I don't need someone to introduce me so I'm just going to introduce myself. I'm Nicolette Davis. I'm a physician assistant by training. I've been a PA for over 17 years and I've done occupational medicine in some form or fashion my whole career. I run 90 clinics that perform some version of occupational medicine in the southeast for Atrium Health. My role is the regional director of occupational medicine for the southeast. I currently serve between ACOM and the American Academy of PAs as a liaison between the two organizations and I'm the president of the PAs in occupational medicine. In my personal life I have four children. I have two adopted little girls and two bio boys and they keep me extremely, extremely busy and tired. So I hope you enjoyed this presentation today. We're going to be talking about red light, green light, the basics of workers comp. I do not have any disclosures today and we're just going to talk about the overarching umbrella of what occupational health is and then how the occupational medicine provider fits into the occupational health umbrella. So as you can see here on the picture, occupational medicine providers are only a very small portion of what is being done to a worker from day to day. This includes HR, it includes safety. These are people that you interact with probably frequently in your occupational medicine practice. It also includes any risk. So who's identifying the risk? Is that you? Is that someone within the employer organization? Are you working together as a partner in collaboration to make sure that the workers stay safe in their environment? This also includes ergonomics, OSHA record-keeping, and many other things that are used to take care of the worker. So again, we're only a small portion of the bubble and if we only look at our bubble then we're really missing the mark when we're taking care of the working population. So where is occupational medicine performed? You know, folks want to say, oh that's not my job. You know, that's the occupational medicine provider's job. It is most definitely not. We do occupational medicine in almost every specialty of medicine to include some pediatrics as well and OBGYN. It sounds surprising but it does happen. So we see occupational medicine performed in occupational medicine, dedicated clinics. You'll see it in employer-based clinics, employee health. You'll see it in urgent cares, primary care. You're seeing it performed via telemedicine now. Other specialties that you'll see it frequently, obviously our emergency departments do see some workers comp injuries, sports medicine, physiatry, physical therapy, orthopedics, and many others. So why is this important? You know, why should it be important to us as occupational medicine providers? Why should it be important to the primary care provider or the urgent care provider? It's because in the end we're taking care of the whole patient, not just their injury. So in February of 2024, there was 131.8 million full-time workers in the United States. If you look at the profile of the working poor, 11.6% in 2021. So why is this important? You know, people with children were five times more likely to be in that working poor population, women more than men, minority more than white. I'm sure that doesn't surprise anyone in the room, but the reason why this is important is when a worker is injured on the job, if they are out of work for a period of time, then their pay can stop. Their pay could stop for almost two weeks. Think about someone in this working poor population. Can they withstand not having a paycheck for two weeks when they've got children at home and grandparents that they're taking care of? Likely not. So it's really important to us, the ones providing the workers comp care to patients, to figure out how to keep them working in their environment in some form or fashion so that we can keep them whole, not only at work but also at home. About 2.8% or about 2.8 per 100 workers will also experience a work-related injury in their lifetime. So that's why this is really important work for us to do. So when we look at workers comp, you know, who defines it? So we've got employers, we've got workers comp insurance carriers, we have state law, there's a lot of players in the mix here. And us as the providers are often caught in the middle and we're the liaison between the patient, the employer, the carrier, and others. There are state laws that apply. Every state is different. Military family, I've moved around to many, many states and every state I go to is different. So you really have to understand what your state laws are and how it applies to the work that you're delivering to the injured worker. So we're going to move into a case study. We're going to follow Maria through her course of care and just break down what happened in her course of care and what red light, green light items we can solve for, why they're important, and what the definitions are behind that work. So Marcia, a 34 year old Hispanic female, presented to the occupational medicine clinic after she was discharged from the emergency department the day prior for a work- related injury. So she tripped on a wood pallet, she was walking in one of our plants, tripped, fell, contused her knee, and then scraped up her right knee as well. Her tetanus vaccine was out of date, she didn't know when she got it last, and in the emergency department they performed these items for treatment. So if you see follow-ups from the ED, this probably doesn't look out of their normal. So written out of work for five days, steristrips after cleaning the wound, wasn't deep enough for sutures, she received a tetanus vaccine and she was given Motrin 800 and then discharged. So when we look at definitions of workers comp, there are a lot of definitions that fall under workers comp. So part of that is what is a work-related injury? So this can be confusing. Sometimes it's employer dependent. It is when an injury occurs while the person is in the line of duty or on the clock. Sometimes this can mean that an injury occurred during a lunch break while the patient was getting out of their vehicle, coming into work, or getting back into their vehicle when they leave work. It could be them driving from point A to point B. A lot of times we have to clarify with the employer what do they feel it's work-related, do they feel like it was during the the line of duty or not. Date of injury is also a definition that we use quite a bit, and so sometimes date of injury is really clear. You know, they cut their hand, they fell and contused their knee, the date of injury is the day the injury actually occurred. Where it's not so clear is in a repetitive motion injury. So my shoulder hurts, I do a lot of overhead lifting and pushing and moving items back and forth, carpal tunnel for example, I have numbness in my hand. When did it start? I don't know. So those kind of things typically with repetitive motion injuries they don't have a definite start date. So you can use the date in which the patient sought care for the first time if you don't have a true date of injury. Work restrictions, so employers call this a whole slew of things. They call them work restrictions, they'll call them functional restrictions, they'll call them return to work, and so employers have various definitions for this, but in the end we're looking functionally what can the patient do following the injury and still be safe. The rest of the definitions we're going to touch on as we move through our case with Marcia. So back to our case study, so in the emergency department part of the treatment plan from her injury was to be out of work for the remaining five days. So we have a red light there, so as you all know writing people out of work creates a lost day, and the reason why lost days are important is because when the employee is injured on the job and written out of work for a period of time when they haven't clocked in, it creates a lost day for the employer, and this is something they have to report to OSHA. Now the reason why this is important is when the employee remains connected to the work environment, it can continue to make a positive contribution to society. It helps to improve their recovery rate so they recover much faster, and it also increases their life expectancy. It's pretty interesting. If we look at some statistics nationally, about one-fourth of our 20-year-olds will become disabled before the age of 67. Think about the financial burden to the U.S. Think about who's going to be doing the work. So this is a really scary statistic, and this is the reason why we need to make sure that we are always keeping our workers engaged in their work environment when it is possible. So think about individuals spending about a third of their life inside of their work environment. What does that feel like? That is where they make relationships. That's where their identity lies, is in their work. It is where they build their community. So if you remove them from that work environment for long periods of time, they start to become depressed, anxious, they lose a sense of purpose, and that does not only affect that worker, it also infects their family. So lost days. So there is a loophole to lost days. So this is when we talked about you write somebody out of work for the rest of the day, but if that person has clocked in on that date, it's not considered a lost day. So if you're looking for a loophole for lost days, that would be it. If they've clocked in, then it's not considered a lost day. Now trust and verify. If the patient tells you they clocked in that day, you might want to confirm that with the employer. Also, if you work in a clinic setting where you may see a patient one day and another provider may see the patient the next day, just be aware of that. Because if you write somebody out of work, that patient might have an expectation that when they come in the next time that that provider would also do the same. So really expectation management with that patient if you choose to use this and write someone out of work. So moving into workers comp recordables and non recordables. So if you've been doing workers comp in any form or fashion, you've probably heard this term before. It's an OSHA related term and it's extremely important to employers to have non recordable injuries. Here's why. So many employers that have 10 or more employees are required to report their OSHA log electronically. This is also public record. So any recordable injuries that occur, they have to report it. So they also have to maintain this record for five years. So today a contractor could go and bid for a multi-million dollar contract and if they have more recordables than another contractor, do you think they're going to get that that contract? No, because they look like they've created an unsafe work environment. So that is why employers get so upset about recordables versus non recordables because it can prevent them from having future business. So it being electronic and being public is very important to employers and so when they look to you to see their injured worker, they want you to look through the lens of recordable and non recordable. Do you have to always make decisions based on that? No. You have to do what's medically appropriate for that patient in that moment, but we should always be putting it through the lens of, hey could this be a non recordable injury at this time? And maybe it is the first couple visits and then maybe you have to transition it. So back to our case study. So the next two things that were done for our Marcia patient, STERI strips were applied and the wound was clean. The tetanus vaccine was also administered. So those are green light items. Those are non recordable items. So things that would have made this recordable, outside the lost days of course, would be a rigid splint. So if we keep in mind, if we place a rigid splint on someone, we're automatically creating a recordable injury. If there is not a fracture, no concern of fracture or ligamentous injury, we really should be trying to look for non-rigid splint options. So that may mean that your clinic needs to get some pieces of over-the-counter options that are non-rigid. And when I've gone to clinics before, there has not been many options. It's been either you put the metal finger splint on or there really wasn't much else I could do. So this could mean that you purchase finger cots for your location, that you buddy tape fingers, that you use knee sleeves, elbow sleeves, back Velcro braces. So Dermabond is also considered recordable, but in this example they use Steri-Strips, which that was great because it was a superficial injury. They weren't worried about any additional bleeding and it did not require Dermabond or sutures. Also the tetanus vaccination was considered, is also considered non-recordable. So all that was good. So next, moving into the additional treatment. So Motrin 800 was given to this patient. So red light stop, right? So Motrin 800, even though it's an over-the-counter medication, it was given to the patient at prescription dosing. So why is that important? So over-the-counter medications at over-the-counter dosing are non-recordable. So oftentimes what I will do is I'll just say over-the-counter medicines at over-the-counter dosing, or I would love for you to take ibuprofen at the dosing on the back of the bottle. So I will not even say 400, two tablets. I'll just say look on the back of the bottle. So what I often hear providers say is they'll verbally tell a patient, you know, take ibuprofen 800. Well we can't do that either. So you just leave it up to the patient to take what's on the back of the bottle and you know if you go home you're probably not taking 400 ibuprofen. You're putting your four tablets in your hand, throwing them back and calling it a day. Let the patient do what they're going to do, but what you write into your note is exactly what you told them. Over-the-counter medicine, over-the-counter dosing. So prescription medicines are considered recordable or over-the-counter medicines at prescription dosing would be recordable. What I often do is I try a stepwise approach. I'm sure you do this in your practice as well. So I start usually with over-the-counter topicals. So Thermacare patches, salon pause type patches, capsaicin creams, and things of that nature. So if you start with over-the-counter topicals, then when the patient returns you can advance to over-the-counter orals. That just bought you two visits. So for those minor injuries you can start with topicals and then move to orals and there's good evidence-based medicine around that for workers comp injuries. So I just wanted to give some examples of what I mean with over-the-counter medicines and over-the-counter dosing and what a patient will see on the back of the bottle. I do want to draw your attention to the acetaminophen category. So on the back of the 650 bottle it does say that they can take two tablets. That would be 1,300 milligrams. So I do not tell patients to do that. We always get concerned of liver toxicity and if they're taking that multiple times a day obviously they're going to reach that that maximum. So just be really careful when you're talking about Tylenol or acetaminophen as an over-the-counter medication. Be really specific as to what you mean. Look on the back of the bottle. If they're taking 650s you probably just want to stick with one 650. So moving on to work restrictions. So there is a plethora of options, whatever fits your fancy. There are so many ways to restrict a worker to still keep them engaged in their work environment in some form or fashion. It is not up to the workers comp, occupational medicine, primary care, urgent care provider to determine if a patient can work or not. Not our job. That is the employer's job. That is safety. That's HR. That's what they do. Us as the occupational medicine provider, workers comp provider, our job is to tell them functionally what do we think they can do safely. When a worker says well my employer doesn't have work for me that that falls under those restrictions, I say that's something for you to talk to your employer about. My job is to tell you medically and functionally what can you do safely. And so that helps you to avoid some really uncomfortable conversations with your patients and also really creates clear boundaries of I am here, your employer, HR safety sits over here. They make that decision. So here's some things that I like to do. So lift, push, pull, really not a science. So talk to the patient. You know, do they have children? What do they do for their hobbies? Get to know your patients. Make a relationship and a connection. So if they have a toddler that weighs like mine, 25 pounds, and I'm lifting her and I'm able to do that frequently throughout my day, then I can tolerate that. So get with your worker, understand what they can do safely in their home life, and then let that translate to work. Because we don't always have the ability to have physical therapy do a functional assessment on patients to really understand truly what can they lift, push, pull without creating pain until we make that referral to PT. We try not to do that. So initially let's really try to look at them functionally, learn what they do in their home life, and let's translate that to work. Flexion at the waist. So I'll see providers write you know zero flexion. Well, the patient has to go to the bathroom, they have to tie their shoes, and they sit down in a chair. You're flexing at the waist when you do those things, right? You have to put your pants on. So let's be reasonable with our restrictions. Don't write something, a restriction that they can't do at work, but yet they're still going to do it at home. Make it equal. What they can do at work, they can do at home. So hours worked per shift. So oftentimes with workers that maybe have a significant injury, I'll restrict the hours worked per shift to avoid writing someone out of work. So if you look at national data, about 3.7 percent of the time patients are written out of work in some form or fashion. So in our institution when I first came, we were at about 50 percent or so of providers were writing patients out of work. After just education like this, we're down now to about one to two percent of the time we write people out of work. And oftentimes providers will message me and say, hey, do you think this is reasonable? And we talk through it, and we come up with some solutions around how we can keep that employee engaged in their work environment in some fashion, because we know it's better for them in the long run. So you can also have them elevate and ice, alternate repetitive motion and non-repetitive motion, just be specific. So if they're going to do a repetitive motion activity for two hours and you want them to take a 30-minute break, call that out. Employers like you to be specific because then they're very black and white. They're going to take what you say and put it into action. If you leave it open-ended, the employer's going to feel that's open-ended. So just try to be specific with the repetitive motion, non-repetitive motion. Avoid kneeling and squatting. So is that possible with this worker? Is that what they're going to do at home? Like we said, let's align home and work and marry the two together. Avoid stairs. Does that make sense? Would they be doing that at home? If yes, then maybe you could avoid that as well. So I use this a lot, a trial of regular duty prior to discharge. So you may call it something different in your practice environment, but it's taking a patient that's almost at maximum medical improvement or maybe back to pre-injury status. They may not be pain-free because we don't expect them to be pain-free. We just expect them to be able to do their full-duty job without having to stop, not being restricted. It may still mean that they have a little bit of pain. So you have to manage the patient's expectations. So you may still have a little bit of pain, but I would expect that pain to not limit you from being able to do your work. And that's where we are right now in your exam. So then we're going to move forward with a trial of regular duty prior to discharge. You're going to do your full-duty job, and I'll see you in a week. At that point, we'll talk about, hey, how did it go? You may still have some pain. Maybe you still need some over-the-counter medicine when you go home. That's totally fine. That's part of the normal healing process. So set the expectation, empower the patient, use positive language. Employers really like this. They feel like it's meeting the employer and the patient halfway. They feel like it helps to mitigate their risk because they can watch the patient in that normal work environment for seven days and realize, oh, hey, this isn't working, or, yeah, this is actually working really well. I think the employee is doing quite well. Now we always give the employee the ability to come back. If within the seven days this is just not working for you, then please come back. Then we can manage that, and we can make some changes to your treatment plan. So always be there for the patient, but empower them that they're going to get better. They need to push through a little bit of pain that's non-limiting. This works really well. So moving on to medical causation. When you talk about causation, you want to get providers really excited, talk about causation. So they think it's legal. It's not. It can be legal in a legal environment, but in our environment, we're the medical providers. So this is medical causation that we're talking about. Now this is different from causality. So they kind of sound similar, or excuse me, from compensability. So compensability is when a worker is eligible for benefits and coverage. That's compensability. We're not involved in that. We're involved in medical causality. So what that means is, was the cause medically probable? So did the effect of the injury and the outcome, your exam, do those two marry together? I'm sure you've seen patients in your environment where what was reported as the injury does not marry up to the exam, and you can call that out. But that's the difference. So providers often think that they're making a legal determination. That is not true. You are making a medical determination in this instance. So in your assessment and plan, you could talk about this. You can say that you feel like this is medically, the causality is medically appropriate to be work-related or not work-related, or at this point, I don't know, I have no idea. So maybe you need an MSDS sheet. Maybe it was a chemical exposure, but you don't know what that chemical is. I can't tell you how many times people come in and say, I was exposed to a chemical. What chemical? I don't know. We need that MSDS sheet to really understand, did that chemical cause the injury that occurred? So work-related, not work-related, undetermined. And when it's not work-related, make sure to call that out. And call it out at the initial injury, and then make sure to share that back with the employer and the patient, and then tell the patient what their next step is. Next, you're going to follow up with your primary care provider, because this wasn't work-related. So an example I have is a patient came in, had a rash, thought it was from a chemical that they were exposed to at work, but they had on their full PPE. I look at the rash, it was shingles, not work-related. So it's setting that expectation of, this is not work-related, this is what the illness is, and next, you're going to follow up with your primary care provider. Let me help you do that. So maximum medical improvement. There's a couple ways of looking at this. So in our occupational medicine environment, our primary care, urgent care, wherever you are, this could be the patient is ready to return to full duty without restriction. So this could mean that the patient still has a little bit of pain. We talked about that, right? So they could still have a little bit of pain, but it's not limiting them. The pain will eventually subside. And other ways of looking at maximum medical improvement would be when the patient has plateaued. So maybe they've had multiple conservative things done, maybe they've had a surgery, and they've plateaued in their treatment. That's another way of looking at maximum medical improvement. But for the purpose of this lecture, we're looking at it from getting a patient back to their pre-injury status, maybe not pain-free. So permanent and stationary disability ratings, this depends on your state. So some states, like the state I live in, North Carolina, it is a physician-only exam. So PAs and PEs are not involved in this. So this is when a patient is stable. Their condition is not changing over a period of time, again, that plateaued patient. But maybe their injury is still limiting them from being able to perform their full-duty job. So we typically refer to physiatry. There's probably a lot of other providers and occupational medicine providers that do this kind of work. But this work is an escalation of care. So this requires usually a referral, or you may do it in your own practice. So switching gears over to HIPAA and workers' comps. So workers' comp and HIPAA, totally different beasts than your other day-to-day patient HIPAA experiences. So does HIPAA actually apply to workers' comp? Well, not really. You can give the employer back whatever information they want to receive on that injury. But it is your responsibility to only put in your note what should be in that note. We don't want to do what's called over-disclosure, which is where you disclose information not related to that work injury. We're going to talk a little bit about how to do that. So you can create templates within your documentation note to prevent those pieces of information from coming in. There are various ways that you can do this. Some really smart medical record folks can figure out how to filter pieces of information out of your note. But in the end, if it's not in the note, then you know it's not going anywhere. So in the end, I prefer the notes to be clean. So looking at a case study on HIPAA and workers' comp. So a patient presents with a finger laceration that occurred at work. They disclose that they have type 2 diabetes that's uncontrolled. Do you document the history of the type 2 diabetes in your workers' comp note, or do you leave it out? So the folks that want to leave it in, raise your hand if you want to leave it in. Do you leave type 2 out? Raise your hand. Okay. So let's talk a little bit more about this case study. So the answer is actually green light. You can leave it in. So you can disclose information that is directly related to the injury treatment care. So if I have a finger laceration on a type 2 diabetic, I'm probably going to change my treatment plan. So maybe I'm adding an antibiotic. Maybe I'm keeping a much closer, tighter follow-up on that patient. It's going to change and directly affect my treatment plan. So yes, I can disclose it. Other things that you can disclose but need to use discretion for would be a depression score. So if you're part of a big medical institution, maybe it's part of one of your quality metrics to do a depression screening. So you can pull the score in. Now, if you need to do something with that score, because maybe it's a high score, you probably want to create a separate encounter outside of your work-related documentation note and then document how you're escalating care if needed. Use discretion. Backhoe status, that can definitely be in your note. I know that's frequently a quality metric for some health care institutions. You can include the history of present illness, talking about how the injury occurred. You can use timelines. You want exhausting detail in your HPI. This is even more important than doing your physical exam portion. The HPI is really important. What is the mechanism of injury, especially at that initial injury exam? And then you can include your review of systems, or you can keep that included in your HPI. All that is totally fine to have in your workers' comp documentation note. So when you're doing a physical exam in workers' comp, typically it's targeted, right? So you're looking at what body part was injured, and then you address that body part with physical exam findings. Now if you start with one physical exam test, you need to follow that same physical exam test as you're seeing that patient back, and you need to document it. So what the workers' comp carrier is looking for is change over time. So today, their flexion was this percentage. Well, when they come back a week, two weeks later, it's now this. So what you document on that first exam, you need to continue to follow that same physical exam throughout the treatment of that workers' comp patient. Now I'll go back and look at what previous providers did, and I try to mimic their previous exam. So if they did a physical exam finding, I repeat that. If I want to add something in because I prefer another type of exam, I'll do that. But I repeat everything that initial provider did, and then I can always add on if I'd like. Very important. Your diagnosis, diagnoses, medications on that date of service can also be included in the note. Obviously, your work restrictions can be in that documentation note. Chronic diagnoses, like we talked about, if they directly impact the care that you're delivering. Now, where to use discretion, HIV diagnoses, hep B, hep C. So yes, you can include that diagnosis in your template. Do you want to? Probably not. So can you use some other language? Can you say patient has a medical diagnosis that can hinder healing? Something like that. So you can use other language without being specific to HIV, hep B, hep C. You can also use that for your diabetes type 2 patient if you like. So that's an option, but use discretion. So what does not need to be in your worker's comp documentation note? Their past medical history does not need to be in there, which includes their diagnosis history, chronic diagnoses, their surgeries and their health maintenance. Their social history does not need to be included. Family history, medication allergies, because medication allergies can kind of tell the story of maybe some of their chronic diagnoses that we don't want to disclose. And their chronic medication list. So all of this needs to be removed from your worker's comp template. And if you use a medical record that's specific to Acmed, it probably already pulls that out. We don't. We use Epic. And so we had to create templates around this work. So when you look at worker's comp documentation, ACOM did a really nice job. I think this was, this might have been last year or the year prior, they did basically comparing the medical, and this is on the ACOM website, the medical model versus the functional model. So when we're performing a worker's comp related patient exam or care, we are working on that functional model. It is very different if you've worked in primary care, urgent care, it's a very different hat that you're wearing, a very different lens that you're looking through. So some of the questions that I ask that actually my partner in crime, Dr. Mary Ruth Hunt, taught me was to really get in and dig into the patient personally. Ask about their, do they like their job? Do they like their supervisor? Do they like their coworkers? That's going to tell you the story on how motivated they are to get back to work. If they hate their supervisor, do you feel like they're motivated to get back to work? Probably not. They probably want to stick it to them. So you really got to dig in and figure out where are they both at home and at work, get to know them personally, ask the right questions, but that's the whole functional model. We need to know what the patient can do at work, what can they do at home? Do they like their home environment? Do they like their work environment? We really need to understand the whole patient to understand their motivation to get better from this work-related injury and what the barriers are to that. We're also looking at risk. Does this patient have a high risk of moving on to disability? These are all really important things for you to understand, but also for you to document so the workers' comp insurance carrier understands the motivation of this patient and do we need to escalate care? Do we need to add a nurse case manager potentially because this patient is at high risk for disability? We don't want that increased risk of disability. We want our patients to get better, be part of society and part of their families again. We use patient-facing resources. I don't know if you all use this. Sometimes there's actually pictures of a body and the patient can mark on there which body parts are hurt. There's various ways of doing this, but I really like for patients at each exam for them to tell me where they are. We also use a rating scale, so 0 to 100. Do you feel like you're back to pre-injury status? Where are you on that 0 to 100? We use that a lot. Actually, patients are really good about it. They'll put on there, I'm 60, 70, 80% and then you watch them progress. Now they'll try to play you. If you have a multiple provider clinic, they may put 30% this day and they come back and see you a week later and now they're saying 15%. Oh, well, it looks like when you saw Logan the other day that you said you were at 30%, what happened? It could be legit. Maybe they worked a longer shift. Maybe they put in some overtime or it could be that, oh, no, no, no, actually I'm doing much better. I'm 30, 40% better. I really like to use that gauge even though it's subjective. It really helps me to follow along and know where the patient is mentally. If they say 90%, then I'm probably moving towards that trial of regular duty prior to discharge to see if we can push them a little bit more to get them to that 100%. I like patient-facing documentation. Other tips for the provider. Outlining how the injury occurred, paint the picture for the person that's coming behind you. I often look at my documentation of an injury as if I were explaining this to my five-year-old, this is exactly how it happened. They flexed over at the waist. They picked up a rectangular box from the ground. It weighed approximately 50 pounds. They moved that box to their waist. They then took the box, pushed it up over their head and pushed it forward onto a shelf that was above their head. They then shifted it right, left, that kind of detail. Oftentimes what I'll see is somebody just says, a patient picked up a 50-pound box, hurt their back. Well, what did they do with that box? Were they twisting? Were they leaning forward? Tell me exactly what the mechanism of injury was. First comp insurance carriers love that. They want to hear exactly how the injury happened. You also need to paint a very detailed timeline. Our providers will go, here's the date of service. Here's what the patient tells me. Here's what we did. Date of service, here's what the patient tells me. Here's what we did. We just keep going. You can copy it from the provider's previous note, however you like to do it. The timelines are key because you really can understand what's being done. If you're picking up behind another provider, they truly appreciate that level of detail. Again, we talked about talking to them like you're a friend or you're a cool mom. Do you like your job? Do you like your coworkers? Then, render care with the purpose of full duty. When we're talking to a patient on the first exam, it's setting the expectation that you're going to get better. Pain is normal. We're going to work through it. I'm here for you the whole time. You also want to understand if the patient has any family members or friends that have been on disability in the past. This puts them at a high risk for disability in the future and should be documented. We want to make sure we're watching those patients closely because they are at high risk. We also want the carrier to know that just so they know if they need to attach a nurse case manager to that early on. You do want to address victim mentality. Sometimes patients come to you and it's, my work did this to me. You really want to address that using empowering language and really let them know that you're here to help them along the way, but they are going to get better. Again, we talked about we use Epic. The way that we use Epic, we filter out any of that past medical history that could come in. We use something called an express lane. If you've worked in Epic before, that's what it looks like. If you work in an OcMed EMR, you probably have something even more streamlined. This is the way that we help providers not make mistakes with their documentation. They have to stay in this one place and they can't go outside of it. Everything that they need is right there. That's the way that we've been able to help providers not include information that could lead to overdisclosure. We're looking at workers' comp referrals. There's various ways that we do that. We talked about things that cause recordables, so placing a referral and escalating care causes a recordable. Also doing something outside of x-rays can create a recordable injury as well. We really need to be cautious about when we use workers' comp referrals, but obviously medically appropriate. Referrals for advanced imaging in the world of workers' comp, unless you work with someone who is just a miracle water walker, you really can't get stat advanced imaging same day because there's a lot of players that have to approve that in a workers' comp case. You've got the employer that would need to approve that. The workers' comp adjuster would need to approve that. It would need to go through an approved imaging center, so it's complicated. You can get that done, and that's great if you have the ability to do so, but it's not always realistic to know that you can get advanced stat imaging. So that may mean that you have to refer to emergency room for care. If we do refer to the emergency room, we typically tell patients we set a follow-up for 24 hours. The case of Marcia, remember, so she was sent to the emergency room. She was written out of work for five days. She was given Motrin 800. So what we try to do, if we need to send or escalate care to the emergency room, we already set that follow-up for 24 hours later so that we can take over the management of the care. At that point, we do realistic work restrictions, we use empowering language, and we try to get them engaged in their work environment quickly. So the workers' comp insurance carriers and employers, like I said, everybody is included in decision-making around referrals, so really stat anything doesn't typically happen. It can. So referrals can be state-specific. So some employers may be involved in referrals, some not. Some carriers may be involved, some not. Some states' patients get to dictate their care. Others, they don't. So it all just depends on what your state law is. When we place referrals to specialists, if we have the involvement of employers and carriers, we have to set the expectation with the patient that it's not like when your primary care requests something. You know, primary care requests something, and maybe they get in in a week or two weeks. It's not like that in workers' comps. We have to set the expectation that it could take us a few weeks to be able to get your referral processed. In the meantime, I'm here for you. We'll continue to try some different medications to make you more comfortable. So some verbiage that you can use for workers' comp. Two ways of doing referrals. One is consult and treat. So this is where you would refer a patient onto a specialist like ophthalmology, neurology, something of that sort, where you're requesting the specialist to evaluate and treat them, but you are going to continue to make contact with that patient, and you'll provide the work restrictions to the employer. So the specialist is truly just consulting and treating. They're not involved in the ongoing management of that work comp claim. The other option is transfer of care. So this is when you use this. I typically use this for musculoskeletal injuries. So I'm referring to sports med, to ortho, places like that, that typically are managing work comp patients. It's a chunk of their business. They understand how to do it. So at that point, I would do a transfer of care, and that care of the patient would move to that specialist on that first date of appointment. The gap time is still my responsibility. So if I place a referral, and they're not seeing the specialist for two weeks, I'm not washing my hands of that patient. They're my responsibility until they have that very first appointment. So I still bring them back in, still have touch points, and I'll still escalate through different medications or conservative methods to try to make the patient more comfortable in the meantime. So billing and coding and workers comp. So again, it goes back to state law. So this is state dependent in my state, or the states that I manage, the four states in the southeast. So we are able to place a new code, a new E&M code on patients if they're seen in a division outside of our home division. So if the patient was seen in the emergency room, like the case of Marcia, then comes to my division, which is part of the medical group, I get to code a new patient visit for that work comp injury at that initial visit. It's considered new. So it all is state dependent, but you're doing the work. Make sure that you know what the state law is and that you're using those new E&M codes when appropriate. You definitely wanna get paid for the work that you're doing. Also remember to code medical decision making versus time. So often in workers comp, I code on time because the amount of time it takes me in an initial injury to talk to the worker, to get their x-ray, to then manage what I'm going to do, recordable or non, interact with the supervisor, whoever's in the office, or I have to call somebody to give them a report. I code on time. So make sure that you're coding appropriately. We did a coding study of some of our Occ Med clinics and they are significantly down coding for the work that they're delivering. So the rest of this year, we're really going to be pushing that because in workers comp, you all understand there's usually a state fee schedule that you're up against. So you really want to make sure that you're maximizing your billing and coding. And definitely partner with your coding folks at wherever you are. The issue is most of the time I find that I'm educating the coding people on how to do work comp. They don't often know how to do that. They don't know the complexities of the work that we're delivering. So really find somebody that you can partner with, but you need to make sure you're getting paid for the work that you're delivering. Really, really important. There is a workers comp coding handout that was shared last year that also went along with that infographic I shared. It's really, really good, very detailed on how to manage medical decision making versus time coding in workers comp on the ACOM website. So I'm going to pause right here. We have 18 minutes. I wanted to see if there were any questions in that beginning part. And then I have some kind of clinical hot topics to review. I know there's already a concussion lecture, but I have some basics on head injury and blood-borne pathogens. So just wanted to see if there were any questions first before I moved into that. Yes, and I don't know if there's a microphone. So you can talk and I can project. What I struggle with, and I'm new, my background's PT, orthosurgery, infectious disease, but I just came into Occupy. Awesome. And I love it. What I struggle with right now is, because I work with a lot of manufacturing, is restricted work duty, because by OSHA guidelines, if they cannot perform one or more of their routine tasks, it's reportable. That said, the problem I'm dealing with manufacturing is, you know, they consider a rotational basis, like eight hours a day for two weeks, and then they switch. I said it has to be two to four hours. They should have two tasks that were different muscle groups and switch. So I've worked around the restrictions in that way, saying you can still do your duty, because most of it's chronic, repetitive. Right. But I'm educating them, because they, you know, rotate every two to four hours. And then they have some robotic options to take a break. My question to you, which is, and I've read through the OSHA guidelines so many times, is really, it's a fine line, and I want your guide on, when you put a work restriction on somebody, if it does, my understanding is, if it does not change performance of their routine tasks, is that not recordable? Great question. So what she's asking is, if you provide a work restriction that does not change their routine job, is it non-recordable? My understanding is that's correct. So we work with employers, and typically that's not where we get involved medically. You know, we're trying to make what's medically appropriate functional restrictions. But I think that's really important to try to look through the lens of the employer. So if you can do a site visit to some of your, you know, top five, top ten employers, and really understand what their work environment looks like, I feel like that's an added value. But yes, that's also my understanding, is that if it stays within their job code and doesn't restrict them, then it would still be non-recordable. And that's what a lot of our employers look at as well. Yes. I'm going to speak a bit from a Canadian background. Sure. Ontario specifically with workers compensation, but my question has to do with, do you have any comment on apportionment when it comes to being questioned by workers comp, you know, what portion is work-related, what portion is not work-related? Sure. And how do you address that? Right, so he's asking, so if you have a work-related injury and you're being questioned on what portion is work-related and what portion is not work-related, I would say it's out of the scope of this lecture because this one's really basic, but would love to talk to you about that offline. But yes. Yes. Yeah, so how much of it is even our responsibility? Like, okay, I understand that laws being what they are, we're going to have decisions where, I don't know, it's going to wind up, somebody's going to ask, do they wind up being reportable, where it's like, okay, is that really fair to the company? Who cares? I mean, our job is to just make like a medical decision. Sure. Yes, they can do this. No, they can't do this. And just sort of leave it at that, and we're not legislators. The other thing that I was going to ask you about is, you know, when it comes to worrying about how and why are we going to get these people back to work and that sort of thing, and sort of wrangling that, how much of that is our responsibility versus, you know, it's sort of the theme here is, what are we really responsible for? And maybe we can keep our sanity for a little bit longer if we can sort of say, look, we're here to kind of do what we're supposed to do. Sure. So, great. So, in summary, he's asking, so if you're looking at, you know, your job versus my job. So, HR and safety versus occupational medicine, who does what? So, to your point, yes. I mean, I think we still have to look through the lens of recordability. So, when we're looking at the patient, can we look through the lens of, can we keep it non-recordable or not? So, if it's a minor injury, can we start with topical over-the-counters, escalate to oral over-the-counters, and then move on to prescription when it's appropriate for something mild? When it's not appropriate, then you just don't do it. You do medical management. And so, that may mean it's a recordable for that employer, and that's fine. You have to do what's medically appropriate for the patient, but look through the lens of recordability. You can't let that define how you're going to manage, though, when it's not medically appropriate. Yeah. And as far as boundaries, so it goes back to, you know, I'll write functionally what can the patient do that I think makes sense based on their exam and what they're telling me they can do at home and in their hobbies. And then from there, it's not my job to determine what the employer can accommodate. Now, if I've done a site visit, then maybe I have a good grasp of what the employer can accommodate. And so, I think those site visits and tours really can make a big difference because then you can make sure that your work restrictions align when possible and medically appropriate. Great question. Yes. Great question. Great question. So, he's asking if we have it in our template or as part of our triage process to ask the patient if anyone in their family or friend has ever been on disability. It's not in our template. It's something that I'm considering adding. I'm going to talk to our, we have workers' comp in-house for our healthcare system, so I'm going to talk to them about it. It is a question that I ask. And I've been able to identify a couple patients that actually ended up being at high risk for disability. One was a young guy, had a neck injury, head injury, really mild. In talking, he started talking about how his wife was on workers' comp disability. And I will tell you that that patient, nine months later, was still not off his work comp claim for a mild head injury. So, but I was able to identify the risk at the beginning. He was assigned a nurse case manager within 30 days, and then the nurse case manager then assumed every appointment with him as just an extra layer of support. Yeah. So, I think you gain a lot of respect from, you know, from workers' comp insurance carriers and adjusters when you're able to flag that in advance and you help them with maintaining that risk. Yes. I understand, like, the reason that you would want to ask those questions. Sure. Obviously, people want to use the system, you know, in a certain way. It can happen. But can people ask that question? Like, because I feel like that's crossing some sort of lethal line. Sure. So, you're not asking genetic-related questions about their family history. So, asking family history related to the family's chronic conditions and documenting that, or genetic history on a patient, yes, that would be crossing the line. Asking if someone's on disability, my understanding, not crossing the line. We are going to, like I was mentioning earlier, talk to our workers' comp adjusters to see if we can document that in the chart because it is a big portion of risk. So, I think it needs to be addressed. Yep. Yes, please. So, if you restrict somebody from work, let's say they work eight hours, but you're wanting to restrict them down to four. Yes. Great question. So, what she was suggesting is if you restrict someone's time, so if they work for an eight-hour shift and you restrict them down to four hours per shift, is that lost time? It's not lost days, according to OSHA, but it would be lost time on a paycheck, yes. So, the employer would not have to report it as a lost day. They would report it as a work restriction if it goes outside of the job code in which that employee was working inside. So, they could potentially have to report that, yeah, as an OSHA recordable, depending on what the job code looks like and how much flexibility is within that job code. Yes. I just wanted to make a comment. I love the conversation about disability, and there are some questionnaires out there. There's one called the Oro Grove Pain Disability Scale. It's a good predictor of future disability. So, what we're trying to do is we're trying to figure out who are the people who are at risk for disability and then try to intervene and keep them working, keep them employed, because that's really important. I've used that in my clinical practice a little bit. If I just get a sense that something's not right in the clinic, I can say, hey, you know, I want to hear some more about what's going on in your head. And if you're thinking I've got this form I'd like you to fill out with those, you know, the patient, come back, and then it's amazing the conversations that you can have when the patient tells you what's going on in your head. So, it's just another tool that you can use to help somebody manage their expectations and get better. So, it's a good tool out there. It's O-R-E-B-R-O. O-R-E-B-R-O. So, what Dr. Hunt was talking about is if you are working with a patient and you're feeling some resistance and then being able to kind of progress through that injury that you can do a risk assessment tool questionnaire that gives you something that's a bit more objective and you can monitor that questionnaire going forward. It helps to lead to more engaging conversation with the patient and try to help identify barriers. So, great feedback. Anything else? Yes, go here and then there. I think you brought up a great point about managing the expectations. If you're going to send someone to the ER, say, we're going to see you in 24 hours. You're going to follow up and kind of look at everything. How is that really skewed by the patient? Because I think sometimes what happens is they get five days off. You call them for their appointment. They're like, I'm not coming. I got five days from the doctor. So, I think it's a fine balance because you want to explain to them, maybe you can come back, but at the same time, they might say, well, you guys just don't want to put a lot of time on the last day. Sure, great feedback. So, great feedback. So, what she was saying is, how do you manage the patient expectations for a patient that you have to escalate care to the emergency department because you can't, whatever needs to be done in your clinic needs to be escalated. So, when you say, I need you to follow up here in 24 hours for recheck after you go to the emergency room, how do you manage the expectations of, the ED just wrote that person out of work for five days and they come back to you, and now you're not going to do that. Great, great point. So, the way that I manage that is, again, it's just setting the expectations of whose job is what. So, in workers' comp, when I send you to the emergency department, it is not like when your primary care sends you to the emergency department. Basically, what I'm doing is, I'm trying to fast track your care, figure out what's going on, make sure that you're safe, and I'm going to bring you back. The emergency department may give you a list of restrictions, medications, and whatnot. I am responsible when you return for looking through the lens of what you do for work and deciding if that is medically appropriate or not. That is not what the emergency department's role is. That's my role as the occupational medicine provider. So, again, it takes more time, but it's really if you just spend the time educating them and setting the expectation, documenting how you set the expectation, and then bring them back. Typically, that works, but you're always going to have those problem patients. Absolutely. Yes? So, I've gone from a full-time sports medicine practice down to the hospital once we do the off-bed. Okay. The question I have is, I can manage all fractures on my own. So, if I'm in the off-bed clinic, I don't need to refer to myself. Great point. I mean, it's almost like I'm self-referring, so there's got to be some ethical... Not at all. That's a great... So, his, which you have a great background, so his background is sports medicine, and now he does occupational medicine. Lucky you. That's awesome. So, in that scenario, then you continue to manage what's in your scope of practice, so based on what your history is. So, I've worked in various practices where my scope was to do injections, and then I came to the place where I'm at right now, and they don't do injections in their occupational medicine clinics yet. So, it's all about scope of practice in that particular setting, and then your history, of course. That's great. No, of course not. No. It's still... So, it depends on what you're doing. So, if it's a fracture, it becomes recordable, and then you're having to splint or use something rigid. So, a fracture does make it recordable, but yeah, you wouldn't have to escalate to refer if you can manage that in-house. Yep, absolutely. Good point. Yes. You talked about there's no stat diagnostics in the work compilation, typically. Typically. One to four weeks, et cetera. Sure. MRIs. We have in-house nurses at several of our sites that can get next-day MRIs, reduce... Lucky you. Sure. Sure. What she's saying is she's very lucky. She has nurses that will help with stat referrals for advanced imaging and things of that nature. So, we also have something similar, not nurses, but we have workers' comp referral coordinators that manage our workers' comp referrals that help to do stat kind of work. But when you don't have that, then we have to set the expectation that it can take one to four weeks. Because unless you have someone that is dedicated until they get a yes, it makes it really difficult to do anything stat. So, that's why I was saying you may have to move to the emergency room as your only stat option for them to evaluate and treat, but then they're coming back to you for the medical management. Yep. There's only upsides there, because you're able to move forward quickly in your care. That's great. You're very lucky. We are right at time. So, I'm going to go ahead and end, and then if you want to come up here, we can talk too. I have a few minutes. Thank you. Yes.

occupational medicine

patient expectations

communication resources

coding and billing

workers' comp

risk assessment tools

follow-up appointments

work restrictions

ethical considerations