Good morning. Welcome to Quaternary Care in Workplace Injuries, Empowering the Occupational and Environmental Medicine Provider with an Approach and Toolkit to Support Return to Work and Recovery. I'm Dr. David Corretto along with Dr. Rupali Das and Dr. Kurt Hegman and we are your speakers for today. I'm a medical director for Sutter Health in Sacramento, California, and all of us declare that we have no conflict of interest, nothing to disclose. Here are our learning objectives for today where we wish to define quaternary care for the injured workers within the workers' comp system, including the current state of access barriers. In our cases today, we want to explain a multidisciplinary approach to managing and treating injured workers with severe disease, including resources needed to support the recovery. Lastly, we hope to identify ways in which providers can collaborate with workers' compensation insurance carriers to successfully manage injured workers with extremely high risk of permanent disability and job loss. I'd like to first start with a case. This is a complex case that may be familiar to many of us in this room. It is a 48-year-old phlebotomist in inpatient services who sustains a slip, trip, and fall, leading to a sacral fracture. Shortly thereafter, this individual develops urge incontinence and lower left leg neuropathy. On imaging at three months, the sacral fracture has healed, but urge incontinence remains. Over the next three to six months, this person's lower left leg neuropathy worsens. We obtain an MRI of the lumbar spine, which shows a small L4, L5 disc protrusion indenting the fecal sac. This person's EMG nerve conduction study is normal, so we refer to PMNR. Neuropathy does not respond to epidural steroid injections. The worker continues to worsen. And in six to 12 months, they present and develop swelling, emphysema, vasomotor changes, diminished motor and sensory changes, leading to a diagnosis of CRPS. As far as the incontinence, increases of number of pads per day are needed. When consulting with the urologist, we're told, nothing to do. Wait until the fracture heals. We refer to other pain management in several of our regional academic medical centers. However, these referrals are declined. This individual's mental health declines. And at one point during this course of care, required hospitalization to address this person's mental health acute issue. So I'd like to know what you think. This is a complex case in occupational medicine. As we think about this case, what are some of the barriers to this person's diagnosis, management, and treatment? And also, what is needed to move forward? So having heard this case of a complex individual, CRPS, mental health, what are some of the barriers to continue with her care? We're kind of stuck right now. I don't think this is CRPS. My question is about EMG. How far did they go up? Did they go to petroleum, sphincters? Did they study that? Or just did the lower extremities? And that's a great, that is a barrier. So what is the quality of the study and the referral specialist that we refer to? Anything else? So did we order the appropriate tests at the right time? Did we expand the scope to other specialists? These are all great points that we're going to discuss today through some cases with our subject matter experts. And so as we talk about quaternary prevention, it's important to put this in the basis of a concept we're all familiar with, which is primary, secondary, and tertiary prevention. Primary prevention being interventions to reduce or eliminate causative risk factors. Secondary prevention, early identification through screening and treatment before the disease has presented. And tertiary prevention, after the disease has occurred, what can be done to prevent sequelae or to stop things from getting worse? And it's important to put this in a framework. So referring to this article from 1999 regarding the relational model where quaternary prevention was first introduced, what you're going to see here on the y-axis is illness defined as the patient's understanding of disease. What do they have? What are they bringing to the table? The doctor's side here on the x-axis is disease. What are we actually diagnosing? What is the framework or case definition that we're using to guide our management treatment? Of course, primary prevention is where both illness and disease is absent. Secondary prevention is where disease is present, but it yet quite hasn't manifested. So in the case on the previous slide, obesity prior to cardiovascular disease. Tertiary prevention, the disease has occurred, the illness is present. So what are we doing at that point to reduce comorbid conditions and symptoms affiliated with that disease? And with that, I'd like to introduce the concept of quaternary prevention from this 1999 article, which really states that the disease is absent, but the illness is still there. And this leads to the question of what do we do next? Well, Jamil, the Belgian family medicine doctor who introduced this concept, really posits three points. One is that quaternary prevention is to identify patients at risk for over-medicalization. Two, to prevent these patients from new medical progression, or in workers' compensation, we would think of this as acceleration of the disease. Three, to suggest interventions that are ethically acceptable. And that leads to this diagnosis, or pardon me, this definition here, that these are actions taken to protect individuals from medical interventions that are more likely to cause more harm and good. So what are we treating? And it's really linking this quaternary prevention piece to quaternary care. And in this, what we're trying to treat is to prevent disability. By reducing disability, we improve function with life's activities and work activities. This is the ethos in occupational medicine and when we engage in care for the injured worker. And this is rooted in a key concept that we all know well from day one of medical school, which is primam non nocere, first do no harm, from Hippocrates. And so this concept of quaternary prevention or quaternary care has taken root in specialties. Cardiology has a similar definition as you think about how it applies to the work we do in occupational medicine. In cardiology, it's thought of the rehabilitation and restoration of function applicable to those with severe cardiovascular dysfunction. In dermatology, the thought is this is a set of health activities needed to mitigate or avoid the consequences of unnecessary or excessive intervention of the health system. This supports the need for specialized clinics to address these issues. For occupational medicine, what we propose is that quaternary prevention is quaternary care. It's needed where tertiary prevention has failed to reduce disability and promote function. And so next, we're going to have two of our experts provide cases that illustrate some of these concepts for occupational medicine, as well as provide tools and support for being able to manage these cases in our clinics. Thank you. Thank you. Good morning. I'm Kurt Hagman. I'm the director of the Rocky Mountain Center for Occupational Environmental Health at Weaver State University and the University of Utah. And my supposition is we've, based on the title of this session today, have an unusually high proportion of crossword puzzle solvers and jigsaw puzzle solvers and other people who like murder mysteries and so forth. Because that's what this is about, is how to affect the best outcomes for all patients, including those who really do not resolve quickly. And that's the nexus of where this session came from. So the case that I chose out of a number of cases over recent time, so we have a roughneck oil worker. And in the western U.S., they travel a long distance. And this guy was traveling across state lines and into Wyoming and had a rollover motor vehicle accident, which could have been more serious than it was. It was a 15-minute loss of consciousness event, but he was wearing a seat belt. So we ended up without the fractures and the fatality that would oftentimes accompany these sorts of wrecks in the west. The individual, however, had cognitive problems. And the cognitive problems were quite significant, actually, in terms of memory loss, recall problems, there were headache problems, higher cortical function, executive function were all problematic for this individual. So of course, after primary care treatment, which was initial and brief emergency care, and there's not exactly breadth and depth of urgent care in Wyoming, that's another story, the state has more envelope than it has people by far. This person was referred to a university traumatic brain injury. And the traumatic brain injury clinic treated this individual for month after month. And they put some significant effort into this. And the person made some progress. And yet, after having cognitive treatments and cognitive behavioral therapy, continued to have incapacitating symptoms. And they were not back at work. The short answer, they were not back at work. And at 12 months, the person was discharged from the traumatic brain injury clinic. You know, we're done. And here we go. And this is a 35-year-old. So a young guy, rest of the life ahead of him. And family and so forth involved, a couple kids, of course. And luckily, thank God, capital G, the big guy, this person did have an excellent nurse case manager involved. And that was a key part of this. Because as you'll see, this person ultimately moves this case to occupational medicine. And if you're in a large system, unless you have really great staff somehow in front of you, you know that this person appears on your schedule suddenly. Mixed in with all of the simpler cases. Somebody else has had that happen. But what do you do? Well, these types of cases hopefully get scheduled at the end of your shift. And hopefully you have a wife, husband, spouse who is very forgiving as you're going to the hospital on a Tuesday or if it's morning shift, and you just simply take a history. And you go literally A to Z everything. Those of you who have done this know what I'm talking about. Those of you not, that is the only solution I've found in my whatever 30-odd years of occupational medicine clinical practice. Because by the time you're into these cases, 12 months, you've indefinitely got a long duration of psychological overlay and factors and worries, appropriate worries. I mean, give me a break. Wouldn't you be worried about how you're going to take care of your family and everything? I mean, you should be worried. And so you cannot possibly get into the what to do about it until you get that part of the box decompressed. And so that's the next step. And indeed, this one took about I think an hour and a half hour and 45 minutes of initial history to get through. And I have found that those are best, again, at the end of the shift kind of situations where you can turn the clock off. The other thing is I have, if they appear on your schedule, the other solution is you say, well, you do what you can. Spend the 30 minutes or whatever and borrow from somebody else's time. And then you say, I've got to see you next week. And you start blocking time at the appropriate time so that you can take that time and they know you're listening to them. Because it's the only way to gain the trust that you actually know all of these issues so that you can actually construct the treatment plan to address these quaternary care issues. Why do we call it quaternary care? Because they failed tertiary care. What else are you going to call it? And the tertiary guys don't like to hear that. But they might as well hear it because it is a failure on their part. And it's not to point fingers and say you failed. It's to say we've got to correct the system, right? So 35 years of age, desires to return to work, still has cognitive difficulties and you start figuring out what you're going to do with these. Well, in this particular case, we looked at cognitive deficits, which we could address, and started literally at the end of that first full complete history assigning this individual reading of books, you know, because there was no longer term capacity to read. So where do you start? Well, that's where you start, those assignments. And numbers issues and calculations and simple stuff. I assigned him Sudoku. I assigned him crossword puzzles, things that were literally addressing his deficits. Now the other thing that we do with these sorts of cases is always try to identify measurable things that you can track because my experience with these cases invariably, someplace along the trajectory, something happens and they get into the rut of I'm not getting better. You know, I expected to be better by now. They didn't listen to me the first time, but that's okay. And at that time, you can say, no, wait a minute. You know, you told me when you first came in, you couldn't see, couldn't read, excuse me, for 15 minutes. And we had up to 45 minutes to an hour of reading. I mean, you clearly were making progress. And you were remembering the text as you carried the story forward that you were And so I do think that that is a really a key aspect is grabbing measurable things you can track each appointment. Related to that is you want to also keep those things in the front of the note so you don't forget it, especially if you've got residents or somebody else you're training because they typically do soap notes oftentimes are not the way to do these things. If you've got enough things going wrong, you need problems. Your problems are the way you do these notes. You know, problem number one is memory. Number two is, it could be pain. Headaches. Three is numerical deficits and so forth. And you track things, each clinic appointment that way. So this person, 10 months later, you've already probably read this on the slide, but 22 months into recovery, they returned to work. We got this person with the nurse case manager who was really good. And she's also a good part of this because she's pulling on the rope in the same direction. All right, this is a really top-notch nurse case manager. I tried to get her here, but she just doesn't like public speaking. So I couldn't get her here. So sorry about that. I'll have to do my best imitation. But she would be pulling on the rope at the same time and talking to the person offline to also help keeping bird-dogging this situation going forward. So she also helped to get the part-time job lined up in something he was interested in, which ended up being a professional painter. So he's no longer gonna be a roughneck, but he's gonna be a painter. And then a few weeks after that, we had him back to full-time work. Was he 100%? No. But this guy's now happy. He's able to produce and fulfill his view of his functions in life, which is to provide for his family. I didn't mention he's Hispanic Latino. So he's got a pretty heavy, my family is my function here. Now, a related thing that I always try to keep in mind in these cases is recovery times, because we all know this. We've been in practice for a long time. These things are not nice bell-shaped curve things. We've got long tails with the more severe cases for various reasons. And whatever data you use, I mean, you can use the MD guidelines, which are data-driven, claims-driven. It's a good idea to know what those sorts of numbers are. To get people back to work, back to recovery. But the other related concept is to intervene before people go off the rails. I think that's one of our failure points is we see too much of where the intervention is. Well, it says 12 months, so therefore at 12 months, we'll start looking at the case and oh, gee, you're off the rails. Let's get an IME and call an end and wash our hands of this situation, okay? Instead of, well, wait a minute, you were off the rails already in six weeks, and we should have been making adjustments at this point in time. This is, of course, now a primary, secondary to tertiary issue. Quaternary, you get these kinds of complex cases. Of course, we're on a totally different timeline and we're largely without data, right? But we still have data of what are expectations. And we know that one to two years for recovery for TBI is within bounds. They're not uncommon cases. And so, excuse me, thus that is something that we both use with the patient for education, but we also use for ourselves to try to help guide and gear the recovery process to keep the person back on track. So key issues driving the success of this case would include, in my opinion, I think number one is you always have to look at this amount of time that just simply is required. There's no substitute for it. Because again, to get to the issues that are the physical incapacities, the mental incapacities and so forth, invariably, the mental psychological burden overlay issues are reigning supreme and they just are in front of people. And I think many patients cannot put those aside to zero in on the physical and mental incapacities first, followed by the other. So in my opinion, that's number one. And related then is those are the ways from which we can coach the patient. I do think having a skillful nurse case manager is very helpful. Bird-dogging appointments, getting them on track because there's so often these patients, well, they told me I can't be seen until three months from now and da-da-da, and all this kind of gobbledygook, which we have to work through and the computers have not made this problem better. They've made it much worse, we all know that. But the nurse case manager, skillful one, can really help to game the system. I realize though that this is somewhat a luck of the draw, right? If you get a not so good nurse case manager and you have a relationship with the insurer or whoever's the payer, then of course, trying to get somebody changed on the case might be another strategy. Targeting, measuring, and tracking specific deficits I think is really a critical part of this. It's important because it communicates to the patient, this is what we're tracking to get better. This is what our homework assignment is from each appointment. I call them homework assignments. Including if it's physical, not just mental. I think that that also helps us to really circle back when we either mentally start talking to ourselves about, gee, I'm not getting better and it's not going as fast, and as well as keeping us on the timeline. Clearly lack of litigation was a significant positive factor in this case. We will talk about that in a little bit more detail. Fear avoidant beliefs or kinesiophobia is a problem. It's a problem with physical pain and it's usually a problem with TBI cases as well. And the parallel in TBI you've probably heard about is brain rest. Well, there's no evidence anybody should have brain rest. It makes absolutely no sense. The brain is somehow different than every muscle in the body and the bone and the joint and the blood and the heart and everything else. It is true, though, we don't put them back in the football game to get another concussion. But other than that, the idea of brain rest really does not make sense and the guidance is actually against it and other guidelines are coming out in that direction as well. And patient motivation, you know, and that's something we can help to strengthen and support. Another thing is pushing back against premature case closure. Anybody in practice has had to do that. But this is one of those cases where they really try to close these cases down prematurely many times and it's appropriate, as you've seen in this case, to say no, not yet. And the other thing about that, though, is remember that if you can show progressive functional gain, you have an extremely strong basis to say this is not an MMI. And you've got data to stand on and there's nothing better than data to make your arguments. And I think that's something I've seen that we don't, I'm talking about all of healthcare, we don't do that enough. And next, Rupa. Thank you. Please. To me, like, you assume the care of a TBI tertiary care, but why, because this patient was not at MMI, I'm not criticizing your management, but obviously you did good as a TBI-leading physician. You were not, actually, the last one. You were assuming tertiary care with this patient. Yeah, well, that's, yeah, so we can get in a philosophical debate about which is tertiary and which is quaternary. I'm just simply defining quaternary as failure of tertiary care, that's it. So we can have more debate about this, we'll get on to Rupa, and you can call it what you want. That's all right. Thank you, and we'll have time for questions for all of us at the end, so please write them down and hold your questions. Thank you, Kurt, for a really nice description of how to use quaternary prevention methods. My name is Rupali Das, I currently work as a medical director at Zenith Insurance. It's a workers' compensation insurance company. We have presence in multiple states. I'm also a clinical professor of occupational, environmental, and climate medicine at UC San Francisco. So my intent is to provide a case example, much in the same way Drs. Correto and Hegman did, to illustrate some quaternary prevention barriers and to describe how we can work together as clinicians with workers' comp insurance companies to provide the best outcomes. Our case is a cattle feeder. He's 49 years old. He was working alone and was found on the ground, concrete, unconscious, under a large haystack, very much like this photo here, that had fallen on top of him weighing approximately one ton. It was unknown how long he had been lying there, but he was alive. He had multiple traumatic injuries, and as you might expect, he was airlifted to a local trauma hospital. His injuries are summarized here. He had multiple skull fractures, subdural, and other hematomas in the central nervous system, multiple severe facial fractures, pelvic fracture, femur fractures, and a left rib fracture. He did receive really good care. I would say primary prevention in this case was making sure that haystack was stacked appropriately, and that didn't happen, but he got excellent primary care and probably secondary care. He was hospitalized for one month, had multiple surgeries to the face and the pelvis. His CNS bleed did recede, and following that one month of hospitalization, he was then transferred to a rehab facility for another month. He did very well and then continued to go on to a specialist neuro rehab facility for an additional two and a half months. He did become litigated at three months after the injury, but he continued his progress. So we, Dr. Hagman mentioned that his patient wasn't litigated, and that was a factor in his recovery. Here, he was litigated, and at this point, it wasn't a factor in his recovery. He was discharged about seven months after the injury, and, or about six months after the injury, and where he lived with his wife and four adult children, and continued his treatment. We didn't close the case. We didn't discontinue treatment. He continued day treatment and not inpatient treatment five days a week for about five months. He returned to work amazingly at about four to six months after this extremely traumatic injury. It was a worksite evaluation. He didn't return to work. With the neuro rehab folks, we tried a return to work trial, and he actually did start working three days a week, six months post-injury, where this could have been a complete disaster. He had a remarkable recovery. Unfortunately, he didn't stay at work. Suddenly, at six months, he started to refuse all modified work and the volunteer activities that we had him going to. We meaning the insurance company working with the neuro rehab and his primary treating physician, because it was really a team-based effort. His work refusal coincided with a change of attorney. Remember, he was litigated. This attorney was known to get very large settlements and be very aggressive, including aggressive to his treating physicians. And his new attorney insisted that he was 100% disabled and unable to be alone at home because it was unsafe and unable to work. In fact, she wanted him transferred to another neuro rehab facility very far from his home. Today, he's seven years post-injury. These are his diagnoses. He continues to have low back and hip pain, which are treated with injections, PT, and home exercise. Because of his facial trauma and head trauma, he never regained his sense of smell. And that was part of the issue of him being alone at home. The concern was maybe he wouldn't smell a gas leak. He has some anxiety issues. He has a high BMI. He has obstructive sleep apnea, probably central apnea. And he remains off work despite that initial successful work trial and multiple treaters declaring him MMI over the last seven years. So what went right? A few things did go right. He received the necessary, I would say initially was quaternary care because it was complex care that was aimed at preventing disability and aimed at return to work. He did return to work initially. About six months after the catastrophic injury, not full-time work, but he did go to some kind of a job. He actually passed a driving test eight months after the injury, which is remarkable given his severity of his injury. And he was declared MMI at 15 months. Another success is that the family as well as he individually and together participated in counseling and seemed to do very well with that. So what went wrong? So quaternary, I guess we failed quaternary prevention in some way. So how did we fail? This worker lost the ability to ever return to work. He's never going back to work at this point. He hasn't been working for over six years. And we know that after three months, if someone doesn't return to work, their ability to return to work at one year is severely diminished. He is influenced by an attorney who's not interested in return to work or medical outcomes. We work with attorneys. I don't have anything against attorneys, but not all attorneys, I think, from a medical perspective have the best interests of the worker at heart, meaning their health outcomes and return to work as we believe in occupational medicine, that's the best treatment. There is a third party lawsuit against the subcontractor who stacked the haystack. And that may be a huge motivation because third party lawsuits result in millions of dollars settlement, unlike workers' compensation, which is in the hundreds of thousands, typically. So let's talk about some of the risk factors for disability and failure to return to work that we see in the literature. Comorbid conditions are one barrier. So hypertension, depression, smoking, diabetes are some of these comorbidities, as well as psychosocial issues, adverse childhood events. Low social support at work. So an employer who's not supportive is less likely to have a worker return to work because the worker doesn't have the motivation to return to that work site. Inadequate skills for competitive employment at a different employer is another disincentive for someone to return to work and a risk factor for prolonged disability. Living in an economically poor area is another factor that's been found to be associated with disability and failure to return to work. As you probably all know, being in the workers' compensation system carries with it a higher risk of increased disability and failure to return to work compared to if you were injured and you got care through another insurance system. Finally, litigation separate from workers' compensation, Dr. Hagman mentioned, is a risk factor for failure to return to work, although in this case we saw that initially it was litigated and continued to make progress, but in general litigation is a risk factor. There are actually not many papers that look at the impacts of litigation and interventions and recovery, but there is one paper that I found in the psychological journal done by Nielsen and colleagues who did a randomized controlled trial looking at the impacts of a clinician intervention and various other modalities in returning workers to work. This is a sub-study of that initial randomized controlled trial that looked at workers who volunteered, they had to volunteer to do this, and take an online free validated pain management course, and they measured several psychological outcomes initially at eight weeks and three months. There were 400 patients, the vast majority were non-litigated, and some had ongoing litigation or some had been litigated in the past, and they were analyzed by ANOVA. Overall, the outcomes were worse in litigated patients. Everyone did improve by taking this online pain management course, but litigated patients regardless of whether they were in the workers' comp system or a personal attorney not in the workers' comp system had higher scores of depression at the end of the study, and less symptom improvement, lower rates of reduction in opioid use, although they did all reduce opioid use a little bit, and they failed to complete the course at a higher rate than workers who were not litigated. The study has some limitations, it was small, you had to volunteer for the study, and there were self-reports, but overall this shows not only that litigation is a risk factor for recovery, but that interventions can improve outcomes, psychological outcomes, and should still be tried whether a worker is litigated or not. Here are some suggestions to improve outcomes, some quaternary prevention outcomes, specifically when it comes to litigation, meaning how can we prevent litigation? I think there's a role for litigation in terms of attorneys are worker advocates, and they can work to get workers the benefits that maybe they sometimes don't get without attorney representation, but often they act as barriers to recovery as they did in this case. I think all of us together have a role to play in preventing litigation. Physicians, some of the things that Dr. Hageman talked about, setting expectations early, taking a really good history, really assessing the severity of the injury, making the proper diagnosis, and assessing the actual timeline to recovery, and educating the worker about this and the family is beneficial. Communicating, I think physicians should take the time, in addition to taking the time for an hour and a half history at the end of the day, to take the time to communicate with carriers and payers when it comes to red flags. If you notice something's not right, or you sense that there are some barriers to recovery, notifying the carrier, for us, we have several physicians on staff, we can intervene with the treater or the patient. I would urge you to look at workers' comp carriers as your partners and not as your enemies, although it does depend on the carrier. Give legal strategies and solutions to others. In other words, when I see a physician recommending that a worker get litigated, it makes me anxious, because I don't think that's the right advice for a physician to give a patient. As you can see, it's not always in the patient's best interest. Employers have a role to be advocates for their employees and to show that they care, because a non-caring employer will have a lower success rate of having workers return to work. Workers' comp carriers also have a responsibility in terms of approving appropriate treatment, not closing cases early, and contacting the worker frequently and helping them move along to recovery. I would say in this case, we did not say no to any treatment that was requested. Every treatment that was requested was approved, because it was appropriate, and it was such a severe injury, needed a lot of treatments. Sometimes workers' comp carriers could be barriers to recovery, because they may not approve appropriate treatments. In this case, we were not barriers. These are some questions I think we can discuss. I'm going to turn it over to Dr. Correto in a minute. When there's a discrepancy between the anticipated recovery and there's failure to return to work, what can we do? In this case, we thought we were safe, and the worker was returning to work, and all of a sudden, something went wrong. What could we have done differently? All of us. In patients who are litigated or have financial or secondary gain, is there something physicians could do to promote their success? Finally, is there a role that other worker advocates like unions could play in promoting worker recovery? These are discussion questions that I'll leave open, but I'll turn it back to you, Dr. Correto. Thank you, Dr. Doss. As we conclude here, the purpose of this talk is really to promote the role of the PTP role. Acknowledging that this is a very hard role at times, and it can take a lot of time. It's important to build that system of care with all those resources that are around you, and to offload that, like Dr. Hageman said, perhaps with assistance of a nurse case manager, to help build and coordinate that system of care. These are the things that we did in this case that I first presented. We worked with the adjuster, the carrier director, and a nurse case manager to increase access. I undertook several peer-to-peer calls with specialist physicians, still involving them at the tertiary care level, but again, retaining my role as a PTP in the overall management and orchestration of the care. Along with this, in conjunction with our excellent nurse case manager, we were able to get this individual accepted by an academic medical center who confirmed the CRP diagnosis based on Budapest criteria, performed diagnostic nerve blocks as well. Speaking to a point that was from both of our speakers, was the role of trust and rapport building with your patient. Oftentimes, when these patients come to our clinic, you're the last line of defense, and time needs to be spent to kind of unpackage some of the fears that they may be bringing to the clinic. It's very important. One of this was around our discussion of mirror therapy for physical therapy. When I first brought this to the clinic, she kind of looked at me askew, like, really, doc? You want me to look at a mirror and do movements? But it really worked. We saw a turning point maybe about five to six weeks into this mirroring therapy, and it really helped with that buy-in and further supported our trust and rapport relationship. Engage with EAP and psychology and perhaps psychiatry early if you identify that that's an issue. In this case, we had her accepted by a second neurologist who provided Botox injections, curing her urge incontinence, and eventually, after 18 months, was able to return her to full duty and released from care. What made this case really fun is on the last visit, she showed up with her cowboy boots, and she said, look, doc, I haven't worn my cowboy boots in 18 months. These are the outcomes that matter to patients, and therefore, I believe they should matter to us as well. In conclusion, these cases are fun. They are unique problems. This is what you are trained to do. Embrace the coach of being, embrace the role of being a coach and an educator to the injured worker and a fair arbiter within the workers' compensation system. Understand that we have to remain objective to the needs of all the stakeholders that help deliver this care. And in doing so, work to build a system of care around the patient through communication with all the stakeholders. It takes time to do it well, but trust me, in my experience, it has been so worth it. And this promotes the injured worker's recovery and less time in the claim system. So I want to thank you for your attention. We have time for ample discussion and questions. So if you have a question, just feel free to raise your hand. Hi, everybody. My name is Linda Forrest from the University of Illinois Chicago. Nice to see you all and great presentations. This is a very idealistic presentation of what can happen when workers' compensation works. And I share your sympathies with working with the system. I know also that working as a company doc, that there's a fair amount of cost shifting in both directions. Shifting workers' compensation cases onto general health insurance or onto individual workers. And also in the other direction, when there's a bad injury that happens that somebody falls in the parking lot, for example, shifting it out to workers' comp because it's a lot cheaper than the lawsuit that would come out of a fall in the parking lot. And so we're living in this complicated system. Workers' comp is supposed to be a no-fault insurance system, but it's litigated, it's contentious, you know, it goes to third-party attorneys, and it's really hard to figure out what the best way is that would serve both the worker and the company and the insurance company. So I wonder what you guys think of that. Okay, thank you, Dr. Forrest. Yes, I would agree with a lot of your observations that it's a no-fault system theoretically, but it's highly contentious and litigated. This presentation is quaternary care, quaternary prevention. I'm going to try to bring it back to that. I think as physicians, I'm not sure about a company doc if you mean the occupational medicine physicians who treat workers' compensation cases. Yes, we probably have some divided loyalties in that we have the patient as client, got to keep the insurance company still, you know, satisfied in some way, and also do justice to the employer. I think this presentation really, the steps that were outlined by Dr. Hageman and some a little bit by myself, I think if we followed those steps, we would be serving all those players. To try to sort out some of the issues you talked about, the cost shifting and whether something gets transferred to one system or another, I think that I'm not sure how you deal with that as a physician. I think as a physician, in this case, we have to focus on the patient and how can we treat the patient most effectively. If that cost shifting is getting in the way, then I think a conversation with the carrier is warranted. As individual physicians, I think it's very difficult to solve that system-wide issue, but I think we really need to focus on the patient and getting them the best care. But sometimes that, I would agree with you, the cost shifting is hard to completely ignore. For example, I see a lot of people with diabetes, and it impedes their recovery. So at what point is the insurer, should they pay for the diabetes treatment? At what point should they stop paying for the diabetes treatment because it's a personal condition? It does tie into court and early prevention. Those aren't simple answers that in every case has to be dealt with individually. I would say that as a workers carrier, we do pay for diabetes treatment when it is clearly impeding recovery, but at some point then that cost does shift to the other side. But I would agree that it's a difficult system to navigate. But I think as physicians, I think you're looking at it from a higher level, maybe a little more trying to solve the system, but I would say most of you are probably treating physicians. You have to look at what's in the best interest of the patient in front of you. I'd like to add there's an excellent article that ACOM published in 2018 by Dr. Hegman and Dr. Matthew Thies, among others, regarding patient satisfaction and occupational medicine practice. And the key, one of the very instrumental for my own practice and approach, there's really two main themes in this article. I think one is a discussion around loyalty bind. So as occupational medicine physicians, where is our loyalty? Is it to the guidelines? Is it to the patient? Is it to the employer? And gives some helpful structure for all of us as individuals to figure out where we land on that continuum. In part, it also discusses a small discussion between the loyalty bind of a primary care physician and having been a primary care physician in a prior life, I can speak to that, how our loyalties sometimes are different in occupational medicine compared to, in my opinion, primary care where at least we were trained to be the consummate patient advocate. So I think to build on that, I would say knowing it's about what we can affect. What is our role in this? And I think understanding and honing our understanding of a causation analysis is key. And causation analysis can be very tough but also very useful in these conversations that we may have with carriers and employers. Really explain the why of why you feel something is work-related versus not work-related. And in my experience, that has gone very well to helping my patients when I feel that these cost-shifting slippage is contributing to the case. The only thing I would add is I am probably largely in the primary care side of this, not advocacy, but insofar as the primary goal is the recovery of the workers. So that's what I always focus on. The two states I'm familiar with, Wisconsin and Utah, both have systems where you get a grace period of a couple appointments anyway. So all the simple stuff you can, even if it's not work-related, you just tell them on the first appointment, they'll probably get denied, but let's just get you recovered. And that's much preferable in my view than routing them into primary care because for many of these types of injuries, primary care may or may not handle it appropriately with evidence-based care. So we can get better outcomes and everybody's happy with the results. Well, people can usually get a hold of me, but for, I would say in those situations probably there isn't, maybe those carriers don't have a medical director or at least not someone you've established a relationship with. There's always a claims adjuster though, if there's a workers' comp case. So that should be the point of contact. I would go to the medical director if you know the medical director. That's what I encourage the physicians in practice to do. They have my number. I'm happy if they contact me. But a lot of times for simple issues, a claims person is the best. If there is a medical director, you would absolutely go to the medical director. To add to that, you could also reach out to the employer. The employer has choice in this. They're the purchaser of the workers' comp care as payers. So that has another been a successful avenue. I think there was a hand up here. So on one of your presentations, you talked about meeting psychological goals a lot more. I personally have done probably close to eight years of education of our claims on the benefits of looking at psychosocial issues and the benefits of providing short-term cognitive behavioral therapy. It doesn't make it a psych case. What's their concern is that this will become, the psychological issues will become another body part, as they like to call it, and result in long-term requirements for treatment. So I think the, it's not really your question is how can you get it, but I think it's education of claims that needs to be done to let them know that this actually helps the worker recover, helps them get back to work, and psychosocial issues are impeding the recovery. As an individual physician, you know, you could try to write that. Perhaps Dr. Hageman has some suggestions for how you can use the guidelines to do that, but documentation and referring to the guidelines is one way that I would recommend justifying treatment. Yeah, I agree with Rupa a couple things. One is for complex things, I think email and letters do not work very well, and her advice of contacting the medical director is very important because you want to have that discussion. You'll also spend a lot less time than you will writing your complex letter. That's after, of course, 30 years of learning not to do that. But the other thing regarding what Rupa said I think is really important. Know the guidelines. I mean, we've reviewed the common things, PTSD, depressive disorders, anxiety disorders. I mean, we've got the evidence. And one of the reasons they are reluctant to pay for mental health is because a lot of what is prescribed in mental health is not evidence-based. Yes, I said that. They prescribe group therapy, they describe individual counseling, and all this sort of stuff, and the randomized trials on that stuff are negative. It doesn't work. It's positive on things like cognitive behavioral therapy. It's positive on exercise for depressive and all three of those disorders. So if you end up relying on the guidance, as Rupa is suggesting, you end up with better results. So that makes your case because then you're talking about a time-limited issue, not an indefinite issue. This group therapy, you know, giving placebo treatment, yeah, that will last a long time. So I think you can get around that. And it's also by disorder, because remember, if you get, like, TBI and that sort of thing, most people are going to pay for, obviously, the mental health-related issues, typically, as opposed to back pain. One of the issues, by the way, in these guidelines, it does support the DTN actual treatment for those TBIs. And what I usually tell my practitioners when I find one, which is my next question, is to bill it under the concussions or TBI code, or that's what I'm talking about, so I'm sorry about that. And part of the guidance. But anyway. And, you know, I find that if you keep it to that and keep it to the treatment of the TBI, the carriers who are in my state, I actually have both state-funded and non-state-funded, you know, you can a lot of times get it approved at least for a given period. But my problem is that when you live in an area that does not have ready access to teach people or support to actually treat the TBI, what do you do? I mean, you know, I don't have anybody close. The closest place I have is two and a half hours away. And even then, it's probably not as great as I would like. So how do you deal with those kinds of visits? The actual support mechanism, is it really going to help? Yeah, so that's a, you know, common problem. Thanks for raising it, the shortage of, say, mental health providers in a certain area. Well, thanks to COVID, we are all using telehealth. And that is an avenue that's worth exploring. You'd have to work with a provider group or a group of, that manages other psychologists, for example, that are available by telehealth. But that's, especially for the providing psychological assistance, mental health assistance, I think telehealth makes a lot of sense. So that's a strategy when there's a shortage of providers. If I can pile on the, we do have the RCTs on distance-based cognitive behavioral therapy versus face-to-face and there's comparable efficacy. Okay, so I was surprised when that happened. But there you go, my prior concepts went right out the window based on science. Regarding what to do about other elements of distance-based issues, I think we, that's part of this quaternary care, right? We have to figure out, or tertiary, we have to figure out how to put together the best program we can. You may want to think about, you know, one-time visits with somebody that's the two and a half hours away. By the way, that's nothing to drive in the western U.S., but anyway. And I'm just trying to ground people in reality. And that's the rural areas in the United States. So, yeah, that's one comment I would make to people is, look, if you want to get better for your life, drive the two and a half hours. Get your program and then bring it local. Let's get you some homework assignments. And that's what I would do is piece it together. We have time for one more question. I don't have a question, I just have a comment. I wanted to thank you for putting a plug in for nurse case managers. And as providers, it might be of interest to the patient if you request a nurse case manager on files that you know are going to be complicated. We work for a large food distributor. We have several locations across the country. Less than 20 with nurses on site. Thank you. Thank you. That was an excellent comment. So we are at time. Our speakers will stick around for additional questions. Thank you for your attention, participation.

workplace injuries

workers' comp system

quaternary care

multidisciplinary approaches

barriers to recovery

litigations

comorbid conditions

psychosocial issues

system of care

telehealth