Bodily Injury Claims: Study 7
Rehabilitation
A
claimant with a soft tissue injury can return to work quickly and
manage disability effectively using a rehabilitation plan. A claimant is
expected to make an effort to minimize a disability (to mitigate the
claim)
Rehabilitation Services:
- Rehabilitation consultant or caseworker
- Medical care and treatment
- Physical and occupational therapies
- Care by psychologists
- Training in self-care: mobility, communication and other daily living skills
- Vocational assessment, training and employment placement
- Social counseling and any related assistance
Special Equipment:
- Orthotic equipment designed to help patients function more independently may be prescribed
- Prosthetic devices may serve both a cosmetic and functional purpose. The equipment is available from many sources and includes:
- Hearing aids, glasses, special clothing and shoes
- Wheelchairs, hospital beds
- Hand controls on automobiles
- Ramps, special toilet and shower facilities
Financial counseling:
- Rehabilitation extends beyond medicine and concerns itself with anything that helps the patient reduce the effects of the impairment and achieve agreed upon goals
- Rehabilitation theory accepts the premise of the holistic medical model that a patient must be treated as a whole person in order to return to wellness in the most timely way
Goals of Rehabilitation:
- Accident rehabilitation in general concerns itself with restoring normal form and function to an injured individual or restoring the best function possible
- Not only involves the physical aspect but the work and social environment as well
- Goals are:
- Maximum medical recovery
- Early return to employment
- Return to pre-accident lifestyle or viable alternative
- The expansion of automobile accident benefits has increased the importance of rehabilitation services
- Primary goal of rehabilitation specialists with respect to the client is centered on the claimant receiving proper care to return to full function or to learn to operate within the limits a disability imposes
- The goal is to shorten the disability period and in turn reduce the amount of the claim
- Rehabilitation process starts with an assessment so that a plan can be developed for recovery
- The injury defines the impairment
- The disability the patient suffers from must be identified
- A rehabilitation specialist can make a critical and measurable appraisal of disability
- Impairments caused by accidents are not necessarily physical in nature. Cognitive abilities, emotional control and social function can also be impaired
Physiatrists:
- Medical doctors specializing in rehabilitative medicine
- Involved in the medical management of catastrophic spinal cord injuries
- Knowledgeable about effects of prolonged inactivity on muscle tissue
- Often work with patients suffering from muscle ailments caused by whiplash
- Specializing in physical medicine, educated in the use of mechanical apparatus and also use of light, heat, cold, water and electricity in the treatment, diagnosis and prevention of disease
Building motivation in patients:
- For cases where poor motivation is likely to act as a barrier to recovery, it may be worthwhile to use a rehabilitation case manager
- Inactivity and stagnation are fatal enemies to the success of rehabilitation
Guidelines for Rehabilitation:
- Factors which can alert the adjuster to consider using rehabilitation services:
- Medical diagnosis or prognosis is not clear
- Normal healing time has elapsed and there is no improvement or situation has worsened
- Treatment not likely to succeed
- Extreme psychological response to a relatively minor injury
- Soft tissue injury with long-term consequences, such as chronic pain syndrome
- Extensive use of medication
- Doctor or treatment shopping
- A drastic lifestyle change
- Prolonged or specialized care required
- Unable to perform some daily living tasks
- Unable to return to previous job
- Limited job, education, or language skills
- Pre-existing condition
- History of prolonged recovery periods or poor health
Evaluate each case:
- A functional capacity evaluation includes measurements and evaluations of aerobic ability, endurance, strength, range of movement, lifting, pulling and pushing
- Chronic pain information is collected and recorded with respect to the consistency of behavior and any discrepancies
- Rehabilitation service providers can identify emotional or psychological blocks likely to hinder patient’s recovery and may also uncover a malingerer
Rehabilitation Team:
- The team consists of the injured party and:
- Treating doctors and other medical specialists
- Nurses
- Physical and speech therapists
- Social workers
- Special education teachers
- Vocational specialists
- Family members
- Members of the clergy
- Community leaders
- Employers
- Rehabilitation case managers
- Insurer’s representative
- The most important member of the team is the patient
- Without the resolve and conscientious desire to reclaim a positive life situation, the combined skill and training of others is not likely to succeed
- Rehabilitation service advisor must be knowledgeable about:
- Rehabilitation services in the community
- Government assistance and programs available
- Rehabilitation process in general
- Advisors are in a position to know the limitations and specialties of the various rehabilitation service providers available in the area
- Advisors review rehabilitation treatment plans to see that they are structured, suited to the individual, goal-oriented and flexible
- Rehabilitation service advisor normally does not get involved in a claim the way a case manager does
- Advisors usually provide adjusters with information and advice
- Case managers generally deal directly with the claimant
Rehabilitation Service Providers:
- Use of professional rehabilitation services is growing
- Professionals with medical training and rehabilitation experience are offering their services to guide and coordinate the efforts of others towards the ultimate goal of returning a disabled person to the best position possible
- Facility based rehabilitation programs operate within hospitals
- Community-based rehabilitation programs operate as independent businesses
- Some physiotherapists operate on their own
- One of the important services entails educating the patient
- Skills such as stress management, relaxation techniques and pain management may be taught
- Professionals can help patients distinguish between what hurts and what is harmful so that appropriate function is achieved
Rehabilitation Case Management:
- Involves coordinating rehabilitation services required and ensuring communication is maintained between all the necessary parties
- Case manager develops goals and objectives for each patient and then reviews cases often to adjust plans as required
- Case manager must facilitate the formation of a cohesive rehabilitation team
- An important component of the managing process includes considering healthcare costs
- There are varied medical rehabilitation specialists that may get involved to clarify a medical issue – the diagnosis, the treatment, the prognosis, to coordinate alternative care, long-term care or catastrophic injury case management
- There should be a single doctor controlling the case
Occupational Therapy:
- Involves teaching and coaching patients to relearn daily living tasks
- Tests may be administered and interpreted with respect to muscle function and range of motion, emotional status, perceptual/cognitive function and developmental status
- O.T. must graduate from a recognized university program and must be a member of a provincial regulatory body and maintain a code of ethics and a standard of practice
- O.T.’s often specialize within their field
- They would be expected to possess special skill in:
- Standardized and non-standardized evaluative approaches
- Ergonomics/job modification/return-to-work strategies
- General physical conditioning/work hardening programs
- Stress/pain management
- Cognitive retraining
Vocational Therapy:
- Vocational rehabilitation process involves those things done to get the injured person back to work or back to doing essential tasks
- A variety of professionals provide vocational rehabilitation
- Many have backgrounds in medical disciplines such as occupational therapy, kinesiology, psychology and psychiatry
- Vocational expert predicts the likely work personality (how the individual will fare in the workplace) and probable maximum potential of the person
- Provides individuals with emotional and psychological support
- Work with the current employer and the employee to devise a plan to lighten workload or otherwise modify duties to enable the employee to return to work sooner
- Return to Work Hierarchy:
- Same employer with same job
- Same employer with modified job
- Same employer with different job
- Different employer with same job
- Different employer with modified job
- Different employer with different job
- No advantage to getting an employee back to work too quickly. This may aggravate an injury, cause a new injury and demoralize the patient
- It is not necessary for pain to subside completely before a work program is begun
- Vocational experts also identify factors that can decrease the chances of success
Psychology:
- Psychologists can help patients with many problems including coping with chronic pain, fatigue and emotional problems caused by the trauma of an accident
- Psychologist may perform cognitive testing to measure the thinking, remembering and knowing processes of the mind
- May also help a patient who has complaints associated with a disturbance in memory function
- May also administer psychometric tests that identify possible malingerers
- Minnesota Multiphasic Personality Inventory (MMPI) is used by psychologists
- It has its drawbacks; requires the individual have a certain level of literacy and reading comprehension, questions in the test are personal and some may feel threatened
Physiotherapy:
- Entails the assessment of physical function and the treatment, rehabilitation and prevention of physical dysfunction and the pain associated with it
- When restoring normal function involves bones, joints and muscles, physiotherapy is often recommended as a treatment
- Physiotherapy is regulated under the Regulated Health Professionals Act
- In Ontario all physiotherapists are registered with the Ontario College of Physiotherapists
- In many minor musculo-skeletal soft tissue injuries the only rehabilitative service needed is physiotherapy
- Physical therapy is used to reduce pain and improve range of movement
- Passive techniques such as applying heat, electrical stimulation, ultrasound and laser and active techniques such as teaching gentle stretching movements and other treatments that combine the two techniques are used
- Physiotherapists diagnose, assess and treat conditions which limit physical and functional independence
- Orthopedic and soft tissue injuries including burns
- Cardiac, respiratory and chronic disease
- Neurological injury
- Structural rehabilitation refers to groups of techniques used to restore symmetry to the body, restore tissue length and alleviate pain
- Final step of a plan is an active exercise regime
Chiropractic:
- Chiropractic medicine involves the assessment of conditions related to the spine, nervous system and joints
- Chiropractors treat conditions primarily by manual adjustment or manipulation
Catastrophic Injury:
- Catastrophic injuries result in serious, permanent impairment of a body function or mental process
- Claimant must relearn basic daily life skills
- Rehabilitation program seeks to help cope with life using whatever functionality does exist to maximum effect
- Adjuster must determine long-term care costs which include equipment and other orthotic devices, nursing and housing, therapy, transportation, personal care and personal mobility
The Adjuster’s Role:
- Maintaining contact with the claimant during the recovery stage is important
- Consider what can be done to improve recovery potential and note any change to the estimate of the insurer’s reserve
- Take care not to express any moral or personal judgments about any disability
- Be alert to situations that would benefit from referral to rehabilitation experts
- Explain the insurance contract, benefits payable and period of indemnity
- Inform the claimant’s doctor as to the financial resources available for any treatment or services required
- Include family members when discussing the rehabilitation program
- Rehabilitation assessment begins with reviewing the patient’s history and includes:
- Family history
- Education
- Employment history
- Financial status
- Physical activities
- Social activities/interests/hobbies
- Home, work and social environment
- General health
- Progress of the recovery
- Rehabilitation expert can identify the patient’s transferable skills
- When hiring an expert it is important to retain a person that has the proper background
- Information relating to work experience, educational background, training courses, lectures attended, lectures given, professional journals subscribed to, articles written, and any qualification with respect to testifying in court is needed
- Adjusters should clearly communicate the issues of concern and the reasons for referral
- Evaluate rehabilitation reports to make sure the necessary information is there
- Be familiar with current legislation, organizations, government agencies and facilities that offer rehabilitation services
- There are federal and provincial acts and laws providing grants and benefits to special groups of persons with disabilities
- Segregate costs that do not relate to the claim
- Pre-existing or unrelated condition being treated should be deducted
- Recommend reimbursement of reasonable charges within the terms of the policy
- Be familiar with the universal healthcare regime in your province
- Determine how much money is available to spend
- Judge whether a chash settlement is possible, desirable, or ethical given the circumstances
Government Services:
- Vocational rehabilitation services are usually provided
- Training can be provided for other suitable work
- Government departments may be expected to assist with:
- Assessment in medical, vocational and social disciplines to determine if a person will benefit by their services
- Remedial or restorative services to return the person to a former job or with training to a new job are provided free when the patient cannot afford to pay
- Counseling to achieve the goal of returning to work
- Technical or vocational training to match the injured person to a suitable occupation
- Home modification grants
- Specialized housing accommodations
Barriers to Recovery:
- Emotional barriers:
- Inactivity
- Despondency, low morale or lack of motivation
- Indifference
- Hostility
- Denial (refusing to adjust to the change in lifestyle)
- Inappropriate dependency on the rehabilitation service
- Over-treatment:
- Watch for the adverse effects of over-treatment
- An unreasonable duration of treatment may indicate either dependency, or lack of proper case management or improper motivation on the patient’s part
- Motivation issues
Abuse of Rehabilitation Services:
- Be vigilant against any fraudulent practice
- When services are being overused the adjuster should probe to determine why
- It may be simply that the adjuster is not exercising sufficient supervision over the case
- When referring doctor owns the rehabilitation clinic or gains some other financial benefit from suggesting rehabilitation treatment the adjuster must make certain that the services and treatments are warranted
- The same potential conflict of interest issue applies when a third-party-claimant lawyer has ownership in a rehabilitation clinic
- Believing they have been mistreated, claimants may rationalize they are justified in exaggerating symptoms and seeking unnecessary treatment
Definitions:
Prosthesis: is an artificial substitute for a missing body part
Orthosis:
is an appliance or apparatus used to support, align, prevent or correct
deformities, or to improve function of movable parts of the body
Rehabilitation Case Managers:
develop goals and objectives for rehabilitation in concert with
claimants. They are responsible for coordinating and facilitating
effective delivery of services
Functional Capacity Assessment:
is a review conducted by a rehabilitation expert based on the
collection of comprehensive medical and nonmedical information to
determine a claimant’s fitness for work
Rehabilitation Service Advisors:
consult with adjusters about available rehabilitation services and how
the rehabilitation process should work. They review and give direction
on specific cases.
IWRP: individual written rehabilitation plan
Work Hardening:
is the process used by vocational experts to help prepare individuals
to re-enter the work force. Often exercises to simulate work activities
are prepared so that individuals can practice work skills and increase
their stamina gradually. Sometimes a real work environment is used.
Kinesiology: is the study of human body movement
Kinesiotherapy: uses movement and exercise to treat injuries
Ergonomics:
deals with the application of scientific principles to improve the fit
between people and their jobs to achieve the best possible result in
work production. A chair that can be adjusted for the employee’s height
and back support is a simple example of the operation of ergonomics. The
employee can reduce the potential of injury by ensuring that the chair
is adjusted appropriately.
Psychometric Testing: is a systematic measurement of mental processes and behavioral acts
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