The role of healthcare providers in return to work and stay at work services for people with mid-career disabilities: A holistic statewide model

Abstract

Background: It is well known that effective return to work (RTW) services following the onset of adventitious disability require the collective involvement of vocational case managers, employers, healthcare providers, and workers themselves. Method: We describe RETAIN Kentucky's approach to engaging healthcare providers as key motivators and facilitators of their patients’ RTW efforts. Results: A cursive review of best practices in integrated disability management is followed by a description of RETAIN Kentucky's broad-based efforts to engage healthcare professionals in all aspects of the RTW process. Ninety-two percent of RETAIN Kentucky participants who complete their RTW plans are employed when they exit the interdisciplinary project. Implications and Conclusions: Implications for collaborating with healthcare systems and providers are presented.

Keywords

return to work healthcare consultation physical medicine and rehabilitation people with disabilities case management interdisciplinary patient care team

The purpose of this article is to describe the RETAIN Kentucky project's approach to integrated disability management (IDM) and Return to Work (RTW) and Stay at Work (SAW) services for individuals who acquire mid-career, non-work-related disabilities. What makes our approach truly integrated is the active involvement of healthcare systems and providers in every aspect of our initiative. Five years after the onset of the COVID-19 pandemic, we are still coping with the impact of this unprecedented global public health crisis. If we have learned nothing else from the pandemic, we have witnessed how important it is for vocational rehabilitation professionals, employers, and healthcare providers to work together to help workers with disabilities remain in our irrevocably changed labor force.

It is true that the disability community has been disproportionally affected by the ongoing pandemic,¹ but it is also true that the current national labor shortage (4.1% unemployment rate) offers unprecedented opportunities for disabled workers to return to employment and contribute to the national economy.² As employers’ needs for all available workers have increased, so, too, has their willingness to provide on-the-job accommodations and universally design their workplaces.^1,3,4 Hiring and accommodating workers with disabilities is a business necessity in the COVID-19 era, and it has the added benefit of helping employers meet the social justice imperative in our national and global economy.⁵ However, to help employers meet the need for workers with disabilities to participate in the labor force, the worker's healthcare and mental health needs must be incorporated into all aspects of RTW/SAW planning and service delivery.^6,7

The need for healthcare providers in IDM and RTW/SAW services

Much of the extant research and literature on workplace inclusion has focused on recruitment and hiring people with disabilities to fill important personnel needs.^5,8 This emphasis has yielded considerable information and proactive policies and practices that employers utilize to improve access to employment opportunities for workers with disabilities, an endeavor that may be viewed as opening the “front door” for the talented and productive labor resource that exists within the disability community. Though important, this emphasis sometimes diverts employer attention from “back door” considerations related to accommodating and retaining workers who acquire disabilities in the midst of their careers, thereby resulting in high rates of costly turnover for employers and unnecessarily high rates of membership on disability benefit rolls for workers.^9–11

Rumrill and Koch¹² asserted that a total workplace inclusion philosophy on the part of employers involves a dual priority on both hiring and retaining productive workers with disabilities who represent the entire American populace. Employers have long engaged in disability management initiatives to reduce the incidence and cost of work-related injuries, often in concert with workers’ compensation carriers, occupational health professionals, and vocational rehabilitation counselors.^5,9,13 IDM is a proven method for helping injured workers maintain employment and for interrupting the progression of disability benefits¹⁴ that has historically inhered to the mid-career disability experience.¹⁵ However, IDM programs in industry seldom focus on the job retention needs of workers whose injuries and illnesses are not work-related,¹⁶ even though non-work-related injuries and illnesses result in more lost workdays and a higher proportion of needed medical interventions than work-related injuries.¹⁷ This unfortunate oversight often finds people with mid-career chronic illnesses,¹⁸ traumatic brain injuries,^19,20 psychiatric disabilities,²¹ and substance use disorders²² lacking RTW supports that could help them retain their careers. This support gap results in a more than 50 percent reduction in the rate of labor force participation following the onset of these non-work related injuries; people with multiple sclerosis, for example, report a 40 percent employment rate in study after study.²³ Dillahunt-Aspillaga et al.²⁴ reported the employment rate for people with non-work related moderate and severe traumatic brain injuries at approximately 35 percent. These extremely high rates of workforce attrition following the onset of mid-career disability deprive workers of the opportunity to achieve and maintain economic self-reliance, employers of the opportunity to keep productive workers and thereby reduce costly turnover, and society of the opportunity to benefit from the valuable contributions that people with disabilities can make to the American economy if workplaces are optimally inclusive. We can and must do better.

Although underutilized in practice, the RTW model^9,10 provides a framework for employers to accommodate and retain qualified and productive workers with disabilities regardless of disability type, the cause or origin of the disability, and the circumstances under which the injury or illness was acquired. Synonymous with total workplace inclusion and expanding upon the IDM model,¹³ RTW guides employers in developing broad-based, organization-level policies and procedures to address all aspects of inclusion in the workplace. The worker's treating physician and healthcare providers are integral to the IDM and RTW models, as they ensure that the worker's return to employment is done safely and in conjunction with their ongoing treatment needs. Rumrill and Koch¹² described the collaboration among vocational rehabilitation (VR) professionals, employers, and healthcare providers as the most important feature of RTW strategies for workers with non-work related injuries and illnesses. They asserted that occupational health and physical medicine/rehabilitation professionals in particular have essential roles in RTW planning and service delivery, understand the therapeutic benefits of work, and ensure that workers with mid-career disabilities continue to receive medical and mental health treatment as they re-engage in the labor force. Indeed, Strauser⁵ has long exhorted VR professionals that helping the worker with a disability maintain health and wellness is both a predictor and an outcome of effective RTW services, underscoring the well-documented and reciprocal relationship between employment success and positive long-term health outcomes.²⁵

Paid employment is a public health imperative in today's global economy, and it is not hyperbole to say that it can be a matter of life and death. Employment and income are correlated with life expectancy, quality of life, and overall healthcare costs.^26–28 Health is an important factor in employability; acute and chronic illnesses can prevent work entirely, cause job loss, and prevent wage gain.²⁹ Steege and colleagues³⁰ noted that the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) consider work as a social determinant of health, noting that healthy people have better employment outcomes and those who remain employed over time report better long-term health. The following section describes the RETAIN Kentucky model and the central role that healthcare systems and professionals play in our statewide RTW/SAW project.

RETAIN Kentucky: leveraging healthcare systems and professionals to improve RTW/SAW outcomes

A four-year inclusive workforce initiative funded by the United States Department of Labor,⁴ RETAIN Kentucky views healthcare as inclusive of both physical and mental health. Mental health diagnoses have been present in the majority of RETAIN Kentucky's 3000 + participants.³¹ The COVID-19 pandemic, which coincided with the beginning of RETAIN Kentucky, resulted in an increase in mental health conditions in the American populace, including anxiety, depression, and substance use disorders.^32,33

From its inception, RETAIN Kentucky recognized the pivotal role that healthcare providers can play in their patients’ decisions and abilities to return to work. By enlisting local healthcare providers to join and advocate for the RETAIN Kentucky program at direct-service and system levels, RETAIN Kentucky began building and expanding a collaborative network of healthcare partners engaged in RTW and SAW best practices. From the direct service perspective, RETAIN Kentucky worked with healthcare providers to identify people who had experienced illnesses or injuries outside of the workplace who could remain in or return to their jobs as soon as possible through early intervention strategies. The RTW Coordinator, in collaboration with the program participant, their employer, and healthcare provider(s), develops a RTW or SAW plan (RTW for those who are not currently employed and SAW for those who are currently employed) for eligible participants. The plan includes services such as case management and coordination, referrals for services to address social determinants of health, assistive technology evaluations, job counseling, and peer support. These plans are reviewed routinely to track progress and identify any additional barriers to staying at or returning to work.

An additional element of continuous quality improvement is achieved by providing the RTW Coordinators with the opportunity to consult with RETAIN's medical directors in case review meetings and attend professional development trainings. The professional development trainings are led by healthcare champions and include topics such as mental health, substance use, pharmacological implications, and population health. This results in enhanced case management service delivery and further informs healthcare professionals about patients’ challenges.

On a system level, RETAIN Kentucky has focused on program sustainability and enduring statewide change. These efforts include program capacity building, training, and the development of the Inclusive Worker Health Leadership Network (IWHLN). Within capacity building and training, RETAIN Kentucky is developing an academic Return to Work Certificate available for undergraduate and graduate students to obtain alongside their degrees. Within this certificate program, students will learn about the role of healthcare in the RTW/SAW process and in total workplace inclusion.

RETAIN Kentucky's partnership with healthcare providers and systems generated approximately one-fourth of the more than 10,000 participant referrals for the overall project. In addition, more than 21 percent of RETAIN Kentucky enrollees, all of whom were people with non-work-related acquired disabilities, worked in the healthcare sector.

The healthcare environment in Kentucky is challenging and dynamic. The COVID-19 pandemic has spurred rapidly changing healthcare industry movements.³³ Kentucky is primarily rural, making recruiting and retaining physicians, especially primary care physicians, a challenge.^34,35 Out of the 120 counties in Kentucky, 35 have five or fewer practicing physicians, and seven had no physicians in 2022. Fayette and Jefferson counties, the two counties with the most physicians in Kentucky, contain the state's largest health organizations – University of Kentucky Healthcare and University of Louisville Health.³⁵ RETAIN Kentucky partnered with these academic healthcare systems and their providers, intending to reach systems that not only provide clinical care but also offer education and training for the next generation of providers. This outreach gave RETAIN Kentucky access to early identification and recruitment of the targeted patient population. RETAIN Kentucky also partnered with the Kentucky Hospital Association (KHA), the leading voice for Kentucky health systems in improving the health of communities. KHA represents hospitals across Kentucky, with 73% of members being rural hospitals. The inclusion of KHA in RETAIN Kentucky furthered the voice of rural healthcare organizations and outreach to individuals in these communities.

To address the gap in physician participation in the RTW/SAW process, RETAIN Kentucky sought to connect with influential physicians to create a network of healthcare “champions.” These physicians aided RETAIN in recruiting participants for the program and building connections for information partnerships to better serve participants. They were also recruited to share their experience and perspectives as members of the IWHLN. Healthcare partners in IWHLN included KHA representatives as well as senior leaders in human resources, population health, occupational medicine, and physical medicine and rehabilitation. One member of the IWHLN, a senior leader in population health, provided a dual perspective as a provider and an individual with a disability. In all, the healthcare champions represented five healthcare systems that employed over 50,000 workers.

Two physician healthcare champions worked in academic healthcare systems and practiced in Physical Medicine and Rehabilitation. This specialty area focuses on restoring function and using a holistic approach to patient care to improve quality of life, specifically embodying the benefits of RTW/SAW practices. These healthcare champions collaborated with RETAIN Kentucky outreach staff to educate physicians on their potential role in RTW/SAW services. They participated in face-to-face planning and implementation meetings with project staff, the development of project promotional materials, the promotion of RETAIN during grand rounds and monthly department meetings, and the development of training programs for healthcare providers. Formal healthcare champions also advocated for the inclusion of RETAIN Kentucky in their healthcare systems’ electronic medical record. This integration was a necessity due to challenges in accessing physicians and hospital staff during the COVID-19 pandemic. Physicians could directly refer patients to RETAIN, resulting in an RTW Coordinator reaching out to the patient to provide program information, obtain consent, and arrange project services. Within nursing and social work, practitioners were trained to incorporate RETAIN referrals into their discharge practices. Furthermore, the electronic medical record system's patient portal allowed patients to self-refer to the project.

The statewide IWHLN consists of physicians, nurses, nurse practitioners, and healthcare leaders who are recruited to recognize the impact of health and the healthcare system in creating an inclusive workforce in Kentucky. Other members include public health professionals, employers, workforce development officials, the Kentucky Chamber of Commerce, and people with disabilities. The goal of the IWHLN is to promote multisystem improvement, innovation, and change to accelerate opportunities for Kentuckians to stay at or return to work. This group defined an inclusive workforce as one in which the unique skills, contributions, and diversity of qualified individuals, including those with disabilities, are actively recruited, valued, and integral to success. It is an environment where the engagement, development, retention, and advancement of an increasingly skilled and diverse workforce is promoted and supported across all employment sectors and levels. The IWHLN makes annual recommendations to the governor regarding policy and systems change to promote more timely, coordinated, and effective services, leading to better employment outcomes for Kentuckians. The perspectives of RETAIN Kentucky's healthcare partners were critical for recommendations regarding the promotion and implementation of RTW/SAW best practices.

To engage providers while recognizing limited availability of care and services during the pandemic, RETAIN Kentucky developed a short training module that provides an overview of RTW/SAW issues, a success story of a participant, and information on how to refer individuals to RETAIN Kentucky services. This training was delivered in faculty meetings, dyad leadership meetings, and grand rounds. In response to feedback from healthcare providers, RETAIN Kentucky developed a continuing medical education (CME) training. The CME was developed through collaboration with physician champions at University of Louisville Health, the Kentucky Nurses Association (KNA), and an occupational medicine provider. The course is designed for a variety of healthcare fields, including physicians, physician assistants, medical assistants, nurses, physical therapists, occupational therapists, and speech therapists, with continuing education credits available for their respective disciplines. This enables the information to be more accessible and applicable across rural and urban settings in Kentucky. Practitioners who take the course learn how to identify relevant federal policies, understand the effects of not returning to work, describe barriers and systems’ approaches to RTW/SAW, demonstrate strategies to include rehabilitation professionals when aiding patients, and learn how to refer to RETAIN Kentucky. Many participants have reported that the CME course aids their understanding of RETAIN and that they will use RETAIN resources to refer patients to RETAIN and discuss RTW with their patients. RETAIN Kentucky held focus groups and provided other opportunities for physician feedback, resulting in the CME being revised to include more interactive components based on their recommendations. KHA also partnered with RETAIN Kentucky in providing RTW/SAW education within town hall meetings, expanding reach to hospitals across the Commonwealth.

Additional training resources are available and have a variety of formats to cater to healthcare workers’ preferred mediums and accessibility needs. One of these resources that resulted from the partnership with KNA is a series of webinars designed for nurses that can be accessed asynchronously for professional development credits. This webinar series includes topics such as COVID-19 and people with emerging disabilities, healthcare literacy and the Americans with Disabilities Act, RTW/SAW best practices, universal design, assistive technology, and job accommodations. Involvement of nurses in RTW/SAW practices is critical, especially in rural locations, as nurses are often the primary source of medical care for patients and have the potential to positively influence inclusive practices.

Through CME and other trainings, RETAIN Kentucky has worked toward increasing healthcare practitioner skills in RTW/SAW practices. Education materials encourage practitioners to increase their understanding of patients’ worksites, job descriptions, and life circumstances. Practitioners are also taught how to facilitate communication between the patient and their employer. When communicating with the patient and their employer, practitioners are instructed to emphasize the patient's strengths to the employer and further support management in accommodating the patient. RETAIN Kentucky also offers monthly webinars for employers, with guest speakers who educate attendees about various topics regarding disability, injury, and illness within the workplace. Several of these webinars have been led by healthcare professionals, allowing employers the opportunity to consult with healthcare professionals who have experience in the RTW/SAW process. Medical residents and students are also included in RETAIN practitioner education efforts, demonstrating another strength of RETAIN Kentucky's involvement in academic medical systems and the ability to impact the practice of future healthcare providers.

RETAIN Kentucky is also developing a series of handbooks, which will be available to project participants, employees, healthcare professionals, and employers. The goal of the handbooks is to empower healthcare providers to discuss returning to work as a health benefit with patients and incorporate the resources into their practice. Healthcare providers have reviewed and provided input for the handbooks. Providers without formal RTW/SAW best practice training have been included in the handbooks’ development to make it accessible to those without training and to create resources that are meaningful and useful to a broad array of healthcare professionals with a role to play in improving RTW/SAW outcomes. The content will be shared in a variety of formats, following universal design principles, to assure the information is used and accessible to professionals in ways that reflect their needs and preferences as learners.

Conclusion

RETAIN Kentucky recognizes the powerful and reciprocal relationship between paid employment and health, going so far as to consider the statewide inclusive workforce initiative a public health imperative. From its inception, RETAIN Kentucky included healthcare providers and systems as integral partners in RTW and SAW services for the experienced, productive, but often disenfranchised population of Kentuckians who acquire illnesses or injuries in the midst of their careers. With a 92 percent employment rate among all RETAIN Kentucky participants who completed their RTW or SAW plans, the authors of this article have been encouraged by the positive effects of actively engaging healthcare professionals in a broad-based statewide RTW/SAW effort.

Footnotes

Acknowledgements

The authors have no further acknowledgments.

ORCID iD

Kathleen Sheppard-Jones

Ethical Considerations

The overall RETAIN Kentucky project received full Institutional Review Board approval from the University of Kentucky. However, this program description article did not involve human subjects.

Informed consent

This program description article did not require informed consent.

Funding

Preparation of this article was funded by the U.S. Department of Labor and the Social Security Administration under a grant award of $21,600,000 to the Kentucky Office of Employment and Training. This article does not necessarily reflect the views or policies of the U.S. Department of Labor or the Social Security Administration, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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