Welcome to Module 2. We will be discussing Return to Work, and my name is Wendy Paraka. I have no disclosures or conflicts of interest for this presentation. The objectives for this session are to identify the role of the health care provider, list the benefits to the employee in a graduated return to work, discuss the implications of FMLA, the Family Medical Leave Act, discuss the psychosocial impact for the injured or ill worker, and how that impacts return to work. Your role initially is to take a thorough work history. It's a great place to start, make everybody feel comfortable, but it's extremely important because you want to know the story of work in their lives. How many jobs have they had? How long have they been at this current position? How does their job fit into the organization? What's the hierarchy? What's the structure? And where are they? Are they a supervisor? Are they an assembly line worker? What is their job, and what is their education or training? Sometimes you'll hear that they don't feel they had really been trained for their job. It's not for you to make those kind of judgments, but to understand where that person is at in relationship to their work. Work provides insight into one's self, so do be sure to do a deeper dive into the work on that very first visit. What do they like about their work, and what motivates them besides money? How well did they function at work? Were they satisfied with their job? Were there any conflicts with either other employees or management? These are all important questions to ask on that initial interview. A provider's main role is to make an accurate diagnosis. That's first and foremost. Then you have to determine this person's work capacity. Can they return to their normal job duties? Will they be on modified duty? Do they even need to be off work for a period of time? There also has to be adequate control of their pain, and that needs to be done outside of opioid use. And what are the rehabilitation goals? Sometimes those goals are impacted by delays in the assessment and the care, often while waiting for authorizations through workers' comp. Since I mentioned workers' comp, let's go ahead and talk about the injured worker. You need to take very specific details regarding this injury or illness. You need to understand and be able to document the day it occurred, preferably even the time, what was going on, what was the situation. Were they handling certain devices or pieces of equipment? Were they driving? Were they lifting? All of those details are very important to document. Then you need to know what is their ability to meet their work demands. So as you're going through the fiscal and you're interacting with this person, that's something to always keep in the back of your mind, is are they going to be able to resume this job and meet those work demands? It's good to ask them what they see as their limitations to get an understanding on their concerns. You'll be surprised. Sometimes people want to go immediately back to work, even though it might not be appropriate for them to do so. And then you do have those workers that are very concerned about returning to work. Are they going to need modification of their job? Oftentimes they do, and every state has different forms that need to be completed. They typically have you being extremely specific about what this worker can or cannot do. Can they lift? Can they bend? Can they squat? Can they do overhead work? All of that needs to be delineated, even down to the frequency and the pounds that that person should be able to lift or carry. You also have to develop a treatment plan, and that's something, again, you're working through as you're seeing this person. What kind of resources may you need to call in to help this worker regain full capacity to work? It might be a specialist. It might be physical therapy or occupational therapy. But those thoughts you should already be laying down in your treatment plan, that if they've not improved by this time, we're going to do this. Do they need to be off work, unable to meet any modified duty? That's a pretty rare situation, but one that when people first start doing workers' comp, they often go down the line of, well, this person has this injury, and they can't possibly return to work and do the job that they were doing. But it's not for you to say that they can't do a job at work. It's up to the employer. So you make out those duty modifications and develop that treatment plan. Then it's up to the employer to say they can accommodate that or not. Some workers, they may put them in the office to answer the phone, if that's an appropriate job for them to do based on what you have said on the duty modifications. If they can't meet it, they can't accommodate it, then they often will send them home. But it's not you that makes that decision, unless it's really an injury of such seriousness that you really don't want them there doing any work whatsoever. Another area to be cognizant of are the psychosocial factors. You need to understand the patient's capacity for teamwork. Are they a loner? Do they work well with others? Do they have a support system at work? Are they flexible and able to adapt to changing demands? And do they see themselves as dependable? Do they show up on time? Do they complete the jobs and the tasks that their employers expect of them? During the physical exam, it's good to keep a feeler out for emotional regulation. Are they anxious? Are they depressed? Are you picking up feelings of hostility or anger? Have there been outbursts, and those may even have occurred at work? And then a sense if there's any substance use disorders going on. Is this person depressed, and they're using alcohol consumption to treat that depression? One area that you may not think so much about is cognition. And typically, I see that more in the traumatic brain injuries, the TBIs, but always something to also be assessing for. Next, we're going to do a case study, and this is actually a patient from my practice. This is Gay, who is a 55-year-old female that has been a patient in your primary care practice for several years. Today, she arrives, and she's anxious and tearful, stating she has a new supervisor at work who repeatedly criticizes her work. Her prior manager was supportive and praised her work. She has not been to work in over a week, and she's experiencing difficulty with sleep and is now fearful to return to work, believing that she will be fired. She has worked for this company for 12 years. So what are your options for this particular person? Can you tell her to go back and talk to her supervisor or go to Human Resources and file for workers' comp? This is all occurring at work, so that might be a logical solution for this. However, workers' comp is not going to typically cover this. They probably will deny it. So what's the next option that she might have? I recommended to Gay that she go to Human Resources and file for a Family Medical Leave Act, an FMLA. So what does this mean? The FMLA provides eligible employees up to 12 work weeks of unpaid leave a year. It does require group health benefits to be maintained during the leave as if they had continued to work. Employees are also entitled to return to their SANE, or an equivalent job at the end of the FMLA leave. The FMLA leave also provides certain military family leave entitlements for deployments or serious injury of a loved one. The criteria for FMLA, there's really a variety of reasons, including when the employee is unable to work because of their own serious condition. It even includes, do they need to provide care to a spouse, a child, or a parent who has a serious health injury? So you can apply for FMLA even in that situation. Who manages it? The U.S. Department of Labor are the ones that oversee this act. However, they do not make any determinations, but they will offer assistance with the process. It's really the Human Resources or VA. However, there is a suggested form that's on the FMLA website. It's also the patient and you as the health care provider that help manage this. And as the provider, you always do want to remember that HIPAA does still apply. So you want to be very careful about giving information to the employer. And you need to make sure that you provide the information to the employer. Now, for my particular patient, Gay, she did go on FMLA. And it actually worked very well for her when she got her anxiety under control, which did take several weeks to accomplish that. She did go back to work. She was able to go back to work. 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She was able to go back to work. She was able to go back to work with that treatment plan, that accommodations are being made at their work site so that there is no re-entry. Expected clinical improvements have stalled and then you have to figure out why. Is something not being done correctly for this particular patient? Do you need to go to other resources or are they malingering? Comorbidities, people come in with sometimes a long list of comorbidities and medications that they may be taking. Injuries at work or injuries that are preventing them from working can aggravate comorbid conditions. Really, really important for the success of returning to work that these comorbidities stay stable and you may be referring back to the primary or working with the primary so that these comorbidities don't impede this worker's ability to return to work. This is another case study, again, from one of my patients. This is John, who is 45-year-old Hispanic male who tripped at work, fell backwards and sustained a right shoulder and low back injury. At his initial visit, he was prescribed a muscle relaxer, an anti-inflammatory and placed on modified work duty with a weight restriction of 10 pounds. At his subsequent visit, he is not showing any improvement, has not been contacted by the workers' comp case manager and his pain persists at eight out of 10. His employer has been able to accommodate the work restrictions but with no significant improvement, physical therapy is ordered with a follow-up visit in two weeks. His work restrictions remain in place. John returns two weeks later and expresses frustration that he has not heard from the case manager, has not been contacted by physical therapy and the pain continues to limit the use of his right arm. He rates his low back pain at a seven out of 10. It is interfering with his sleep and his home life. He is not taking any of the medications stating they don't work. Some back information regarding the case manager and some information regarding this particular case, John speaks very little English and he always arrives with one of his children to translate. I also use Google translator so that I'm sure we are all on the same page. His job requires him to be using his right arm a lot. His employer had him mostly doing mopping and that sort of thing, which actually was aggravating the arm and the low back. So some adjustments to his work duties were made, contacted his employer, switched up his medications to get some better pain relief. But what would your next steps be? Those are some of the things that I did, but getting a hold of the workers' comp case manager was a priority. You always have that thought in your mind when they're not improving. Are they malingering? And it's a justified question. I did not get the sense from him that he was malingering. He really wanted to get back to work and was frustrated that he could not do his normal job. I did tell him to ice, which he wasn't doing, to use lidocaine patches on his low back, which he wasn't doing. And again, by changing his work accommodations, he was able to get some relief from the right arm pain. The part of this that also made it difficult was because of his pain level. I could not do a true graduated plan of return to work. Did he need a referral to an orthopedist or a physiatrist? Here, initially, we really just needed workers' comp to get on board and to get his physical therapy ordered. They did by pushing from my office and from the employer, both of us calling and hitting workers' comp. And unfortunately, it was just one of those things where his particular case kind of fell through the cracks, but they did get him going in physical therapy. He returned after a month's worth of physical therapy. His pain was down to a zero. He was smiling and he was ecstatic to be able to return to work and do his normal job. So he was released for full duty. Let's talk about documentation for a moment. Most of the forms provided are going to be state-sanctioned forms that do have to be completed at the time of the visit with a copy given to the employee, as well as one sent to the employer. There is a resource for this with the Job Accommodation Network. They have lots of samples of forms for employee applications. For employee accommodation, requests for leave of absence, and a plan of action for medical emergencies. They do have information on documenting and monitoring an accommodation, and that's more for the Disabilities Act. There is a toolkit for employers and even an entire section on COVID-19 accommodations. Essentially, it's an A to Z of disabilities and accommodation. So it's a really good resource for helping you with the return to work and the accommodations that might be needed. You do want to lay out a return to work plan that is employee-specific and goes beyond just a simple clearance, but really lays out that roadmap of what's going to happen. If you're not at this point, we're going to do this. And if you're not at this point, we're going to do this. That really makes it clear for you, the employee and the employer. What is a graduated return to work? It's a plan that you're going to lay out on how the employee is going to return to their normal duties. It can be done a couple of different ways, but you do want to have some clear goals and that this gets laid out to the employee that they are on board with this. Initially, it might be reduced hours with modified duty. Then you may want to go to still reduced hours, but at their full capacity. And eventually back to normal duties and normal hours. You can also do it where it's reduced hours, modified duty, then it may be full hours, modified duty, and then normal duties and hours. So you're doing a stepwise approach to get that employee back to work doing their normal job. A graduated return to work program is going to involve the modified work duties and a temporary work assignment that is different from their normal responsibilities. The positives of a graduated program is that it helps prevent re-injury and it also limits physical deconditioning. In developing a graduated return to work program, you do have to be cognizant of their job-specific duties. And that's where taking that initial work history at the very beginning really comes into play. You will have to take into account any accommodations related to things like casts, crutches, splints, and really understanding what physically this employee can do and how you're going to gradually increase their ability to perform their jobs. Benefits to the employee include maintaining some earnings, maintaining their skills, faster recovery than being put out of work. And this doesn't necessarily mean just worker's comp. This is for any injury, illness that you're dealing with that would require this employee to have a recovery time. They maintain a feeling of being a productive contributor to the organization, social interaction at work, which is often a huge support system, and maintain benefits such as the accrual of time off. It also helps to avoid depression, anxiety, and gets them back into full recovery quicker. Benefits for the employer include they still have an employee that is productive and help so that they don't have a lack of personnel, decreasing costs for hiring someone, replacement or contract workers, control over their worker's comp, indemnity benefits, and a decrease in short-term disability expenses, a decrease in long-term disability, and a decrease in absenteeism. Think of returning to work for that employee as a team effort. The employer getting to know what resources they have that are available at the workplace. Many of the larger employers will have on-site physical therapy, occupational therapy, wellness clinics, or maybe an occupational nurse on-site, and oftentimes vocational rehab for a coordinated care. So understanding what the employer has to offer, getting to know your employer and what's available will help in that return to work. Let's switch gears a little bit and look at some information that's specific to the commercial fishing industry. This is a story that was printed in the local newspaper in 2003. I opened my practice in 2003, and my office is located near the marina. Shortly after I opened my doors, I started having fishermen coming through my door telling me they had fish disease. I had never really heard that term before, and it was a bit of a surprise to see what they were talking about and what fish disease, as they called it, really was. They would have these really nasty abscesses on their hands, on their legs. You would open them up, IND them, and culture them, and every single one of them was coming back as MRSA. Now, in 2003, when this first was brought to the attention of the state health department, research was conducted, and they sent some of the fish off to be examined, and they found no evidence of any MRSA or staph infection involving the fish. But as time went by, and more and more fishermen, and even the people that were handling the fish and the seafood in the meat markets were showing up with MRSA infections. There was an interesting study done not too long ago in one of the local rivers that feeds into the Gulf of Mexico, and they actually trapped fish, and then they would take the fish and swab them, the inside of their mouths and on their bodies, and then they would put them on agar, and guess what they found? MRSA. The CDC has put out a statement related to MRSA and fish handler's disease, stating that if they are contracting MRSA, it's because they already had an open wound on their hands or the water or cleaning solution that they're using with the fish is contaminated. Now, I can tell you from anecdotal that I see this a lot, and probably over 90% of the time, these abscesses and infections are from MRSA, and then pretty soon, their families start appearing with lesions, so it is a community spread issue. Do keep in mind, though, that there are other organisms that can impact the people involved in this industry, so other infections that can occur, Vibrio and staff, regular staff, Strep, Klebsiella, there's a long list of other organisms that they can be exposed to within this industry through the water contamination, but I typically treat these as if they are MRSA until proven otherwise. So that leads us down to how do we keep these workers at work? They typically will go back to work very quickly, and keep in mind that they're going out on these commercial boats, and they may be gone for days or weeks at a time, so if they do present with an infection, it may have been going on for a while, and then you have to worry about necrotizing fasciitis, or it may be something that's really just started. Interestingly, they do keep on their boats, typically cephalaxin, because the fishermen feel that that's what's gonna take care of this infection, so it's been a real education process to get them away from those kind of antibiotics, and when they're out there, they are picking up antibiotics sometimes in Mexico, sometimes they're having them shipped to them from other countries where prescriptions are not needed. It really gets complicated in treating these people, and keeping them healthy, and keeping them working. So now we're to the question, in order to keep them working, and return them to work in healthy states, and keep them that way, do we then supply them with antibiotics, such as doxycyllin, or sulfa-based? And that's a real question, because we all are hit with not over-prescribing antibiotics. There's an interesting study that's taking place at the University of Texas at the moment, and they are currently enrolling people into the study of whether they should be on doxy continuously in areas where there is a high concentration of MRSA. What I typically do is provide them with some doxycyllin to keep on the boat, so that when something happens, and they're starting to develop abscesses, they have something they can begin to use, so we don't get to the necrotizing fasciitis. They will go in, and they will dock someplace, and then they'll call me. And then I can see, we can do a televideo, and I can see what it's looking like. Can't culture it, but depending on how it looks, I can continue the antibiotic. That's the way I'm managing it at the moment, to keep these workers working, and keep them healthy and out of the hospital. But it's just a very interesting, different thought in the return to work. Specific issues that can impact the return to work for that employee, traumatic brain injury is one of them. Remember, they might have trouble concentrating, headaches, issues with balance. And there is a risk for seizures. These are folks that may need rest periods, or even naps during the day, so they can work so many hours, and then they have to have a rest period of however long is appropriate for that person. Repetitive overuse injuries, if these don't get addressed at the employer level to accommodate and prevent further trauma, they will re-injure. So that's something that you always have to address during your visits too, is what's being done. And sometimes it means even contacting the employer to find out what they're able to do so that this does not cause, does not re-injure. Chronic pain, important to manage, often multi-modality, getting physical therapy, occupational therapy, or your specialist, such as ortho or physiatrist. Just remember, not opioids. Depression and anxiety often go undiagnosed. And can definitely impede an employee's recovery. So that does need to be addressed, and can mean sending them back through their primary care. If it's not controlled, you will find that the recovery period takes much longer, it's extended. You also want to address any psychosocial issues, including alcohol and drug use during the recovery period. PTSD is another one where it really is going to be a multi-modality issue. And there are specialists in PTSD that you can incorporate into the care. COVID, long haulers, it's a tough one. And they're another one that I do rest periods for. Their breathing, their shortness of breath, the cough, all those residual type things, the cardiac issues that go along with it. And now there are many specialty COVID long haul clinics. So you may want to incorporate that into the recovery as well as pulmonology. Another case study. This is Linda, who's 42 years old. She was diagnosed with COVID in 2022. She experienced a persistent cough, dyspnea, fatigue. Lab values were all normal, but her chest X-ray demonstrated an infiltrate. Her symptoms persisted. So a chest CT was ordered and it demonstrated resolution of the infiltrate, but that classic COVID ground glass pattern was present. She works from home. Her employer had already made that change during the pandemic, but had become insistent that she return to work was not understanding why she couldn't continue to telework since she was already doing that. So what are Linda's options? She filed for short-term disability and initially was completely off work until she reached a point where she felt she could do some hours. We started with return to work of four hours with a rest period, and that was gradually increased to six hours. However, her employer continued to call her and become very insistent that she returned to her normal eight-hour work. So what other options does Linda have? Her short-term disability was extended, but now six months have passed since her initial diagnosis, and she does continue to receive treatment for long COVID. But her symptoms wax and wane. She'll have a good day, and then she'll have a bad day. And currently, she's experiencing extreme fatigue, dyspnea, and the cough has returned. Does this change her options for her modified work hours? For her, I ended up putting a really wide range of hours for her to work rather than a set time. I also worked in rest periods for her that she could work two hours, and then she had to have downtime. Her employer, while very insistent in the meaning that she returned, eventually began to understand how ill she was. She also moved during this time period and is now in a rural area with very limited healthcare options. I did finally get her into a long COVID clinic relatively near to her. It's a two-hour drive, and they agreed to do telehealth after the initial visit. So that's where she's at right now, and she continues on her modified work hours and is now under the care of the long COVID clinic. When you're working with people who have been diagnosed with COVID and it's rolling into a long haul situation, the Job Accommodation Network has some really amazing resources. They have developed an entire stepwise approach for both the employer and for medical personnel on how to handle the person that does have COVID and helping them to return to work or to file for disability. This is the URL for them, and another resource that you can use is the U.S. Equal Employment Opportunity Commission, the EEOC. They also have some COVID resources that you can utilize. Questions to consider for a variety of illnesses, but what limitations is the employee experiencing? How do these limitations affect the employee and the employee's job performance? In the previous case study we did, one of the major things that impacted her was the cough and the fatigue. It was very difficult for her to interact through the computer, through the meetings that she had to have in working with customers because she was constantly coughing and then would become very exhausted. Specific job tasks that are problematic. So for her, it was even talking. That's where it began to be very difficult to keep her working and we had to incorporate in a variety of different things for her to do to control her cough as well as to rest. Accommodations that may be available to reduce or eliminate these problems, and are all possible resources being used to determine possible accommodations. Once accommodations are in place, would it be useful to meet with the employee to evaluate the effectiveness of the accommodations and to determine whether additional accommodations are needed? It's that constant conversation with that employee that you're having in helping them return to work to their normal job. Do supervisory personnel and employees need training? And in that case study with Linda, it did require some working with the employer to get them to understand the severity of the illness. This is a list of issues that a person may be experiencing that's impairing their ability to return to work or return to full duty and may need accommodations for. The problem with these is that they are predominantly subjective in nature and very difficult to quantify. Yet they still are going to need accommodation with rest breaks or a flexible schedule. Working with the employer for telework, memory aids such as flow charts and checklists, and the job may need to be restructured so that it just focuses on essential duties and not the peripheral things that an employee might have to do. Let's talk about the Americans with Disabilities Act, the ADA. What is a disability? The definition of disability is very broad. Basically it's, do they have an impairment? And does that impairment affect a major life activity? It can be physical or mental, but it must substantially limit one or more major life activities. The askjan.org website that we talked about earlier is really the place to go when you're discussing, talking about the ADA. They have what's called SOAR, which is a searchable online accommodation resource where you can search almost any impairment that you can think of, and they will give you resources on accommodating that employee or as a medical provider, what you need to do to assist in obtaining accommodations. Essentially it boils down to, will disability affect essential functions of the job? So let's take an example such as a back strain. Very, very common. And the employee may go to the employer and say, I need an ergonomic chair. Does that employer have to accommodate that? Well, if the impairment is affecting a major life activity, they can't sleep because their back hurts so bad, then they really should. But the employer has the right to make a determination about that. A determination on whether or not this is medically needed. So there on SOAR, there is a form that they actually can click on to request some limited medical information, some confirmation that this back strain is real and that they're being treated for it. That's some of the resources that they have. And it really is really good information as providers. The EEOC is another entity that can play into the return to work or denial of employment. They are responsible for protecting people from one type of discrimination and that's employment discrimination. They look at discrimination that might occur because of your race, color, religion, sex, and that includes pregnancy, gender identity and sexual orientation, the national origin of a person, do they have a disability, if their age is 40 or older and protection of genetic information. They want to see consistency in that employer's returning employees and the assignments that they provide and even at will states must abide by the terms under the EEOC. They do say that retaliation by an employer is by far the number one complaint that they receive. They do have a list of conditions that are always disabilities. And if the employee falls into one of those categories, then the employer really needs to accommodate. Marie is a 23 year old machine line worker in a manufacturing plant. She has been out of work for a grade three sprain of a right ankle that occurred two weeks ago when she tripped over her puppy. She brings you her primary, a note from the orthopedist placing her back to work with no restrictions. She confides in you that she will be fired if she does not come back now. Her orthopedist was contacted and it turns out it was a telehealth visit and the note was written at her insistence that she was not having any further symptoms. In communicating with her, you discover that she has not yet completed physical therapy, but her ankle has improved and surgery has been ruled out. Her insistence comes from the statement from her employer that she will be fired. So at this point, we need to do some accommodations for her return to work. For Marie, return to work accommodations are really not what she needs. She is working on a product line and she will be unable to stand for that length of time and could potentially cause that ankle to then need surgery. So for her, a family, the FMLA, the Family Medical Leave Act would be the recommendation that would protect her job and allow her to heal and then to come back to work to the same job or an equivalent job. There's also time-limited work for accommodation. We've discussed that of doing that graduated return to work with shorter hours, modified duty, and then slowly advancing that to shorter hours, full work duty, and eventually returning to the normal shift and their full duty. You can also limit it by the days per week. Telework is also an option that can help employees if they're in that sort of a position where that is able to be done. Decrease in productivity expectations that their actual workload be lessened so that they can do portions of their job and meet some of those expectations, but maybe not the full productivity. Is cost the deciding factor? It can be for the employer. Ergonomic assessments and workstation modifications can cost an employer quite a bit. So that's where the employer needs to assess the medical necessity for that particular employee versus everyone requesting an ergonomic chair, for example. Noise-canceling headphones may actually place that employer under some OSHA regulations. And if they do have the decibels at that worksite, then they absolutely need to accommodate that. Support animals are an interesting area. They got crazy on the airlines for a while. And for most places, they're going to need a mental health professional's documentation as to the need of the support animal and whether or not the employer can even accommodate that. Here are some examples from the askjan.org website and how to write this up to provide information to the employer for accommodation. So because of patient X's depression and associated concentration problems, she is having difficulty completing reports on time. One accommodation that might be helpful is to reduce distractions in her workplace. This could be done by moving her to a private office or providing a headset with white noise. Another example, because of patient X's progressive vision loss and associated blurred vision, she's having difficulty reading her computer screen. One accommodation that might be useful for her computer access is screen reading software. Here's another example that they have on their website. And this is basically the language and how you would write these things up. Because of patient X's rotator cuff injury and its associated limitations of lifting no more than 25 pounds, pushing, pulling no more than 50 pounds and no overhead work, he is having difficulty moving some of the boxes in the warehouse. Accommodations that might be helpful include a height adjustable lifting device, small lightweight ladder, and help moving some of the heavier boxes. This is a sample medical documentation letter. It's again from that askjan.org website. So this is what you would actually write up for the employer, and you can do it on your letterhead. And if you remember that last example, it was very specific as to what the issue was, the impairment and the limitations and the work accommodations that needed to be made. So that's what you really want to do is just be really specific and give those ideas on how the employer could accommodate this employee so that they can return to work. Again, to review restricted work duty will require reviewing the job description and the conversation with the employee, the essential functions of the job you will need to know, and you're going to have to query as to what they feel they can do and come up with that plan for rehabilitation. Again, be specific in pounds, minutes per hour of how repetitive this particular activity can be, body movement, if they need to avoid certain positions, screen time in front of that computer, and complex problem solving they may or may not be able to accomplish depending on the underlying issue. Here's a list of the weights of some common items. I think one of the ones that we use quite a bit when we're talking about a weight restriction of less than 10 pounds, which is pretty frequent for some of the back injuries is a gallon of milk is nine pounds. And so anything that feels as heavy as that, that's their limit. The state of Washington actually has a really nice publication that lays out a couple of pages worth of examples of pounds for different items. And that's a really good resource and one that is actually visual because of the pictures of the items and can help when you're talking to the employee to help them gauge what they can or cannot lift. You go into an exam room to see your next patient and the person in front of you is telling you about a very serious injury or a high level of pain that they're experiencing, yet they do not appear in any acute distress. You have to put the bias aside and be very careful with your documentation of this. You want to be very thorough with your assessments and have any additional provocative tests been incorporated into the examination process. At this point, do you need to obtain some lab work or radiology studies? And is a referral to a specialist needed? Options for return to work? Well, you still can use the graduated approach, but it does have to be a shared decision-making in order to get this injured or ill worker back to work. And then there's the visit where they tell you they cannot work at all. You do the examination and the subjective is not correlating with the objective. You're just not finding anything to substantiate this statement of not being able to work. The related symptoms do not match the mechanism of injury and the pain level remains high, 10 out of 10, but the employee presents to this visit as appearing in no acute distress. And again, you have to go back to very thorough examination, additional provocative tests, additional testing in general, and ultimately a referral to a specialist. You have reached the final visit when you as a provider and the patient in front of you are ready to return to full duty, full work capacity. When you do that clearance visit and you're writing that return to work for them, it's preferred that it be done in person. That makes the most sense so that you can see and examine them and talk to them regarding their capabilities to then resume full duties. The worker's comp will require you to put a percentage to any rating for impairment. So when you reach that final thing, your 0% rating for maximal medical improvement is really preferred to be in person. You can do telehealth, but remember that it needs to be HIPAA compliant. Doximity is a really nice site for that. Zoom and Teams, they have different platforms for HIPAA compliant versus the regular Zoom and Teams. Provider portals often have the telehealth part to it. Mentelephonic in this day and age, oftentimes that's the way people are communicating and that's fine because you can still see them and talk to them, but again, preferred to be in person. I don't do email clearance. That was one of the ways though that the literature says you can, I'm not comfortable with it and that's entirely provider preference and it depends on what the injury or the illness was. The final visit though, that's review things, review their progress and the ways that they are going to prevent a re-injury.

Return to Work

Healthcare Provider

Work History

Diagnosis

Work Capacity

Treatment Plan

Psychosocial Factors

Family Medical Leave Act

Challenges and Accommodations