Tag Archives: albertsons

How to Identify Psychosocial Risks

We know that early intervention is critical to prevent delayed recoveries for injured workers. One of the challenges has been to identify those at higher risk of poor outcomes.

Fortunately, we have the tools to determine which patients are more likely to develop chronic pain and languish in a disability mindset. The process is fairly simple and backed by strong, research-based evidence. With increased awareness among payers, providers and other industry stakeholders, we can prevent creeping catastrophic claims, help injured workers regain function quicker and significantly reduce workers’ compensation costs.

Reasons for Getting Stuck

Psychosocial risk factors used to be little more than a buzz term among workers’ compensation professionals. While those of us who’ve worked extensively with chronic pain patients understood that psychological issues can easily derail a workers’ compensation claim, the research that proves this to be true has become widespread only in recent years.

In fact, some of the most recent research says that psychological factors can be more of a predictor of poor outcomes than the underlying medical conditions. We now know for certain that the biomedical model of disease does not hold true for everyone, and the biopsychosocial model of illness must be considered.

Where the first is based on the idea that a physical ailment can be cured through medical solutions, the second acknowledges that some people have an underlying psychobiological dysfunction that has clinically significant distress or disability. They are the injured workers who can greatly benefit from early identification and intervention.

Inadequate coping skills and a lack of knowledge of what is causing their pain can drive delayed recoveries and overuse of treatments and medications. Chronic pain is the final common pathway of this delayed recovery.

See also: A Biopsychosocial Approach to Recovery  

Research validated through meta analyses, prospective studies and control group studies shows that injured workers with delayed recoveries typically have:

  • Catastrophic thinking
  • A history of anxiety or depression
  • Anger and perceived injustice about their plight
  • An external locus of control
  • Minimal resilience

They may also have fear avoidance, meaning they engage in little to no physical activity out of fear they will injure themselves more and experience increased pain.

There are myriad reasons why some people have these issues. The cause could be childhood and life experiences, their relationship and interactions with their environments, issues in the workplace or home or other reasons altogether. It’s important that we identify injured workers with these issues as soon as possible after their injuries.

Pain Screening Questionnaires

One of the most effective ways to pinpoint injured workers with psychological issues is through specially designed, self-administered questionnaires. The one we use to identify patients at risk of developing chronic pain and disability is the Pain Screening Questionnaire (PSQ).

The PSQ was developed by a Swedish professor of clinical psychology and is used in many countries. It has been shown through studies to accurately predict time loss, medical spending and function — but not pain.

The PSQ takes about five minutes to complete and consists of 21 questions that focus on the injured worker’s:

  • Pain attitudes, beliefs and perceptions
  • Catastrophizing
  • Perception of work
  • Mood/affect
  • Behavioral response to pain
  • Activities of daily living

The injured worker is asked to rate on a scale of 1 to 10 things such as, “How would you rate the pain you have had during the past week?”; “In your view, how large is the risk that your current pain may become permanent?”; and “An increase in pain is an indication that I should stop what I’m doing until the pain decreases.”

Depending on the score, the injured worker is categorized as low risk, moderate risk, high risk, or very high risk. Those on the lower end of the scale are most appropriately managed through take-home educational materials on chronic pain. Moderate-risk injured workers are good prospects for a self-managed workbook style intervention. High- and very-high-risk injured workers should be referred for additional assessment and an intervention program, such as cognitive behavioral therapy (CBT).

See also: Impact on Mental Health in Work Comp  

In a program of early identification and intervention, Albertson’s Safeway found 12% of injured workers scored high. Those affected were referred to CBT. After an average of just six CBT sessions, a large percentage of them were able to return to work. Because of the results, primary treating physicians who work with Albertson’s injured workers have been referring them to the program earlier in the claims process.

Conclusion

It is estimated that 10% of workers’ compensation claims consume at least 80% of medical and indemnity resources. The vast majority of these are injured workers with delayed recoveries due to psychosocial risk factors.

With solid science backing up the successful identification and interventions of these employees, we can prevent needless disability and substantially reduce workers’ compensation costs.

Impact on Mental Health in Work Comp

According to the World Health Organization, mental health is described as: “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stress of life, can work productively and fruitfully and is able to make a contribution to his or her community.” But the World Health Organization’s definition applies only to part of the population.

At any given time, one in five American adults suffers with a mental health condition that affects their daily lives. Stress, anxiety and depression are among the most prevalent for injured workers. Left untreated, they can render a seemingly straightforward claim nearly unmanageable, resulting in poor outcomes and exorbitant costs.

Increasingly, many in our industry are recognizing the need to do all we can to address this critical issue. We must openly discuss and gain a deep understanding of a subject that, until now, has been taboo.

Four prominent workers’ compensation experts helped us advance the conversation on mental health in the workers’ compensation system during a recent webinar. They were:

  • Bryon Bass, Senior Vice President for Disability, Absence and Compliance at Sedgwick
  • Denise Zoe Algire, Director of Managed Care and Disability for Albertsons Companies
  • Maggie Alvarez-Miller, Director of Business and Product Development at Aptus Risk Solutions
  • Brian Downs, Vice President of Quality and Provider Relations at the Workers’ Compensation Trust

Why It Matters

Mental health conditions are the most expensive health challenges in the nation, behind cancer and heart disease. They are the leading cause of disabilities in high-income countries, accounting for one third of new disability claims in Western countries. These claims are growing 10% annually.

In addition to the direct costs to employers are indirect expenses, such as lost productivity, absenteeism and presenteeism. Combined with substance abuse, mental health disorders cost employers between $80 billion and $100 billion in these indirect costs.

In the workers’ compensation system, mental health conditions have a significant impact on claim duration. As we heard from our speakers, these workers typically have poor coping skills and rely on treating physicians to help them find the pain generator, leading to overuse of treatments and medications.

See also: Top 10 Ways to Nurture Mental Health 

More than 50% of injured workers experience clinically related depressive symptoms at some point, especially during the first month after the injury. In addition to the injured worker himself, family members are three times more likely to be hospitalized three months after the person’s injury. Many speculate that the distraction of a family member leads the injured worker to engage in unsafe behaviors.

Mental health problems can affect any employee at any time, and the reasons they develop are varied. Genetics, adverse childhood experiences and environmental stimuli may be the cause.

The stress of having an occupational injury can be a trigger for anxiety or depression. These issues can develop unexpectedly and typically result in a creeping catastrophic claim.

One of our speakers relayed the story of a claim that seemed on track for an easy resolution, only to go off the rails a year after the injury. The injured worker in this case was a counselor who had lost an eye after being stabbed with a pen by a client. Despite his physical recovery, the injured worker began to struggle emotionally when he finally realized that for the rest of his life he would be blind in one eye. Because his mental health concerns were raised one year after the injury, there were some questions about whether he might be trying to game the system.

Such stories are more commonplace than many realize. They point out the importance of staying in constant contact with the injured worker to detect risk factors for mental health challenges.

Challenges

Mental health conditions — also called biopsychosocial or behavioral health — often surprise the person himself. Depression can develop over time, and the person is not clued in until he finds himself struggling. As one speaker explained, the once clear and distinct lines of coping, confidence and perspective start to become blurred.

In a workers’ compensation claim, it can become the elephant in the room that nobody wants to touch, talk about or address. Organizations willing to look at and address these issues can see quicker recoveries. But there are several obstacles to be overcome.

Stigma is one of the biggest challenges. People who realize they have a problem are often hesitant to come forward, fearing negative reactions from their co-workers and others.

Depictions of people suffering from behavioral health issues in mass media are often negative, but are believed by the general public. Many people incorrectly think mental health conditions render a person incompetent and dangerous; that all such conditions are alike and severe; and that treatment causes more harm than good.

As we learned in the webinar, treatment does work, and many people with mental health conditions do recover and lead healthy, productive lives. Avoiding the use of negative words or actions can help erase the stigma.

Cultural differences also affect the ability to identify and address mental health challenges. The perception of pain varies among cultures, for example. In the Hispanic community, the culture mandates being stoic and often avoiding medications that could help.

Perceptions of medical providers or employers as authority figures can deter recovery. Family dynamics can play a role, as some cultures rely on all family members to participate when an injured worker is recovering. Claims professionals and nurses need training to understand the cultural issues that may be at play in a claim, so they do not miss the opportunity to help the injured worker.

Another hurdle to addressing psychosocial issues in the workers’ compensation system is the focus on compliance, regulations and legal management. We are concerned about timelines and documentation, sometimes to the extent that we don’t think about potential mental health challenges, even when there is clearly a non-medical problem.

Claims professionals are taught to get each claim to resolution as quickly and easily as possible. Medical providers — especially specialists — are accustomed to working from tests and images within their own worlds, not on feelings and emotional well-being. Mental health issues, when they are present, do not jump off the page. It takes understanding and processes, which have not been the norm in the industry.

Another challenge is that the number of behavioral health specialists in the country is low, especially in the workers’ compensation system. Projections suggest that the demand will exceed the supply of such providers in the next decade. Our speakers explained that, with time and commitment, organizations can persuade these specialists to become involved.

Jurisdictions vary in terms of how or whether they allow mental health-related claims to be covered by workers’ compensation. Some states allow for physical/mental claims, where the injury is said to cause a mental health condition — such as depression.

Less common are mental/physical claims, where a mental stimulus leads to an injury. An example is workplace stress related to a heart attack.

See also: New Approach to Mental Health  

“Mental/mental claims” mean a mental stimulus causes a mental injury. Even among states that allow for these claims, there is wide variation. The decision typically hinges on whether an “unusual and extraordinary” incident occurred that resulted in a mental disability. A number of states have or are considering coverage for post-traumatic stress among first responders. The issue is controversial, as some argue that the nature of the job is, itself, unusual and extraordinary and that these workers should not be given benefits. Others say extreme situations, such as a school shooting, are unusual enough to warrant coverage.

What Can Employers Do

Despite the challenges, there are actions employers and payers are successfully taking to identify and address psychosocial conditions.

For example, Albertsons has a pilot program to identify and intervene with injured workers at risk of mental health issues that is showing promise. The workers are told about a voluntary, confidential pain screening questionnaire. Those who score high (i.e., are more at risk for delayed recoveries) are asked to participate in a cognitive behavioral health coaching program.

A team approach is used, with the claims examiner, nurse, treating physician and treating psychologist involved. The focus is on recovery and skill acquisition. A letter and packet of information is given to the treating physician by a nurse who educates the physician about the program. The physician is then asked to refer the injured worker to the program, to reduce suspicion and demonstrate the physician’s support.

Training and educating claims professionals is a tactic some organizations are taking to better address psychosocial issues among injured workers. The Connecticut-based Workers’ Compensation Trust also holds educational sessions for its staff with nationally known experts as speakers. Articles and newsletters are sent to members to solicit their help in identifying at-risk injured workers.

Continuing communication injured workers is vital. Asking how they are doing, whether they have spoken to their employer, when they see themselves returning to work reveal underlying psychosocial issues. Nurse case managers can also be a great source of information and intervention with at-risk injured workers.

Changing the workplace culture is something many employers and other organizations can do. Our environments highly influence our mental health. With the increased stress to be more productive and do more with less, it is important for employers to make their workplaces as stress free as possible.

Providing the resources to allow employees to do their jobs and feel valued within the organization helps create a sense of control, empowerment and belonging. Helping workers balance their work loads and lives also creates a more supportive environment, as does providing a safe and appealing work space. And being willing to openly discuss and provide support for those with mental health conditions can ensure workers get the treatment they need as soon as possible.

As one speaker said, “By offering support from the employer, we can reduce the duration and severity of mental health issues and enhance recovery. Realize employees with good mental health will perform better.”

To listen to the full webinar on this topic, click here.

Claims Advocacy’s Biggest Opportunity

We know the single greatest roadblock to timely work injury recovery and controlling claim costs. And it’s not overpriced care, or doubtful medical provider quality or even litigation. It is the negative impact of personal expectations, behaviors and predicaments that can come with the injured worker or can grow out of work injury.

This suite of roadblocks is classified as “psychosocial” issues – issues that claims leaders now rank as the No. 1 barrier to successful claim outcomes, according to Rising Medical Solutions’ 2016 Workers’ Compensation Benchmarking Study survey.

Psychosocial roadblocks drive up claim costs far more than catastrophic claims, mostly due to delayed recovery, and claims executives told us they occur regardless of the nature of injury. In other words, one cannot predict from medical data the presence of a psychosocial issue; one has to listen to the injured worker with a fresh mind.

See also: Power of ‘Claims Advocacy’  

It’s likely no coincidence that, while the industry has progressively paid more attention to psychosocial issues this past decade, there’s also been a shift toward advocacy-based claims models over adversarial, compliance- and task-based processing styles. Simply put, advocacy models – which treat the worker as a whole person – are better equipped to control or eliminate psychosocial factors during recovery. According to the 2016 Benchmarking Study survey, claims advocacy and greater training in communication and soft skills, like empathy, are associated with higher-performing claims organizations.

Psychosocial – What It Is, What It Is Not

The Hartford’s medical director, Dr. Marcos Iglesias, says that the “psych” part does not mean psychiatric issues, such as schizophrenia, personality disorders or major depressive disorders. Instead, he points out, “We are talking about behavioral issues, the way we think, feel and act. An example is fear of physical movement, as it may worsen one’s impairment or cause pain, or fear of judgment by coworkers.”

The Hartford’s text mining has found the presence of “fear” in claim notes was predictive of poor outcomes. Similar findings were recently cited by both Lockton (“Leading with Empathy: How Data Analytics Uncovered Claimants’ Fears”) and the Workers’ Compensation Research Institute (“Predictors of Worker Outcomes”).

Emotional distress, such as catastrophic reaction to pain and activity avoidance, is predictive of poor outcomes. Other conditions, behaviors and predicaments include obesity, hard feelings about coworkers, troubled home life, the lack of temporary modified work assignments, limited English proficiency and – most commonly noted – poor coping skills. Additionally, being out of work can lead to increased rates of smoking, alcohol abuse, illicit drug use, risky sexual behavior and suicide.

When peeling back the psychosocial onion, one can see how adversarial, compliance- and task-driven claim styles are 1) ill-suited for addressing fears, beliefs, perceptions and poor coping skills and 2) less likely to effectively address these roadblocks due to the disruption they pose to workflows and task timelines.

Screening and the One Big Question

Albertsons, with more than 285,000 employees in retail food and related businesses, screens injured workers for psychosocial comorbidities. To ensure workers are comfortable and honest, the company enlists a third-party telephonic triage firm to perform screenings. “It’s voluntary and confidential in details, with only a summary score shared with claims adjusters and case managers,” says Denise Algire, the company’s director of risk initiatives and national medical director.

At The Hartford, Iglesias says claims adjusters ask one very important question of the injured worker, “Jim, when do you expect to return to work?” Any answer of less than 10 days indicates that the worker has good coping skills and that the risk of delayed recovery is low. That kind of answer is a positive flag for timely recovery. If the worker answers with a longer duration, the adjuster explores why the worker believes recovery will be more difficult. For example, the injured worker may identify a barrier of which the adjuster is unaware: His car may have been totaled in an accident. This lack of transportation, and not the injury, may be the return-to-work barrier.

It Takes a Village

Trecia Sigle, Nationwide Insurance’s new associate vice president of workers’ compensation claims, is building a specialized team to address psychosocial roadblocks. Nationwide’s intake process will consist of a combination of manual scoring and predictive modeling, and then adjusters will refer certain workers to specialists with the “right skill set.”

Albertsons invites screened injured workers to receive specialist intervention, usually performed by a network of psychologists who provide health coaching consistent with cognitive behavioral therapy (CBT) principles. This intervention method is short in duration and focuses on active problem-solving with the patient. The Hartford also transfers cases with important psychosocial issues to a specialist team, selected for their listening, empathy, communication skills and past claims experience.

Emotional Intelligence – Can It Be Learned?

Industry professionals are of mixed minds about how and if frontline claims adjusters can improve their interpersonal skills – sometimes called “emotional intelligence” – through training. These soft skills include customer service, communication, critical thinking, active listening and empathy. Experts interviewed agree that some claims adjusters have innately better soft skills. But they also concur that training and coaching can only enhance these skills among claims staff.

See also: The 2 Types of Claims Managers  

Pamela Highsmith-Johnson, national director of case management at CNA, says the insurer introduced a “trusted adviser” training program for all employees who come into contact with injured workers. Small groups use role-playing and share ideas. An online training component is also included.

Advocacy – The Missing Link to Recovery

Could it be that advocacy – treating the injured worker as a whole person and customer at the center of a claim – is the “missing link” for many existing claim practices to work, or work better? Whether for psychosocial issues or other barriers, organizations like The Hartford, Nationwide, CNA and Albertsons are paving the road to a more effective approach for overcoming pervasive barriers to recovery. Participants in the 2016 Workers’ Compensation Benchmarking Study confirm that higher-performing claims organizations are taking this road.

The coming 2017 study will continue to survey claims leaders on advocacy topics. A copy of that report may be pre-ordered here.