Work Disability Risk
Level of Risk
Level of risk to the patient is a criterion in determining the medical decision making complexity. In the ACOEM function-oriented model, chronic work disability is considered a severe outcome, equivalent to loss of life or limb. Risk is based on highest level in any column, as in CMS system.
Managing Work Disability Risk
The proposed alternative risk table for workers’ compensation care includes clinical problems known to increase the risk of chronic work disability, including opioid use, already being off work, and presence of disability risk factors. Risk management strategies appropriate for mitigating these risk factors have been added to the “management options selected” column. This table can also serve to help determine whether the medical decision making is appropriate for the clinical problem level identified.
The treating provider must provide clear documentation of the rationale for attributing high risk for chronic work disability to a clinical situation.
Ideally, there should be evidence of screening for evidence-based risk categories: adverse childhood experiences (ACE); yellow flags for pain behavior, disability beliefs, catastrophization, fear/avoidance; blue flags for problems between the worker and workplace; black flags for systemic barriers to return-to-work such as employer policy; orange flags for mental illness. (ACOEM proposes establishing a separate code for billing for performing screening for disability risk using standardized forms, with planned future development of related criteria and ground rules.)
The management plan should address mitigation of the identified risk factors, including an evidence-based opioid management plan when opioids are used.
Return-to-work should be addressed at the first meeting with the injured employee, and be updated at each additional visit.
Because a prolonged period of time off work will decrease the likelihood of return to work, the first weeks of treatment are crucial in preventing and/or reversing chronicity and disability mindset.
Early Identification and Management of Psychological Risk Factors (“Yellow Flags”) in Patients with Low Back Pain: A Reappraisal. Nicholas MK, Linton SJ, Watson PJ, Main CJ, “Decade of the Flags” Working Group. Physical Therapy, May 2011 Vol 91 (5): 737-753.
Early Patient Screening and Intervention to Address Individual-Level Occupational Factors (“Blue Flags”) in Back Disability. Shaw WS, Van der Windt DA, Main CJ, Loisel P, Linton SJ, “Decade of the Flags” Working Group. Journal of Occupational Rehabilitation, 2009, Vol 19: 64-80.