Employee Health and Case Management

Jaishri Ramesh, M. D.Board Certified Internal Medicine

Agenda

• Benefits of Partnering with Occ Med Provider• Medical Determination of Causation• First Aid vs. Recordable• Fit for Duty Exams• How New DOT Regulations Affect Employers

Partnership Benefits

Partnership Between Employer &

Occupational Health Clinic is Vital as it Provides:

1) Best Outcomes for Injury Resolution

2) Employee Satisfaction

3) Motivation to Return to Work and/or Keep

Working

4) Significant Reduced Lost Time Off Work

5) Prevention of Further Injuries

Partnership Benefits

1. Best Outcomes for Injury Resolution

• Quality of clinic: occupational health only• Variety of services – 1 stop shop• Good communication• Flexibility: ability to accommodate• Employee’s work schedules

Partnership Benefits

2. Employee Satisfaction

• Physical and emotional• Provision of safe and nurturing environment

both by Employer and Occupational Medical Provider

• Showing concern for their condition

Partnership Benefits

3. Motivation to Return to Work

• Safe work environment• Same message from Employer and

Occupational Health Clinic• Provision of modified work• Information regarding work comp injuries & how

to file a claim, temporary disability benefits

Partnership Benefits

4. Significantly Reduced Lost Time Off Work

• Modified work accommodated• Good communication• Provision of caring nurturing environment

Partnership Benefits

5. Prevention of Further Injuries

• Education/Safety Managers• Physical Rehabilitation/HEP• Ergonomics• Posture & Body Mechanics• Fatigue Prevention

Occupational Clinic vs. Urgent Care

Causation:

Occ Med providers don’t assume every injury is

Work related, they spend time researching

causation.

First Aid:

Occ Med providers follow CalOSHA guidelines

of what is considered first aid and will try

conservative treatment whenever possible.

Causation

Causation

Industrial Injury Breakdown

• About 75% of industrial injuries are straight forward- they want to get better

• About 20% are in between, will get better with more attention

• Remaining 5% fall in the suspicious category

Burden of Proof

• Injured worker has the burden to prove that an injury or condition arose out of employment.

• If the ER is asserting that the injury was deliberately self inflicted, then the ER has the burden to prove this point by a preponderance of evidence.

Reasonable Medical Probability

• Probability simply means more likely than not

• Physician is called upon to simply state if the injury was “more likely than not” or “at least a 51% likelihood” that the work incident or exposure caused the injury or disability.

Medical Provider’s Role in Worker’s Compensation

• Workers Compensation is a medically driven system

• Medical information is used to guide key decision points, including entry into the system, legal issues of compensability, etc.

Medical Provider’s Role

• Defining injury• Detailed history• Determining causation• Mechanism of injury• Physical examination• Treatment plan• Assessment of work status

Determining Causality in Workers’ Compensation

• Alleged relationship between the diagnosis and the work-related exposure.

• Estimate of the risk of developing the diagnosis from the actual work exposure

• If the relationship has a greater than 50% probability then it is medically probable.

Causation Assessment

1) Record an occupational medical history including detailed description of incident and complete job description.

2) Take a complete medical history, including non-occupational activities.

3) Establish a different diagnosis for patient.

4) Assess the medical probability of the relationship between the assumed diagnosis and the work-related exposure.

Risk Assessment Method

To assess causality you must apply traditional risk assessment techniques developed by Bradford-Hill.

1) Strength of the association

2) Consistency of the evidence

3) Specificity of the result

4) Temporal Relationship

5) Biological gradient

6) Coherence

Workers’ Compensation Statutes

• Work related exposure must be the “proximate cause” of the disease or injury.

• Proximate cause is defined in Black’s Law Dictionary as the last act “contributory to an injury, without which such injury would not have resulted. The dominant, moving, or producing cause.”

Pre-Existing Medical Condition

• A pre-existing medical condition which may pre-dispose the worker to an injury does not necessarily mean the case is not work-related, the injury is most likely also work-related.

• Case example – Patient with a partial meniscus tea is hit in the leg with heavy equipment and falls, suffering a full thickness meniscus tear.

• Physicians should discuss the impact of pre-existing disease or injury on the current work related condition.

Using Risk AssessmentUsing Risk Assessment

Case example – A worker is exposed to levels of formaldehyde below the OSHA permitted limits

1) The worker claims to have irritant-induced reactive airway disease

2) The worker claims the formaldehyde aggravated his pre-existing asthma.

How would you prove or disprove these assertions?

Always answer this question: “Without the work-related

exposure or accident, is it medically probable that the

patient would have the current diagnosis and require

treatment?”

Activities of Daily LivingActivities of Daily Living

Generally, if a worker is performing an activity he would normally be expected to perform in day-to-day tasks at home the injury will not be work-related.

Case – An executive suffers a heart attack while reviewing his routine, office

email.

Isolated Mental Impairment

Pursuant to C.R. S. 8-41-301(2)(a), mental impairment:

“…means a recognized, permanent disability arising from an accidental injury arising out of and in the course of employment when the accidental injury involves no physical injury and consists of a psychologically traumatic event that is generally outside of a workers’ usual experience and would evoke significant symptoms of distress in a worker in similar circumstances. A mental impairment shall not be considered to arise out of and in the course of employment if is results from a disciplinary action, work evaluation, job transfer, layoff, demotion, promotion, termination, retirement, or similar action taken in good faith by the employer.”

Remember the final determination of work-relatedness rests with the judicial system. This allows the consideration of course and scope of duties, enforced safety standards, and location of injury.

Steps in Causality Determination

1. Establish diagnosis (or differential diagnosis if further testing required)

2. Define Injury or Exposure

Exposure include: Length of exposure Level of exposure Comparison of workers’ exposure to that of the normal population

3. Discuss Intervening Factors

4. Explain any scientific evidence supporting a cause and

effect relationship between the diagnosis and the

exposure or injury

5. Assign a medical probability level to the case in question Medically probable > 50% likely Medically possible < 50% likely

Analyzing Causation

Three Basic Questions:

Does? Can? Did?

CA Workers’ Compensation

• AOE (Arising out of Employment):

Conveys the idea of a causal relationship between the employment and the workers’ disability. A worker has the burden of proving the cause and origin of the injury flows from his/her work activities.

• COE (Course of the Employment):

Phrase “COE” refers to the time and place where the injury occurred. A worker must prove the time, place, and circumstances of the injury, relate the injury to his or her work or duties and activities incidental to his/her work.

Red Flags

1. Delayed Reporting

2. Sketchy Details

3. No Witnesses

4. Discrepancy in Story

5. Monday Morning Claims

6. Disgruntled Employee

More Red Flags

1. Old injuries

2. Pregnancy

3. Whole body pain

4. Financial Hardship at Home

5. Misses Medical Appointments

6. Does not follow Treatment Plan

Physician Must Define Injury

• Did the injury Arise Out of Employment?

• Did the injury occur in the Course Of

Employment?

• Is it More Likely Than Not (at least 51%

likelihood).

• Is the injury Reasonable (even if not

absolutely certain)

Case #1

• Hx: 50 year old male VP at a biotech company. He came in with CC of a chipped tooth-first upper left incisor.

• Mechanism of injury- he was chewing a pencil while he was sitting and talking to security personnel at work.

• Past Medical history was significant for similar problems in the past. His dentist told him he has brittle teeth.

• He thought it was related to work because he was at work when the injury happened.

Causation – Work Related?

• Is this injury related to work?

• Does it fulfill the “arising out of employment” criteria?

Determination of Causation

• What pathological conditions or disability are present?

• What relevant work exposures were present?• What other causes might produce the disease?

(Non-industrial? Pre-existing factors? )• Simple or Complex• Direct cause• Contributing cause• Flare up of old injury• Exacerbation • Aggravation

Is the Injury Old or New ?

• Flare up - worsening of symptoms of an Old Injury. There is no new event.

• Exacerbation - temporary worsening of symptoms of Pre-existing condition (eg. arthritis)- Considered New Injury

• Aggravation - permanent worsening of pre-existing condition - Considered New Injury

Case #2

• 25 yr female with history of a plastic tubing falling on her right forearm at 9 am this morning.

• She has right forearm pain and her whole arm and forearm is swollen and painful.

• PM Hx is significant for RSI of her right shoulder/neck and upper extremity one year ago.

• She was seen at the same clinic for many months. Declared permanent and stationary with permanent restrictions and future medical treatment by a QME.

Case #2 Examination & Treatment

• Exam showed diffuse swelling/tenderness present all over the right hand, forearm, and arm. No localized bruise or swelling over contused area of Rt. forearm.

• Assessment: Mild contusion Rt. Forearm.• Diffuse swelling is pre-existing, from prior

injury, unresolved.• X ray, ice/ OTC MEDS, Regular work.• Observation/Reassurance

Important Details of Injury

• What is the actual Date of injury?

• What is the Time of injury?

• Was Exposure at work?

• Is there Physical or Psychological Trauma that is measurable by objective findings?

• Are there an Unbroken Chain of Events?

Case #3 Don’t ask, Don’t tell

• 40 year old male working in the car assembly plant for 8 years in paint shop. He worked in the paint booth and his work involved use of a spray gun connected to heavy tubes, and repetitive bending and twisting all day. EE reported low back pain to his supervisor at 8.30 am and was sent to the onsite clinic right away.

• The nurse triaged him and thought that his injury was pretty bad and she consulted with me to authorize rest of the shift off.

Case #3Exam & History

Q- When did the back pain start?A- This morning.Q.- What time?A.- Very early.Q.- Did you have any pain before coming to work

today?A. Yes, I had a bad back pain when I got up this

morning.Q.- Why do you think that this is related to work?A.- I did not say it was related to work.

Connect the Dots

• Never assume causation

• Ask relevant questions

• Make sure that exposure at work and the concerned injury have a cause and effect relationship.

First Aid Cases

First Aid/Non-Recordable• Use of nonprescription at nonprescription strength• Administration of tetanus vaccine• Cleaning, flushing or soaking wounds on the surface of

skin• Using wound covering such as bandages, Band-Aids or

gauze pads, or using butterfly bandages or Steri-Strips• Using hot or cold therapy• Using any non-rigid means of support• Using temporary immobilization devices while transporting

an accident victim

First Aid Cases (cont.)

• Drilling of a fingernail or toenail to relieve pressure or draining fluid from a blister

• Using eye [atches• Removal of foreign body from the eye using only irrigation

or cottom swab• Removal splinter or foreign material from areas other than

eye by irrigation, tweezers, cotton swabs or other simple means

• Using massage• Using finger guards• Drinking fluids for relief of heat stress

First Aid vs. Recordeable (cont.)

• Negative x-ray diagnosis (use of diagnostic procedures such as x-rays or blood tests for diagnostic purposes only)

Medical Treatment/Recordable• Use of prescription medication or non-prescription

medication in prescription strength• Restriction of work or motion beyond the day of injury• Injury requiring transfer to another job• Injury causing days away from work• Administration of other (non-tetanus) vaccines such as

Hepatitis B vaccine or rabies vaccine

Recordeable Cases (cont.)

• Use of wound closing devices such as sutures (stitches) or staples

• Using devices with rigid stays or other systems designed to immobilize parts of the body

• Physical therapy, chiropractic treatment or acupuncture• Loss of consciousness• Significant injury of illness diagnosed by a licensed health

care professional such as: cancer, chronic irreversible disease, fractured or cracked bone, punctured eardrum, or progressive disease

Recordeable Cases (cont.)

• Positive x-ray diagnosis• Hearing loss of more than 10 decibels• Death

Fitness for Duty Exams

Fitness for Duty Exams

FFD evaluations are done when an employer has a

reasonable belief base on objective evidence that

either:

1. The Employee’s ability to perform his/her essential job functions is impaired by a medical condition or

2. The employee poses a direct threat to the safety of others due to a medical condition

Fitness for Duty Exams (cont.)

Benefits to employers:1. Demonstrates good faith effort by attempting to

resolve and/or prevent potentially continuous and litigious workplace situations.

2. Protects from potential liability costs

3. Facilitates more positive & productive work

environment4. Relieves employers of the stress and burden of managing a disruptive employee.5. Provides employer with objective, verifiable data upon which critical decisions can be based.

Fit for Duty Exams (cont.)

Your Partner Clinic Provides:1. Knowledge of the legal constraints within which FFD/RTW

decisions must be made2. A thorough knowledge of the essential physical and

environmental components of the jobs in question3. The medical expertise to gather all the necessary and

appropriate medical information upon which to base a placement or FFD recommendations

4. An evaluation of the employer’s specific situation and develop a plan to assure that full and adequate medical and job information is available to allow for a correct and legally defensible determination of his/her work ability to continue performing the job at full duty or with restrictions.

Fit for Duty Exams (cont.)

Case # 4

Mr. X is a 60 yr old male who was employed for 2 months as a shuttle bus driver. One evening at the end of his shift, he told his employer he was feeling unwell and wanted to go home. He wasn’t driving at the time. Just as he was walking outside he was witnessed to have a seizure and lost consciousness. EMTs were called and he was taken to the ER. Employer called us to discuss his concerns. We recommended a “fitness for duty” evaluation. When I examined the patient it was discovered that he had a history of Grand Mal Epilepsy since his teens and has been under care/treatment with a neurologist. He was never supposed to drive a commercial vehicle!

Outcome: Declared unfit for duty based on his job description. Employer was happy with the results of findings.

DOT Exams

DOT Exams Page 1

DOT Exams Page 2

DOT Exams Page 3

DOT Exams Page 4

DOT Exams MEC

Any Questions?Thank you

Jaishri Ramesh, M. D.Board Certified Internal Medicine