Facilitating early return-to-work after musculoskeletal conditions: A system-level pilot intervention program (RETAIN) in Connecticut

February 2019

Contributed by William S. Shaw, PhD, George V. Moore, MD MSc FACPM FACOEM, and Michael Erdil, MD FACOEM, University of Connecticut Health Center

The growing problem of permanent work disability. Work disability represents an enormous burden to workers, employers, insurers, and for health care and disability systems. In the State of Connecticut, the number of workers on Social Security Disability Insurance benefits has shown a sharp increase from 53,815 to 81,330 since the year 2000 (a 50% increase), while the State population grew by only 5 percent. The majority of SSDI recipients have musculoskeletal, mental health, and other episodic and chronic conditions where permanent disability might be prevented with more proactive employer support and accommodation. This has led Connecticut labor and public health officials to seek new strategies to curtail this growing workforce problem. 

Why focus on musculoskeletal disorders? Musculoskeletal disorders (both occupational and non-occupational) represent a highly prevalent, but preventable, source of work disability. Musculoskeletal disorders of the back, neck, shoulder, legs, elbows, and hands are quite common and often emerge during prime earning years. In many cases, acute pain remits or improves with conservative care. Most guidelines for acute or new onset musculoskeletal disorders suggest an initial period of symptom management and watchful waiting (barring any medical “red flags”), with resumption of normal activities as soon as tolerable. Despite these guidelines, there is still tremendous variability among physicians regarding opioid prescribing, imaging and diagnostics, specialty and surgical referrals, and recommended time off work. Unnecessary medical treatment can unnecessarily slow recovery and return to work (RTW).

Worker and employer involvement is paramount for effective RTW planning. Workplace support factors (job modification, supervisor support, etc.) are key predictors of successful return-to-work after musculoskeletal pain or injury. Permanent disability might be prevented if workers have better access to support from their employers, insurers, and medical providers to manage pain, gradually resume normal function.

The RETAIN-CT system-level RTW intervention program in Connecticut. RETAIN-CT is a State-level intervention program that will be designed to improve long-term RTW/Stay-At-Work (SAW) outcomes for workers with emerging musculoskeletal concerns. This will represent a new coordinated effort among several State agencies as well as a multi-stakeholder collaboration including health care providers and insurers. The plan is to train RETAIN-CT providers through an existing network of regional occupational health clinics already under contract to the CT Department of Labor; these clinics will become RETAIN-CT Training and Consultation Centers to provide specialized training to community health care providers. Coordination through private insurers will allow the use of new project-specific billing codes for early RTW planning and to collect work disability outcome data. In the Phase I study, 500 disability insurance claimants from The Hartford insurance company will be included and tracked, with half receiving care and services from a specially trained RETAIN provider, and RTW coordinator services will be offered as an adjunct to conventional medical care.

What are the elements of the RETAIN-CT initiative? The RETAIN-CT initiative is modeled after the successful Centers of Occupational Health and Education (COHE) program adopted by the State of Washington Department of Labor and Industries. At the individual level, the RETAIN-CT program is guided by behavior change principles in social-cognitive theory, with an emphasis on self-efficacy beliefs related to pain and work. Program activities will be divided between specially trained RETAIN providers, insurance case managers, and RTW coordinators. Providers will ensure best medical practice and be more involved and supported in RTW planning efforts. Insurance case managers will act as early telephonic RTW coordinators and provide proactive lost time tracking and employer coordination in the first few weeks of the claim, and field-based RTW coordinators will be called upon to provide a more individualized and participatory approach to job modification and RTW after one month of work absence.

Project timeline and contact information. Phase I of the RETAIN-CT study will be conducted over an 18-month period starting October 1, 2018. If the pilot phase of the study shows a high level of feasibility, produces positive outcomes for workers, and successfully engages stakeholders to facilitate early RTW, then a Phase II effort will involve roll-out of the project with multiple insurers across all regions of the State.

Acknowledgements. The cooperative agreement for the RETAIN-CT study is fully funded by the United States Department of Labor, Office of Disability Employment Policy in the amount of $2,111,269.00 under Cooperative Agreement No. OD32541187549. This document does not necessarily reflect the views or policies of the U.S. DOL, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government.

References

  1. Cullen KL, Irvin E, Collie A, Clay F, Gensby U, Jennings PA, et al. Effectiveness of workplace interventions in return-to-work for musculoskeletal, pain-related and mental health conditions: An update of the evidence and messages for practitioners. J Occup Rehabil. 2018; 28:1-15.
  2. Franklin GM, Wickizer TM, Coe NB, Fulton-Kehoe D. Workers’ Compensation: Poor quality health care and the growing disability problem in the United States. Am J Ind Med. 2015; 58:245-251.
  3. Kristman VL, Shaw WS, Boot CRL, Delclos GL, Sullivan MJ, Ehrhart MG et al. Researching complex and multi-level workplace factors affecting disability and prolonged work absence. J Occup Rehabil. 2016; 26:399-416.
  4. Shaw W, Hong QN, Pransky G, Loisel P. A literature review describing the role of return-to-work coordinators in trial programs and interventions designed to prevent workplace disability. J Occup Rehabil. 2008; 18(1):2-15.

William S. Shaw, George V. Moore, and Michael Erdil, are faculty members in the Division of Occupational and Environmental Medicine at the University of Connecticut Health Center. Dr. Shaw is PI on the RETAIN-CT project. He is a clinical psychologist and engineer with 20 years of research experience focusing on pain and work disability.

CPH-NEW is a Center for Excellence to Promote a Healthier Workforce of the National Institute for Occupational Safety and Health. CPH-News & Views is a semi-monthly column written by Center researchers on emerging topics related to healthy workplaces. These comments reflect thoughts of the individual researchers and do not represent conclusive research summaries, nor do they necessarily reflect a consensus among all Center personnel.

We welcome your responses and discussion. Please send all questions and comments by email to: CPHNEW@uml.edu.