, and determining the risks associated with a job, and then developing and implementing solutions. An important goal is to ensure that recommendations actually reduce the risk or solve the problem without compromising productivity or creating new risks. Proposed solutions are pretested using mockups and are validated in field tests conducted in the actual environment. These solutions may in-
S. Rhomberget al. / Work 5 (1995) 115-122
clude any of the following: hazard prevention and controls, engineering controls, equipment and workstation design, administrative controls, work practice controls, and personal protective equipment. Solutions are implemented based on preliminary testing of proposed solutions, evaluating and field testing, and establishing validity. One advantage of an integrated program is that the ergonomist has easy access to data which describe the number and nature of WRMSDs seen at each worksite. This enables BarnesCare to appropriately target preventive interventions based on actual conditions observed. Many BarnesCare corporate clients are asking for methods to assure a healthy work force and to prevent the onset of epidemic proportions of upper extremity cumulative trauma cases. Developed jointly with researchers from the Division of Plastic Surgery and the Program in Occupational Therapy at Washington University, the upper extremity screening is conducted by hand therapists to detect signs and symptoms of CTDs. This quick screening establishes a baseline for monitoring health status throughout employment and identifies needs for medical or ergonomic intervention so that a condition does not worsen. The baseline data are used for future injury reference to identify trends and to assist with return-to-work placement. It is currently being piloted as a preplacement screening tool. Job candidates who are identified with high risk are referred for additional medical evaluation and may be placed in jobs with less demands for upper extremity sustained postures or repetitive function. With these multiple applications, this screening tool supports both primary and secondary prevention models. Other screening tests that support our prevention model and assist employers in selecting workers who are fit to sustain required job duties include: a musculoskeletal screening of range of motion, strength and muscle balance and a functional screening of job specific tasks to assure a worker's capacity to assume the position upon beginning employment or prior to return to work. The functional test is based on a detailed job analysis to assure that the evaluation measures the match of a worker's capacity with the assigned job tasks. Bonafide occupational qualifications
119
(BFOQ), which can be determined through job analyses, must be the basis of all hiring decisions, whether the person is disabled or not. The ergonomic intervention benefits that can be gleaned from the screening are not always realized, due to recent focus on ADA compliance. On-the-job ergonomic evaluation and training, however, will be money well spent on injury/illness prevention, employee morale and sense of management commitment. 4.3. Secondary prevention: managing work injury The occupational medicine physician conducts the initial evaluation of the injury and prescribes early treatment and return-to-work recommendations. For both acute and chronic conditions, the focus is on expediting recovery and limiting any progression of the disorder. Acute physical or occupational therapy interventions may be indicated. The physician in the BarnesCare system keeps very close communication with the employer during this phase. This phase involves appropriate diagnosis and treatment, minimizing an employee's lost work time, and proper record keeping to comply with OSHA regulations and to provide data to use for preventive efforts. Developing methods for detecting and responding to early signs and symptoms of cumulative trauma disorders is also encouraged in this component of the program. In the past year, BarnesCare physicians and hand specialists have begun using the carpal tunnel carepath to promote a consistent approach to diagnosing and managing the patient with carpal tunnel syndrome. While it does not currently specify the treatment regimen for all upper extremity CTDs, it is a framework for further growth and utilization within this broad diagnostic group. This carepath, along with the upper extremity screening, is becoming an effective package to offer companies frustrated with managing upper extremity CTDs. 4.4. Tertiary prevention: minimizing disability The more serious or chronic injuries require accurate evaluation to determine functional status and its impact on occupational roles. Functional capacity evaluations and rehabilitation pro-
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grams of work conditioning and work hardening focus on improving capacity for work and identifying skills to resume work activities. Preventing reinjury is extremely important for repeat and multiple injury patients. This is accomplished through work style retraining, education and practice with difficult tasks to assure safe performance. Functional capacity testing assures the proper match between a worker's capacity and the specific job demands. The ergonomist assists in redesigning the workstation to decrease risks and to avoid returning to the same exposures that caused the initial injury or illness. The ergonomist and therapists may jointly recommend modifications to offer customized accommodations to aid the worker upon return to full duty. After the workstation has been modified to promote safety as much as possible, the therapist also provides education programs, stretching and exercise, or recommends modified work duty programs to minimize risk of future injury. 5. Strategies and barriers to success
As we market our services to existing BarnesCare client companies and others who express interest in improving their methods for managing and preventing WRMSDs, we have been challenged in how to package and sell them successfully. Some of the barriers that we face are described below as well as our responses to these issues.
5.1. Barrier #1: company focus on short term price versus long term value Many employers find it difficult to realize the short term payoffs to achieve long term effectiveness in managing WRMSDs. Most corporate perspectives emphasize short term profitability and cost containment. The potential savings through future reduced injuries are often not adequate justification for the approval of new, or modified equipment and consultant fees. The accountability to prove the value of ergonomic services initially is difficult when outcomes are not realized immediately. A health care institution providing ergonomic
services must also have vision to the future and a long term commitment to injury prevention to establish a comprehensive ergonomic program. Immediate profitability may be difficult to achieve. It is impossible to count injuries that never occur because of ergonomic interventions. Although some interventions result in short term cost savings, injury rates for cumulative trauma injuries may take years for the effects to be realized. Other outcome measures such as symptom surveys or production records may be more sensitive measures of the short term effects of an ergonomic intervention. Injury rates and trends can also be a difficult method of quantifying success in the short term. Because measures such as OSHA 200 logs or worker's compensation claims may miss or improperly categorize cases of WRMSDs, an early symptom detection program can actually result in an initial increase in reported injuries. However, such early detection programs typically result in decreases in severity, lost work time and overall costs. One short term solution is to document cost savings by quantifying eqnipment cost savings. Some companies are convinced by vendors to believe they need expensive equipment described as 'ergonomically correct.' An alternate, more modest solution such as selectively distributing equipment modifications to the appropriate work group (rather than an across-theboard 'give everybody one' attitude ) can often resolve the problem more cost effectively with very good outcomes.
5.2. Barrier #2: difficulty in identifying companies with ergonomic needs Another barrier we have encountered is the difficulty in identifying characteristics of the 'best' company in which to market an ergonomics program. Successful projects that we have conducted over the past year do not reveal any trends in company characteristics. For example, company size has varied from 30 to 8000 employees, companies with high injury rates to those with no recordable injuries, and those with pro-active as well as reactive management philosophies. Once
S. Rhombergetal. /Worlc5 (J995) 115-122
a company with ergonomic needs is identified, it can be difficult to locate the best contact person. At BamesCare we have had a proposal rejected by one division within a company and yet found a new contact in a different division that was excited about our services and initiated a contract immediately. To overcome this barrier, we are using successful case studies from within a particular industry as testimonials and are showcasing this material when marketing to other companies in the same industrial group. This enables the newly approached company to realize, in understandable and real terms, how ergonomic interventions have proven to be effective and how the results illustrated may be applicable to them in solving similar problems.
5.3. Barrier #3: reactive company attitudes toward work injury management Corporate culture typically promotes a reactive rather than pro-active response to ergonomic issues and problems that are not well understood. Future OSHA regulations may significantly influence this attitude and demand a different perspective. An integrated program of medical, rehabilitation and ergonomic services will best serve companies with current treatment of their injured workers, as well as prepare them for the future with an attitude of prevention and wellness. Companies may have to respond to legislative changes if components of these services become mandated in efforts to promote optimal health and safety of workers. To illustrate our response to overcome this barrier, a simple case is reviewed. The BarnesCare interdisciplinary team approach was particularly helpful with a company that claimed to have a terrible work force epidemic of carpal tunnel syndrome. A task analysis was conducted to identify the risks inherent in the work, but those identified were not limited to CTS. Medical record file review and results of the upper extremity screening confirmed that the injuries included a myriad of upper extremity CTDs. Awkward body postures evident during the job task analyses became the basis of workstation redesign to minimize risk. Follow-up employee training
121
was recommended to educate the employees regarding the identified risk factors and to discuss effective work techniques for decreasing chances of worsening the condition. Company satisfaction for this 'reactive' company was due to the coordinated team effort of the physician, occupational therapist, and ergonomist. 6. Summary This article reviews the issues of reimbursement and health care system perspectives as they influence current and future work injury prevention and management practices. The classic preventive model of primary, secondary and tertiary prevention are presented and discussed. This approach has influenced the development of the BamesCare integrative program which emphasizes risk assessment and ergonomic interventions, injury management and minimizing disability through functional assessment and multidisciplinary rehabilitation services. The reality of successfully carrying out this concept in day-to-day service delivery is not without an ongoing challenge. Key barriers that we face in promoting our approach within a changing health care environment and corporate America are presented, as well as some views on managing these issues. Responding to a dynamic health care environment creates challenges and opportunities. We must stay alert to the changes around us and assume active roles to shape future health care and ergonomic practice models. Future regulations and shifts in cost packaging will hopefully assist in changing corporate attitudes to better understand the long term value of ergonomics and the benefits of an integrated approach to managing costly musculoskeletal work injuries. As we strive to overcome our barriers, there are some important steps that we, as occupational health care providers, need to take. It is essential that we demonstrate a differentiated high value service and find ways to help employers realize long term savings that will offset the initial costs of prevention. As health care providers, we share a mutual goal with companies to better manage employee health and productivity. We believe an
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integrated program of medical, rehabilitation and ergonomic services will best accomplish this goal. By monitoring the efficiency and effectiveness of our prevention and injury treatment services, we will better prepare companies to be responsive to shifts in health care policy and assist them in minimizing their overall costs. References American National Standard for Human Factor Engineering of Visual Display Terminal Workstations. ANSI/HFS 100-1988.
Cowan, c.A. and McDonnell, P.A. (1993) Med. Benefits 23,1. Occupational Safety and Health Administration. (1991) Ergonomics Program Management Guidelines For Meatpacking Plants. U.S. Department of Labor (OSHA 3123). Human Engineering Design Criteria for Military Systems, Equipment and Facilities (Military Standard). (1989) MILSTD-1472D. Human Factors Engineering Design for Army Material (Military Handbook). (1975) MIL-HDBK-759A. Last, I.M. and Wallace, R.B. (Eds.) (1992) Maxcy-RosenauLast Public Health and Preventative Medicine. 13th edn. Norwalk: Appleton and Lange. Loeppke, R.R. (1993) Restructuring the American health care system - direct contracting: the future of health care? Medical Group Management Journal 30-36, 77, 80.
ELSEVIER
Work 5 (1995) 115-122
An integrated program for the prevention and management of musculoskeletal work injuries Sue Rhomberg*\ Laurie Wolfb, Bradley Evanoff c a Rehabilitation
Services, BamesCare Corporate Health Services, 5000 Manchester, St. Louis, MO 63110, USA bErgonomics, BamesCare Corporate Health Services, 5000 Manchester, St. Louis, MO 63110, USA C Section of Occupational and Environmental Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA
--_._--_._--- ---------------- - - -
Abstract With rising health care costs and a dynamic health care structure in the USA, many medical and rehabilitation professionals are seeking cost effective strategies to assist employers in preventing and managing musculoskeletal work injuries. An integrated approach based on the classic three component model of preventive medicine which includes primary, secondary and tertiary prevention is discussed. This approach includes ergonomics, medical injury treatment and rehabilitation services to provide a comprehensive occupational health program. The manner in which these services are packaged for purchase by industry is shifting from a fee-for-service system to a capitated program with the provider coordinating service delivery at risk. The incentives for successful outcomes are tremendous. Challenges in carrying out this program are presented as well as discussion of approaches to overcome these barriers. Ergonomics; Occupational health; Injury prevention; Musculoskeletal work injury; Return-to-work; Industrial rehabilitation; Model prevention program _._--_._----._-------------Keywords:
1. Introduction
The health care system of the USA is undergoing enormous transition, with even greater changes anticipated in the near future. Health care costs are an obstacle to global economic competitiveness. Private business spent $205.4 billion on health care for employees in 1991 (Cowan
* Corresponding author, Fax: + 314531 8773.
and McDonnell, 1993). Employers are becoming much more sophisticated as active purchasers of health care rather than remaining passive payors (Loeppke, 1993). There is a growing consensus that costs may outweigh consumer value. These changes have created a climate of uncertainty among deliverers and purchasers of health care, but enormous opportunities are emerging for providers to create new service delivery models for medical treatment and health promotion. This article will discuss an integrated program
1051-9815/95/$09.50 © 1995 Elsevier Science Ireland Ltd. All rights reserved. SSD11051-9815(95)00113-Y
116
s. Rhombergetal. /Work5 (1995) 115-122
for managing patients with work-related musculoskeletal disorders (WRMSDs), including both acute injuries and the group of chronic conditions referred to as cumulative trauma disorders (CTDs) or repetitive strain injuries (RSIs). We will present the regulatory and reimbursement environments that guide the concepts of this integrative approach and the program components which include elements of prevention, treatment, and rehabilitation. We also want to share some of the experiences that have challenged us as we establish this program within a comprehensive occupational health clinic setting and a larger health system. 2. Regulatory and reimbursement environments
National trends in health care delivery seem to favor the integration of prevention, acute injury treatment, and rehabilitation. We are moving away from a system which reimburses most handsomely for procedure-oriented treatment interventions and pays little, if at all, for consultationbased prevention services such as ergonomics. One type of shift from the traditional fee-forservice model is capitation, in which a health-care delivery organization agrees to provide all necessary treatment services to a population for a flat fee. This form of reimbursement encourages health care providers to take two important positive perspectives. The first is to actively promote wellness and injury prevention in the covered population. The second is to monitor and carefully examine the expense and efficiency of service delivery to the covered population. In order to take on the financial risk of providing comprehensive care to a group of workers at a fixed cost, a health care organization must: be able to direct and control preventive measures aimed at keeping the work force healthy; (2) oversee the provision of care to injured workers in order to assure that high-quality care is provided without incurring unnecessary expenses, and (3) direct the rehabilitation of injured workers so that they are assisted in returning to their (1)
jobs and to their maximum functional abilities in a timely and efficient manner. Capitation and other changes in health care financing have been driven in part by the demands of purchasers and users of health care to demonstrate the value of the health care received. Rather than merely pay for health care based on volume, purchasers are asking for measures of value received. Such measures of value (or outcomes) include: patient satisfaction, demonstrated medical appropriateness and effectiveness of treatment, and ultimately improvements in the health of the population. Crucial to both the purchasers and providers of health care are improvements in our measures of health outcomes and wide-scale implementation of healthoutcome databases. Current health-care databases are almost entirely based on billing or other administrative data, and often do not contain the types of data which are necessary to measure the effectiveness of preventive, treatment, or rehabilitative services. Outcome measures need to be implemented not only for individual episodes of care or treatment, but also for measuring changes in the health of whole populations. Additionally, as medical and rehabilitation professional groups, it is imperative that we utilize outcomes to prove the value of our services in terms of effectiveness and cost containment. Another force which favors the integration of health services is the increasing governmental regulation of monitoring and controlling workplace physical exposures and WRMSDs. Both the federal and some state governments currently have ergonomic guidelines and regulations for governing allowable exposures (Military Handbook, 1975; American National Standard Institute/Human Factors Society, 1988; Military Standard, 1989; Occupational Safety and Health Administration, 1991). As merely guidelines, these are not enforceable. The Occupational Health and Safety Administration (OSHA) is expected to release draft ergonomic regulations for general industry this fall. It is widely believed that these regulations will require employers to institute programs for hazard assessment, hazard preven-
s. Rhombergetal. /Work5 (1995) 115-122 tion, and surveillance of WRMSDs. Guidelines for medical management will also be an important component of these draft regulations. It is apparent that many companies lack the needed expertise to develop programs meeting all provisions of the anticipated federal regulations, and therefore, will rely on consultants such as occupational health groups to guide them. Many employers are still struggling to comply with the Americans with Disabilities Act (ADA), which requires employers to reasonably accommodate workers with disabilities who have the qualifications for a specific job. Integrated prevention and treatment programs are uniquely suited to help employers comply with these new regulations. Both workers and employers will benefit from the lower rates of injury and disease which are expected to occur as a result of better surveillance and hazard assessment. 3. An integrated prevention and treatment program
The successful integrated program for WRMSDs can be modelled after the classic three-component model of preventive medicine: primary, secondary, and tertiary prevention «Last and Wallace, 1992) See Fig. 1). Primary prevention is the pro-active approach to preventing the occurrence of disease or injury. Secondary prevention stops the progression of a disease or illness in the early stages. Tertiary prevention attempts to minimize the effects of an injury and disability once an injury or disease has occurred. A comprehensive ergonomics program focused on primary prevention, includes: risk assessment, injury/illness file review, workstation evaluation and redesign, pro-active on-the-job injury prevention education and training, ergonomic task force development and follow-up to assure long term effectiveness. Pre-placement screenings of musculoskeletal function, upper extremity CID signs and symptoms, and functional capacity for job specific tasks will assist in identifying high risk individuals and will also guide job placement. These screenings should identify needs for accommodation as well as disqualify those individu-
117
als who cannot safely perform a job (with or without accommodation). Ongoing surveillance of an individual's or work group's health status will be essential for promoting optimal employee health and long term cost effectiveness. Results of the assessment assist companies in prioritizing interventions and corporate spending to focus on the most important ergonomic issues. Secondary prevention is the early detection and treatment of the disease or injury in order to prevent its progression. Acute injury medical treatment and occupational and physical therapy facilitate quick recovery, maintain work status and prevent lost work time. With corporate compliance in encouraging early reporting, many CIDs can be recognized early after onset, when treatment is less costly and symptoms can be effectively managed with a conservative approach. Many employers struggle with adopting this early reporting approach, however, in fear of epidemic and exaggerated responses and with little insight toward the tremendous potential for long term savings. Having in-house access to the results of the risk assessments, the occupational health providers will be able to optimally manage the case immediately following injury and be able to make accurate return-to-work decisions. In this setting, treatment of WRMSDs can occur with minimal interference with work performance. Sharing of information facilitates good quality treatment while maximizing productivity, preventing lost work time and facilitating recovery to the preinjury status. Tertiary prevention means minimizing the effects of disease or injury after it has occurred. At this level, the priority is to minimize functional disability through appropriate evaluations of work capacity and treatment models such as work conditioning and work hardening to manage the more severe and chronic cases. Emphasis is placed on capacities and accommodations to maximize employment potential rather than identifying work limitations. Education to prevent reinjury or worsening of a condition is an important component of rehabilitation in a tertiary prevention program.
118
s. Rhomberg et al. /
4. The BarnesCare integrated approach
BamesCare Corporate Health Services assists approximately 1500 client companies in the St. Louis metropolitan area in managing employee health and work-related injuries. BamesCare has five occupational health clinics, is affiliated with the Washington University School of Medicine and operates as an entity within the BamesJewish-Christian Health System. This large health system has developed as a result of several corporate mergers in recent years and currently includes 14 hospitals and over 20000 employees. Its member organizations extend throughout the St. Louis metropolitan area and to outstate Missouri. The comprehensive model that BamesCare has adopted has evolved over the past 5 years as our services have interrelated with and expanded from departments within the Washington University School of Medicine. Clinical research studies have been conducted jointly between BamesCare and the Departments of Plastic Surgery, the Program in Occupational Therapy and the section of Occupational and Environmental Medicine. One line of comparative research has been to determine measures for detecting upper extremity CTDs at different stages of the illness. The research has focused primarily on workers within the food processing, manufacturing and clerical occupations, however, a variety of industries have adopted one of the clinical measures developed, the upper extremity screening, as a component of post-offer testing. During the past 7 years, the upper extremity battery of tests has been refined and become the basis for the development of the BamesCare Carpal Tunnel Carepath. This carepath is a guideline for in-house medical management, hand therapy, and ergonomic workstation intervention. BamesCare is committed to evaluating the prevalence of cumulative trauma problems within identified work units or a company as a whole, as well as to implement cost-effective treatment.
4.1. The comprehensive BamesCare team The BamesCare interdisciplinary team combines the expertise of the occupational medicine physicians, rehabilitation therapists in physical
Work 5 (I995) 115-122
therapy, occupational therapy, and exercise physiology and our ergonomist who has a degree in human factors engineering. Roles of each team member are based on the expertise of each individual. The inevitable overlap in roles gives us a broad perspective of the risks, treatment approaches and effective injury prevention strategies to offer a comprehensive package. Proper team structure and interaction is important to carry out a project efficiently and to maximize, yet not over utilize, the input from each expert. Consistent with the classic preventive model, an integrated program has been developed at BarnesCare which is illustrated in Fig. 1. Risk assessment in our system is primarily coordinated by the ergonomist. Injury management is provided by the medical staff, the acute physical therapists and occupational therapists. Minimizing functional disability has become the role of the physician, occupational therapist and the rest of the work-hardening staff who work closely with the injured worker and employer. Below we will discuss the functions in the BamesCare system that are associated with each of these prevention areas.
4.2. Primary prevention: assessing risk and controlling hazards
The objective of the risk assessment component of the model is to provide pro-active ergonomic interventions to prevent injury whenever possible. Our ergonomist conducts workstation evaluations and designs solutions for hazard prevention and control. Whether a company is in the phase of planning a new site or modifying an old one, it is important to investigate the risks and recommend optimal job and workstation layout that will resolve any existing or potential problem. The risk assessment involves identifying, quantifying, and determining the risks associated with a job, and then developing and implementing solutions. An important goal is to ensure that recommendations actually reduce the risk or solve the problem without compromising productivity or creating new risks. Proposed solutions are pretested using mockups and are validated in field tests conducted in the actual environment. These solutions may in-
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clude any of the following: hazard prevention and controls, engineering controls, equipment and workstation design, administrative controls, work practice controls, and personal protective equipment. Solutions are implemented based on preliminary testing of proposed solutions, evaluating and field testing, and establishing validity. One advantage of an integrated program is that the ergonomist has easy access to data which describe the number and nature of WRMSDs seen at each worksite. This enables BarnesCare to appropriately target preventive interventions based on actual conditions observed. Many BarnesCare corporate clients are asking for methods to assure a healthy work force and to prevent the onset of epidemic proportions of upper extremity cumulative trauma cases. Developed jointly with researchers from the Division of Plastic Surgery and the Program in Occupational Therapy at Washington University, the upper extremity screening is conducted by hand therapists to detect signs and symptoms of CTDs. This quick screening establishes a baseline for monitoring health status throughout employment and identifies needs for medical or ergonomic intervention so that a condition does not worsen. The baseline data are used for future injury reference to identify trends and to assist with return-to-work placement. It is currently being piloted as a preplacement screening tool. Job candidates who are identified with high risk are referred for additional medical evaluation and may be placed in jobs with less demands for upper extremity sustained postures or repetitive function. With these multiple applications, this screening tool supports both primary and secondary prevention models. Other screening tests that support our prevention model and assist employers in selecting workers who are fit to sustain required job duties include: a musculoskeletal screening of range of motion, strength and muscle balance and a functional screening of job specific tasks to assure a worker's capacity to assume the position upon beginning employment or prior to return to work. The functional test is based on a detailed job analysis to assure that the evaluation measures the match of a worker's capacity with the assigned job tasks. Bonafide occupational qualifications
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(BFOQ), which can be determined through job analyses, must be the basis of all hiring decisions, whether the person is disabled or not. The ergonomic intervention benefits that can be gleaned from the screening are not always realized, due to recent focus on ADA compliance. On-the-job ergonomic evaluation and training, however, will be money well spent on injury/illness prevention, employee morale and sense of management commitment. 4.3. Secondary prevention: managing work injury The occupational medicine physician conducts the initial evaluation of the injury and prescribes early treatment and return-to-work recommendations. For both acute and chronic conditions, the focus is on expediting recovery and limiting any progression of the disorder. Acute physical or occupational therapy interventions may be indicated. The physician in the BarnesCare system keeps very close communication with the employer during this phase. This phase involves appropriate diagnosis and treatment, minimizing an employee's lost work time, and proper record keeping to comply with OSHA regulations and to provide data to use for preventive efforts. Developing methods for detecting and responding to early signs and symptoms of cumulative trauma disorders is also encouraged in this component of the program. In the past year, BarnesCare physicians and hand specialists have begun using the carpal tunnel carepath to promote a consistent approach to diagnosing and managing the patient with carpal tunnel syndrome. While it does not currently specify the treatment regimen for all upper extremity CTDs, it is a framework for further growth and utilization within this broad diagnostic group. This carepath, along with the upper extremity screening, is becoming an effective package to offer companies frustrated with managing upper extremity CTDs. 4.4. Tertiary prevention: minimizing disability The more serious or chronic injuries require accurate evaluation to determine functional status and its impact on occupational roles. Functional capacity evaluations and rehabilitation pro-
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grams of work conditioning and work hardening focus on improving capacity for work and identifying skills to resume work activities. Preventing reinjury is extremely important for repeat and multiple injury patients. This is accomplished through work style retraining, education and practice with difficult tasks to assure safe performance. Functional capacity testing assures the proper match between a worker's capacity and the specific job demands. The ergonomist assists in redesigning the workstation to decrease risks and to avoid returning to the same exposures that caused the initial injury or illness. The ergonomist and therapists may jointly recommend modifications to offer customized accommodations to aid the worker upon return to full duty. After the workstation has been modified to promote safety as much as possible, the therapist also provides education programs, stretching and exercise, or recommends modified work duty programs to minimize risk of future injury. 5. Strategies and barriers to success
As we market our services to existing BarnesCare client companies and others who express interest in improving their methods for managing and preventing WRMSDs, we have been challenged in how to package and sell them successfully. Some of the barriers that we face are described below as well as our responses to these issues.
5.1. Barrier #1: company focus on short term price versus long term value Many employers find it difficult to realize the short term payoffs to achieve long term effectiveness in managing WRMSDs. Most corporate perspectives emphasize short term profitability and cost containment. The potential savings through future reduced injuries are often not adequate justification for the approval of new, or modified equipment and consultant fees. The accountability to prove the value of ergonomic services initially is difficult when outcomes are not realized immediately. A health care institution providing ergonomic
services must also have vision to the future and a long term commitment to injury prevention to establish a comprehensive ergonomic program. Immediate profitability may be difficult to achieve. It is impossible to count injuries that never occur because of ergonomic interventions. Although some interventions result in short term cost savings, injury rates for cumulative trauma injuries may take years for the effects to be realized. Other outcome measures such as symptom surveys or production records may be more sensitive measures of the short term effects of an ergonomic intervention. Injury rates and trends can also be a difficult method of quantifying success in the short term. Because measures such as OSHA 200 logs or worker's compensation claims may miss or improperly categorize cases of WRMSDs, an early symptom detection program can actually result in an initial increase in reported injuries. However, such early detection programs typically result in decreases in severity, lost work time and overall costs. One short term solution is to document cost savings by quantifying eqnipment cost savings. Some companies are convinced by vendors to believe they need expensive equipment described as 'ergonomically correct.' An alternate, more modest solution such as selectively distributing equipment modifications to the appropriate work group (rather than an across-theboard 'give everybody one' attitude ) can often resolve the problem more cost effectively with very good outcomes.
5.2. Barrier #2: difficulty in identifying companies with ergonomic needs Another barrier we have encountered is the difficulty in identifying characteristics of the 'best' company in which to market an ergonomics program. Successful projects that we have conducted over the past year do not reveal any trends in company characteristics. For example, company size has varied from 30 to 8000 employees, companies with high injury rates to those with no recordable injuries, and those with pro-active as well as reactive management philosophies. Once
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a company with ergonomic needs is identified, it can be difficult to locate the best contact person. At BamesCare we have had a proposal rejected by one division within a company and yet found a new contact in a different division that was excited about our services and initiated a contract immediately. To overcome this barrier, we are using successful case studies from within a particular industry as testimonials and are showcasing this material when marketing to other companies in the same industrial group. This enables the newly approached company to realize, in understandable and real terms, how ergonomic interventions have proven to be effective and how the results illustrated may be applicable to them in solving similar problems.
5.3. Barrier #3: reactive company attitudes toward work injury management Corporate culture typically promotes a reactive rather than pro-active response to ergonomic issues and problems that are not well understood. Future OSHA regulations may significantly influence this attitude and demand a different perspective. An integrated program of medical, rehabilitation and ergonomic services will best serve companies with current treatment of their injured workers, as well as prepare them for the future with an attitude of prevention and wellness. Companies may have to respond to legislative changes if components of these services become mandated in efforts to promote optimal health and safety of workers. To illustrate our response to overcome this barrier, a simple case is reviewed. The BarnesCare interdisciplinary team approach was particularly helpful with a company that claimed to have a terrible work force epidemic of carpal tunnel syndrome. A task analysis was conducted to identify the risks inherent in the work, but those identified were not limited to CTS. Medical record file review and results of the upper extremity screening confirmed that the injuries included a myriad of upper extremity CTDs. Awkward body postures evident during the job task analyses became the basis of workstation redesign to minimize risk. Follow-up employee training
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was recommended to educate the employees regarding the identified risk factors and to discuss effective work techniques for decreasing chances of worsening the condition. Company satisfaction for this 'reactive' company was due to the coordinated team effort of the physician, occupational therapist, and ergonomist. 6. Summary This article reviews the issues of reimbursement and health care system perspectives as they influence current and future work injury prevention and management practices. The classic preventive model of primary, secondary and tertiary prevention are presented and discussed. This approach has influenced the development of the BamesCare integrative program which emphasizes risk assessment and ergonomic interventions, injury management and minimizing disability through functional assessment and multidisciplinary rehabilitation services. The reality of successfully carrying out this concept in day-to-day service delivery is not without an ongoing challenge. Key barriers that we face in promoting our approach within a changing health care environment and corporate America are presented, as well as some views on managing these issues. Responding to a dynamic health care environment creates challenges and opportunities. We must stay alert to the changes around us and assume active roles to shape future health care and ergonomic practice models. Future regulations and shifts in cost packaging will hopefully assist in changing corporate attitudes to better understand the long term value of ergonomics and the benefits of an integrated approach to managing costly musculoskeletal work injuries. As we strive to overcome our barriers, there are some important steps that we, as occupational health care providers, need to take. It is essential that we demonstrate a differentiated high value service and find ways to help employers realize long term savings that will offset the initial costs of prevention. As health care providers, we share a mutual goal with companies to better manage employee health and productivity. We believe an
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integrated program of medical, rehabilitation and ergonomic services will best accomplish this goal. By monitoring the efficiency and effectiveness of our prevention and injury treatment services, we will better prepare companies to be responsive to shifts in health care policy and assist them in minimizing their overall costs. References American National Standard for Human Factor Engineering of Visual Display Terminal Workstations. ANSI/HFS 100-1988.
Cowan, c.A. and McDonnell, P.A. (1993) Med. Benefits 23,1. Occupational Safety and Health Administration. (1991) Ergonomics Program Management Guidelines For Meatpacking Plants. U.S. Department of Labor (OSHA 3123). Human Engineering Design Criteria for Military Systems, Equipment and Facilities (Military Standard). (1989) MILSTD-1472D. Human Factors Engineering Design for Army Material (Military Handbook). (1975) MIL-HDBK-759A. Last, I.M. and Wallace, R.B. (Eds.) (1992) Maxcy-RosenauLast Public Health and Preventative Medicine. 13th edn. Norwalk: Appleton and Lange. Loeppke, R.R. (1993) Restructuring the American health care system - direct contracting: the future of health care? Medical Group Management Journal 30-36, 77, 80.
