Spring 2022 Edition
Best of the Best
Recognizing Industry Leaders
– Page 44
RETHINKING SPINE CARE 470 . 57 9 . 3962 | axionspine . co m
PAIN MANAGEMENT: It Doesn't Have to Hurt Ankur B. Patel, DO, RPH
Jordan L. Tate, MD, MPH
Athens | Gainesville | Jasper At Southern Pain and Spine our providers focus on non-narcotic treatment options to alleviate pain and rehabilitate patients. Our goal is to get injured workers back on the job quickly by effectively evaluating and treating their pain and improving their level of function. We Offer: Independent Medical Evaluations Second Opinions Utilization and Record Reviews Transfers of Care Routine Drug Screening Communication of Work Status, MMI, and PPI Prompt Appointments Board Certified Physicians Full-Time Worker's Comp Director
(678) 971-4167
Cost effective treatment plans with defined endpoints Return to work plans Non-opioid pain relief options
| workcomp@southernpainandspine.com
Understanding Trauma-induced Sacroiliac Joint Pain Jordan Lee Tate, M.D., MPH Trauma-induced sacroiliac joint (SIJ) pain is common in workplace injuries. However, the diagnosis and treatment can be complex. Understanding the anatomy of the SIJ and the mechanism of injury is imperative. In addition, taking an accurate and comprehensive history of the patient’s musculoskeletal symptoms is crucial for making the correct diagnosis. A fellowship-trained pain management physician is best equipped to provide specialized evaluations and initiate a customized plan of care. The SIJ is the largest axial joint in the body. It connects the spine to the pelvis, allowing load transfer from the lumbar spine to the lower extremities. In youth, the joint is more mobile and becomes fibrotic with age, which minimizes movement and enhances the stability of the SIJ. Trauma to the joint can cause laxity and hypermobility of the joint due to ligamentous strain and subluxation of the articular surfaces. SIJ pain can be caused by hypomobility due to degenerative joint disease and may predispose the patient to injury. Studies have shown that the SIJ is a pain generator in up to twenty-five percent (25%) of patients complaining of chronic low back pain. Surprisingly, it is an often-overlooked diagnosis, especially when attention is instead focused on disc or facet joint pathology. Pain is most common after a fall on the buttock or deceleration injury such as a motor vehicle collision. Postpartum status, prior lumbar fusion surgery, scoliosis, and leg length discrepancy may predispose a patient to SIJ dysfunction. Patients will often complain of pain localized below the waistband, which may radiate to the posterior thigh or anterior groin. The pain is often mechanical in nature and may be intensified by sitting, loadbearing, walking, and hip twisting maneuvers. Conservative measures—such as physical therapy, chiropractic manipulation, and bracing—should be implemented as first-line treatments. Imaging of the SIJ only serves to rule out fractures and tumors, as normal x-rays, CTs, and MRI scans do not correlate to the absence of SIJ pain. Diagnostic and therapeutic steroid injections performed under fluoroscopy or ultrasound confirm the diagnosis and often provide long-lasting relief, enabling a return to function and work. Contrast enhancement of the fluoroscopic injection can also identify joint disruption which may not be seen on imaging studies. For refractory patients, denervation of the SIJ with radiofrequency ablation (RFA) may be performed. Regenerative options, such as PRP and prolotherapy are often beneficial. When necessary, SIJ stabilization and fusion procedures can be performed by fellowship-trained interventional pain specialists with minimally invasive techniques. SIJ pain and dysfunction from workplace traumatic events should be considered in the differential diagnosis and workup of patients with low back pain. Treatment options are available and effective. I recommend early referral to a double board-certified and fellowship-trained interventional pain physician for the most efficient and comprehensive solution. Jordan Lee Tate, MD, MPH, is an interventional chronic pain medicine specialist who dedicates herself to comprehensive, holistic care for her patients. She graduated from Vanderbilt University with a focused study on Neuroscience and earned her medical degree from Emory University School of Medicine. Dr. Tate obtained a master’s degree in Health Education from Rollins School of Public Health at the CDC where she dedicated her thesis work to initial research on clinical opioid use, misuse, and diversion. As an active clinician, researcher, and busy mom of three, Dr. Tate is also passionate about traveling, education, and wellness. She practices in Jasper, Georgia at Southern Pain and Spine. Currently, she directs several research projects on Spinal Cord Stimulation and Peripheral Nerve Stimulation and runs a subspecialty clinic on Chronic Pelvic Pain. 1
Published by:
Owner/Managing Editor
Garlana H. Mathews President
Director of Sales
Michelle C. Wilds Please contact the Workplace Health team to advertise in our next issue. Call Workplace Health Magazine: 912-667-0441 or e-mail: garlanamathews@selectonenetwork.com or visit us online at:
www.workplacehealthmag.com
1- Understanding Trauma-Induced Sacroiliac Joint Pain
30- Rehab, Recover, & Restore
4- Evaluating the Injured Worker
32- 5-YR Rule for a GA WC Case
6- Florida Legislative Update
35- Home Care workforce impacts
11- Top 5 Ways to Influence EE Health & Max ROI
36- Taking the RISK out of Light Duty work
14- OSHA Inspections? What Employers need
39- Summertime WC Hand and Upper Exremity Injuries
17- What’s an FCE?
40- Enhanced Recovery after surgery
18- Employers: Communication is Crucial
42- Chiropractic for WC Injuries
20- Georgia Legislative Update
46- Ergonomics in the Workplace
25-Translation VS Interpretation
48- Whose Employees are they?
26- Return to Work Decisions
50- Streamlined Protocols for treating the Injured Worker
29- Stress Management in the WC World
52- Can Hand fractures be treated like Femur fractures?
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2022 Upcoming Educational Events: Workplace Health Magazine gets around! Disclosure: Event dates could be postponed, cancelled, or virtual. Please use the following as a guide. If you would like your event added to the Workplace Health magazine calendar of events, please contact Michelle Wilds at michellewilds@selectonenetwork. com. Workplace Health magazine would love to come and cover your event.
March 24- Alabama WC DOL Perdido Key
April 10-13- National RIMS San Francisco CA 13- Georgia State Board of WC Regional- Cartersville GA 14- Atlanta Claims Association Educational ConferenceAtlanta GA 20-22 – Georgia PRIMA- Savannah GA Hyatt Regency 20- Georgia State Board of WC Regional- Columbus GA 28- Georgia State Board of WC Regional-Athens GA
May 3- Physio Symposium- Atlanta GA 13- Georgia State Board of WC Regional- Savannah GA 20-Georgia State Board of WC Regional-Alpharetta GA
June 1-3 -Georgia Association of School Personnel Administrators- St Simons Island GA 2- Strategic Leadership Summit- SHRM Jacksonville 5-8-National PRIMA- San Antonio TX 6- Atlanta Claims Golf Tournament – Country Club of Roswell 9- Moore, Ingram, Johnson & Steele Annual Claims Adjuster CEU Seminar- Atlanta GA - Georgia Bar Association 12-15 – NCSI Conference – Back Together Again, Hyatt Regency Scottsdale Resort & Spa at Gainey Ranch, Scottsdale, AZ 19-21- Georgia Workers Compensation Association- Jekyll Island GA
July 7- Alabama WC DOL Birmingham AL -Winfrey Hyatt 17-20 – Florida Self-Insureds Annual Conference and Trade Show- Naples FL 26-30- Florida RIMS- Naples FL
August 7-9 – Alabama Self-Insureds Summer Conference – Sandestin FL 21-24 – WCI Orlando FL- Marriott World 28-31- Georgia State Board of WC Annual ConferenceAtlanta GA
September 7-9 – Georgia Safety Health and Environmental Conference- Savannah GA 8- Alabama WC DOL Birmingham AL-Winfrey Hyatt 28-30- Georgia SHRM Annual Conference- Savannah GA
October 6- Alabama WC DOL Birmingham Ala-Winfrey Hyatt 6- Talent Management Summit- SHRM Jacksonville 19-21- National WC and Disability Conference- Las Vegas, NV Mandalay Bay 26- Georgia Workers Compensation Association Fall Conference- Atlanta GA
December 1- Legal and Legislative Summit- SHRM Jacksonville
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Evaluating the Injured Worker Brian J Ludwig, M.D. The Occupational Safety and Health Administration (OSHA) reported more than 2.6 million non-fatal workplace injuries in 2020, which are unfortunately all too common and can cause considerable difficulties for patients. In addition to the patient factors, workplace injuries result in significant loss of time, productivity, and morale for the employer, as well. The initial evaluation of an injured worker is extremely important to determining the appropriate treatment plan to minimize the repercussions to both the worker and the employer. Here are key considerations when initially evaluating the injured worker: History The most important part of evaluating a patient with a work-related (or non-work related) injury is the patient’s historical account of what happened. Questions such as, • • • • • • • • •
When did the injury occur? What was the worker doing when the injury occurred? Where is the pain located? Does it radiate in any direction? Are there any associated symptoms (numbness/tingling/burning)? What are the aggravating and relieving factors for the pain? What treatments—both successful and unsuccessful—have been tried? Does the patient have a prior history of pain in the area? Has the patient had prior surgical procedures in/on the area? How long has the worker been doing the job where they were injured? • A detailed job description is helpful for the evaluating physician as it aids in understanding the demands placed on the worker and possible ergonomic environments that could lead to causality or be changed to bring the worker back to their baseline functional status.
These are a few basic questions to start evaluating a Workers’ Compensation injury. The patient’s history is crucial because it guides the remainder of the evaluation, including a physical exam, imaging, and the treatment process and is vital when determining causality in Workers’ Compensation claims. Physical Exam 4
A comprehensive physical exam is useful when evaluating an injured worker to note findings such as strength, range of motion, provocative tests (impingement, instability), neurologic, motor, and sensation, all of which gives insight into the potential pathology. Often overlooked on examination is an inspection of the skin and muscle tone. Watching how the patient carries themselves when entering and leaving the exam room, as well as during the exam, can offer subtle signs of the presenting injury and any potential indication of malingering or symptom exaggeration. A thorough history and physical exam can often lead to a diagnosis before any imaging or testing is initiated. Imaging Imaging via x-ray is an easy first step and can help determine if the worker’s injury is a fracture, dislocation, underlying degenerative joint disease, or other osseous pathology. An MRI scan can be ordered based on the patient’s symptoms. MRIs are the best imaging modality for evaluating soft tissue pathologies such as tendons, ligaments, cartilage, or muscle injuries. As patients age, it could be difficult to assess whether the MRI-discovered pathology is related to the normal aging process or the noted work injury. This is especially true for patients fifty (50) years and above when the MRI shows degenerative signs or changes. Determining acuity of the findings is, at times, difficult with MRI imaging. Other modalities such as ultrasound and CT scans can be useful in the appropriate clinical scenario (CT for fracture delineation, as an example). Treatment Options Treating the injured worker can take many forms depending on the pathology found during an evaluation: • Time and activity modifications (work restrictions) • Physical therapy • Injection therapy • Oral anti-inflammatories • Slings, braces, or, similar • Surgery, if necessary • Work restrictions allowing the patient modified duty – this can keep the patient in the work environment, rather than out of work altogether • Narcotic pain medication should be avoided except when indicated by the injury Treating injured workers is a complex process that entails multiple steps. A thorough history, physical examination, and review of the imaging will frequently lead to an accurate diagnosis and treatment plan. Following these steps can help determine causality of the injury if that is in question. Assisting the injured worker’s return to their career after a work injury is extremely gratifying for both the medical provider and the patient.
Brian J. Ludwig, M.D., is a Board-Certified orthopaedic surgeon, fellowship-trained in Sports Medicine at Andrews Sports Medicine Institute. He specializes in athletic injuries and is the team physician for Mercer University’s baseball and softball programs and the head team physician for Middle Georgia State University and Fort Valley State University. Dr. Ludwig also provides care for Workers’ Compensation injuries. 5
Florida Legislative Update David Langham, Deputy Chief Judge Workers’ Compensation in Florida may see legislative changes this year. There are multiple bills filed that could address Chapter 440 (the Workers’ Compensation statute). Notably, many bills are filed, fewer are passed, and even less become law. The process is, at times, arduous and ponderous. However, it behooves us to understand the potential. House Bill (HB) 959 would amend Section 120.541, which has an ancillary impact on Workers’ Compensation. This law imposes safeguards on the implementation of administrative rules. Any rules that have a significant economic impact must be ratified by the legislature. Among the many rules in Florida is the provider “schedules of maximum reimbursement” mandated in section 440.13. The 120.541 ratification requirement has slowed adjustments to physician reimbursements in recent years. HB959 would exempt those schedules from the 120.541 requirements. While there is a “similar” bill in the Senate, there is not as yet a “companion bill” that is identical to HB959. Senate Bill (SB) 1874 is a much broader proposal (78 pages). It includes adjustments to fifteen chapters of the Florida Statutes. Several of the proposals are in Chapter 440. This includes changes to the definition of “Employer,” constraints on the election of exemption from coverage, clarification of the use of such an exemption, changes in the penalty process regarding coverage, educational requirements (“tutorials”), reimbursement manuals adjustment (as in HB 959), an email alternative for the Workers’ Compensation informational notice and changes in the statutes regarding adjusters. Just as there are broad and lengthy proposals, bills can be very brief. Senate Bill (SB) 1066 is one page in length. It has an “identical” bill in the House, HB 689. This would not amend Chapter 440, but Section 112.1815, commonly referred to as the PTSD statute, which created compensability for mental injuries without a physical trauma. The law was new in 2018 and affords compensability when a “first responder” suffers PTSD from any of the statute’s eleven “qualifying events.” The law includes a “statute of repose” for PTSD. Repose refers to a period that can begin to run before any injury accrues. Lawyers often confuse repose with statutes of limitations (SOL). The distinction is that SOL does not begin to run until the time to file such a claim begins. The Florida Court in Palm Beach Fire and Rescue v. Wilkes, 309 So. 3d 687 (Fla. 1st DCA 2020) interpreted section 112.1815 and concluded it has such a repose. A claim under 112.1815 “must be properly noticed within 52 weeks of the qualifying event,” that is the exposure that causes the medical condition. Senate Bill 1066 would alter the limitation and allow such claims to be filed within 52 weeks of a diagnosis of PTSD. Thus, compensation for such an “occupational disease” might be timely claimed years or decades after a “qualifying event.” That will likely be discussed and debated as this bill travels. Similarly, the occupational disease statute, 440.151, has been interpreted to allow the filing of such a claim within two years of the “injury,” which is when a worker is first “disabled.” Thus, in those claims, a significant period may similarly pass between exposure and the “event” that precipitates notice and a claim. The future is uncertain. Whether substantive steps are taken in the 2022 legislative session or not, these proposals are worthy of study. Whether the community returns post-COVID to the old “normal” or a “new normal” remains to be seen. But, this dynamic and collegial community has proven it is up to any challenge. So, there are perhaps considerations on both sides of the discussion regarding the application or amendment of this statute of repose. The legislative season is likely to be interesting and engaging. There will be much to consider and time will tell whether any amendments ultimately impact the world of Florida Workers’ Compensation. David W. Langham, has been the Florida Deputy Chief Judge of Compensation Claims since 2006. His legal experience includes workers’ compensation, employment litigation, and medical malpractice. He has delivered hundreds of professional lectures, published over forty articles in professional publications, and has published over 950 blog posts regarding the law, technology, and professionalism. David is a student, a teacher, a critic, a coach, and a leader. He lives in Pensacola, Florida, with his wife, Pamela Langham, Esq. 6
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Top 5 Ways to Influence Employee Health & Maximize Return on Investment (ROI) Lauren Larkey, PT, MTC, Cert.DN, CEAS I/III In an ever-changing world, an emphasis on employee health and wellness is paramount. The new normal is a shift of focus to wellness, stress reduction, mental health awareness, inclusivity, and employee engagement that creates a positive culture within an organization. All have become a driving force to support a company’s most valued asset: your employees. According to Integrated Benefits Institute, “poor health” costs employers $530 billion and 1.4 billion lost workdays in 2018. That cost to employers was greater than the combined net revenues of Apple, Amazon, Microsoft, Netflix, eBay, and Adobe altogether. Employee health is essential to the function and operation of your workplace. Explore these five (5) options for influencing employee health and maximizing your return on investment: 1. Early Symptom Intervention: administration of OSHA defined first aid level care by a licensed health care provider • Minimizing injuries early reduces worsening of the issue and offers solutions for timely resolve • Return on investment (ROI) in a six-month study demonstrated a $6,150 investment returned $197,000 cost savings 2. Employment Testing: screens to assess if a candidate is capable of performing their essential functions of the job • Includes musculoskeletal (MSK) screening, heart-rate/blood pressure screening, and can be performed on new hires or existing employees • ROI was completed for the administration of post-offer employment testing vs. carpal tunnel surgery as a result of a workplace injury over five years of implementation - Cost of testing = $182,000 - One (1) carpal tunnel surgery/each year x 5 = $312,000 - Cost Savings = $133,000 3. Stretching Programs: development of specialized stretching programs based upon job site analysis • Provides proactive education on stretching and flexibility to maximizing working safely • ROI was a six percent (6%) improvement, on average, of a general range of motion and decreased back injuries six-fold saving potential of $40,000-$80,000 per employer 4. Ready for Work Programs: strengthening and flexibility conditioning programs designed to ramp total work volume by increasing weight and repetition • ROI in a controlled case study reported a reduction in weight and decreased blood pressure in sixty-eight percent (68%) of participants thereby reducing risk for heart attack, diabetes, high blood pressure, and stroke 5. Physical Therapy: evaluation and treatment of musculoskeletal (MSK) conditions resulting from an injury • With an employer providing a direct pay option to the provider, it removes barriers to access healthcare, eliminates the middleman, decreases the use for unneeded diagnostics and testing, and improves morale and engagement with proactively addressing employee health faster • ROI: Implementation of a direct pay, value-based program to the provider resulted in a thirty percent (30%) reduction in costs compared to using insurance, saving on average $380,000/quarter. Bottom Line: What better way to invest in the future than investing in your employees, which invest in your clients, which invest back in your company, creating growth opportunities not only for your organization but for those that you serve. Your employees are engaged and committed to excellence which builds a safer, stable, and sustainable workplace to decrease costs which will allow you to invest back in your workforce. Take care of your employees and they will take care of you. Lauren Larkey graduated from the University of Georgia with her Bachelor of Science degree in Microbiology and went to the Medical University of South Carolina to finish her Master’s of Rehabilitation Science in Physical Therapy. She opened the Newnan, GA clinic for BenchMark Physical Therapy in 2009, and shortly thereafter completed her Manual Therapy Certification and Trigger Point Dry Needling Certification. Her current role is the Director of Network & Payer Management for the Upstream Rehabilitation family of brands which encompasses BenchMark Physical Therapy, Drayer Physical Therapy Institute, and Results Physiotherapy. 11
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Things Employers Need Before OSHA Inspections Phillip B. Russell
This year is likely to bring more inspections from the Occupational Safety and Health Administration (OSHA) than ever before. The new leadership at the agency either came from California’s state OSHA plan or labor union leadership, neither of which are known for having a cooperative relationship with employers. OSHA is also making policy changes, shifting enforcement priorities, and hiring more compliance safety and health officers (CSHOs) to conduct more inspections. Employers should have four (4) things in place before OSHA shows up. If an employer can show all four, then even if tragedy strikes and there is a fatality or serious incident, the employer will be in a stronger position to avoid or minimize a citation and, most importantly, to save lives. 1. Policies and procedures Every employer should have robust safety policies and procedures that generally cover the hazards employees are most likely to encounter in the specific workplace. The types of policies and procedures will vary among industries and by job tasks. What works in construction may have no impact on a manufacturing facility. That is one reason OSHA has standards that vary by industry. The key is to address the hazards that workers are most likely to face in their industry, at the specific employer, and performing specific tasks. 2. Training Having the best policies and procedures in the industry will serve no purpose if they are not properly and effectively communicated to workers and supervisors. When OSHA shows up, they usually interview nonsupervisor employees first. The CSHO will ask workers whether they know the company’s safety program and, specifically, whether they know the particular safety policy or procedure that may be at issue during the inspection. The CSHO will also ask workers whether they have been trained on the company’s policies and procedures. Those workers must tell OSHA accurately and confidently how they know the company’s policies and procedures and have been fully and repeatedly trained on compliance with them and how to report any safety issues. 3. Observation During inspections, CSHOs will interview job site supervisory and safety personnel; usually after interviewing non-supervisory workers. A key line of questioning will be how these managers know workers are following the company’s safety policies and procedures and their training on those. This means employers must also have a robust program for making sure workers are following the rules and staying safe. It is part of how an employer can avoid incidents, which is the purpose of having safety rules and training. It is also an essential way for employers to minimize or avoid OSHA citations, even if tragedy strikes. 4. Enforcement Some workers; however, just won’t follow the company’s safety policies and procedures even though they have been trained repeatedly. They simply ignore the rules. Employers must also have a robust safety enforcement strategy. Coaching workers on near misses or procedure violations may be helpful in the short run, but any worker who ignores more informal attempts at addressing safety issues must be dealt with more formally and firmly. Employers must fire unsafe workers: especially supervisory personnel who don’t do their part in keeping the workplace safe. Every OSHA inspection involves a request for documents. Thus, every request for documents includes a request for the employer’s safety-related disciplinary records. Having none—especially on a larger project— suggests to the CSHO that the employer is not enforcing its own safety program. Their perspective is that employers should not tolerate unsafe workers, supervisors, or conditions and someone’s job should be at stake if they ignore the rules. Will these components help save lives? Absolutely. Having these four components in place saves lives and is good for business. Especially in a tight labor market, workers will not work for an employer who does not take safety seriously. Employers demonstrate their commitment by effective implementation of these four components. 14
Can an employer avoid or minimize an OSHA citation, even if tragedy strikes? Yes. OSHA does not write citations just because there was a fatality, another serious injury, or illness. OSHA must prove the employer violated a specific OSHA standard or the general duty clause of the OSH Act. OSHA tends to write citations it believes it can win (yet, sometimes, OSHA writes a citation to issue a press release or for other improper motives). They know if they write a citation not supported by the evidence, the employer will file a notice of contest. OSHA does not decide if they got it right in a citation. The U.S. Occupational Safety and Health Review Commission (OSHRC or Review Commission) evaluates contested citations. OSHRC is neither part of OSHA nor the U.S. Department of Labor. OSHRC can and will vacate any citation item OSHA does not support with evidence. Bonus Benefit – The poorly named “unavoidable employee misconduct” defense. These four components are also the elements of an affirmative defense employers can raise against any citation. It is called the “unavoidable employee misconduct” defense. However, the name is misleading. The defense has nothing to do with what an employee did or did not do. An employer can only raise the defense if it can prove it has all four of these components in place, which means the focus is on what the employer (not its workers) did or did not do to avoid the incident. Phillip B. Russell is an OSHA lawyer who helps businesses avoid or minimize citations and improve safety. He is board-certified in labor and employment law and has handled hundreds of OSHA inspections and contested citations, including over 150 fatality cases.
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What is a Functional Capacity Evaluation? Jon Nettie, PT, MPT, DPT Although there are many different types or brands of Functional Capacity Evaluations (FCEs), they all have the same goal - to help determine functional outcomes. There are several potential criteria for when an FCE should be used. A few such instances are when a patient has maximized all of the potential rehab (PT, OT, Chiropractic) and/ or medical interventions (injections, surgery, etc.) and there is a need to determine an individual’s ability to safely return to work full time or on modified permanent or transitional duty. Based on the outcome measures and clinical recommendations by the physical therapist, the FCE can help the physician set the appropriate restrictions. If the restrictions will be permanent, then they are presented to the employer in order to help them decide which job would be most appropriate for the injured employee. If the restrictions are transitional, then a recommendation of work conditioning can be made to help the employee return to full, unrestricted duty. A few additional ways an FCE can be used are for a disability assessment and to help assist a Vocational Counselor with a plan of care to help an individual find productive, safe employment within their limitations. The make-up of the FCE makes it a worthwhile assessment for physicians, case managers, insurance adjusters (TPAs), and the employer. Built into the FCE are psychophysical and kinesiophysical endpoints. The psychophysical endpoint is when an individual stops an activity due to their own perceived abilities. These are usually set up by pain, lack of range of motion, lack of strength, their understanding of what their injury is, and mostly lack of confidence and fear of re-injury. The kinesiophysical endpoint is when an evaluator recognizes poor mechanics and stops and activity. The poor mechanics can be due to generalized or joint-specific weakness, lack of range of motion causing substitute movement patterns, and identification of poor endurance. Subjective pain is not a limiting factor under kinesiophysical endpoints. Reliability of pain and consistency of effort is determined. Reliability of pain is determined from the patient taking psychometric tests, reporting of subjective pain as it relates to exertion scale, and heart rate. Additionally, clinical assessment of mechanical change, subjective pain rating, and physiological responses. For example: if poor mechanics are noted, and pain is rated high (six out of ten or greater) there should be an associated physiological response of increased heart rate within eight to twelve seconds following the pain stimulus. Sweating or clamminess may occur. Additionally, the clinician will look for true pain behaviors such as facial grimacing, wincing, holding of a body part, crying. Consistency of effort is determined through clinical observation (General AROM and strength testing vs AROM and strength needed for testing) and research-based outcomes (Occasional vs Frequent lifting; Grip/Pinch assessments). An FCE wants Reliability of Pain and Consistency of Effort to make sure the individual is putting forth full effort for the clinician to make an appropriate assessment of the outcomes. Ultimately, the assessment is to help determine what is best for the patient. Team Rehabilitation Physical Therapy is committed to performing quality FCEs for its patients. We employ a highly skilled team of individuals to service the Workers’ Compensation sector of physical and occupational therapy in each of our participating states of Michigan, Illinois, Indiana, Wisconsin, and Georgia. Jon Nettie has a Master’s in Physical Therapy from the University of Michigan-Flint and a Doctorate in Physical Therapy from Wayne State University. His experience is with a variety of orthopedic conditions and extensively with return to work programming. For information on our services please check out our website at www.team-rehab.com, call (888) OUR-TEAM, or email wc@team-rehab.com. 17
Employers: Communication is Crucial Roberta S. Mike, WCLA, FCLA Following a work accident, communication is the most important component to working with your injured employee, their treating physician, their family members, your staff, and insurance claim professional. Any time an employee is injured on the job, it is a good idea to remind them—and reeducate them, if necessary— about the policies and procedures from their date of hire and including after their work injury. Make sure the injured worker understands the importance of communication with the insurance claim professional as well as representatives of the company’s human resources department. Following their work injury, it’s a good reminder to recap the process for them. Here are some important tips to share with your team leads/supervisors: • Give your employee a hard copy of the policies and procedures for their own information. • Recap any accident detail information. • Explain the return-to-work transitional duty program. Show them the job to ensure they are going back to a safe environment. • Any lack of communication throughout the process will lead to distrust and can increase anxiety with the injured employer, as well as other employees who may have a limited understanding of the situation. • Family members should always be kept informed, as well, to keep the lines of understanding and communication open. • Explain the Family Leave and Medical Act (FMLA) and other benefits such as their health insurance. • Review their 401(k) contributions, etc. • Be clear on when the company will continue salary payments and notify your insurance claim professional promptly. • Contact your employee to ensure they are getting benefits and medical treatment. • Work with your insurance claim professional to guarantee consistent communication. You are an advocate for your employee. It is not only important but crucial that they know you’re in their corner and will be their voice as they go through treatment and recovery. Offer to contact a family member of the injured employee to arrange for assistance with transportation, medical appointments, shopping, or getting prescriptions. The more involved you can be in what their “next step” is, often anticipating what that might be, the more helpful it will be on the injured worker and their loved ones. If your employee decides to elect for legal representation, continue to communicate with them clearly and concisely to ensure everything is monitored from medical outcome to conclusion. Always establish a return to work with the employee to let them know their position is secure and they can focus on their recovery. It’s polite to send get well wishes and/or cards to your injured employee so they know they matter. Make sure you check to see if there’s anything the family needs during this time. Words make a big impact during sensitive times such as these. Always be thorough and forthright with the employee/their family and convey the importance of understanding the next step in the process. It’s good to keep up to date on any state rules or regulations affecting them or ones they may encounter. Take the time to review the Georgia Board State website to familiarize yourself as much as possible with the various resources available through them at www.sbwc.ga.gov. Many of these suggestions may seem obvious, but they stand to be reiterated. Only through repetition of these positions and supportive actions can you and your organization demonstrate that you care through understanding and compassion. Roberta Mike, current president of the Atlanta Claims Association, is a senior field claim adjuster for Strategic Comp, a division of Great American Insurance Group. She began her career forty years ago at Travelers Insurance Company in New York, and also worked for Fireman’s Fund Insurance Company in New York and Georgia, Ryder Claim Services, and Zurich North America, and Muller Water Products . Roberta served as president for Atlanta Association of Insurance Professional (AAIP) which is a local chapter of the National African American Insurance Association. She is a recipient 2017 Recipient Claims Person of the Year and Pioneer’s Award of 2018. 18
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A Message from the Chairman Ben Vinson, Chairman and Chief Appellate Judge Happy New Year! I hope everyone is doing well and enjoying the beginning of 2022. As a proud and loyal Georgia Bulldog, let me say my year is off to a fantastic start. Congrats to the University of Georgia football team on an exciting national championship victory. What a season. Between the Dawgs’ win and the Braves’ World Series title, it seems the State of Georgia is riding a wave of positive momentum. On that note, the State Board of Workers’ Compensation is in good health despite the ongoing challenges of COVID-19. We are maintaining our goal of preserving a balanced and stable Workers’ Compensation system for all of our stakeholders. Looking back over 2021, we are happy to report that several key metrics for the Board indicate a positive status and point to an encouraging outlook for this year. Our hearing division, led by Chief Judge David Imahara, saw an increase in awards, hearings, motions, and petitions for medical treatment compared to the prior year. In fact, hearings were up forty-five percent (45%) from 2020 and we continue to see a variety in the type of hearings held with options for in-person, virtual, hybrid, and brief only. Our settlement division, headed up by David Kay, reports that the Board approved 13,618 stipulations in 2021, which amounted to over $593 million in the total value of settlements. Finally, our Alternative Dispute Resolution (ADR) division, directed by Judge Liesa Gholson, stayed busy up until the end of the year and continued to experience high demand for in-person and virtual mediations. Recently, I was able to attend the Georgia Workers’ Compensation Association (GWCA) conference in Athens and provide a legislative update as part of the agenda. The Georgia General Assembly convened on Monday, January 10, for the first of forty legislative days that will form the 2022 Session. Regarding Workers’ Compensation legislation, I pointed to three issues that might be discussed this year: 1. A presumption for first responders with post-traumatic stress disorder (PTSD) 2. A measure to address the coverage gap with Professional Employer Organization (PEOs) 3. A possible increase in the max temporary total disability (TTD). Our Advisory Council is aware of each issue and will stay involved as the legislative process plays out. I am looking forward to the GWCA Spring conference in June, to be held on Jekyll Island, and the GWCA Fall seminar scheduled for September in Atlanta. I hope to see many of you there and I am sure we will enjoy the programs. Like many businesses in the private sector, the Board has endured staffing challenges with COVID-19 surges and protocols, plus a degree of retirements and turnover. However, in the face of these difficulties, the staff remains on mission and operates the work of the Board efficiently. One final optimistic note, as part of strong revenue growth and responsible state budgeting, Governor Kemp announced he is proposing a pay increase for all state employees this year and a cost-of-living adjustment pay increase in future years plus a few other benefits. When you combine that news with continued job growth and historically low unemployment rate, and the Braves…and the Dawgs…we are indeed experiencing positive momentum and a great start to the year. Ben Vinson was appointed Chairman and Chief Appellate Judge of the State Board of Workers’ Compensation by Georgia’s Governor Brian Kemp in May 2021. He previously served as Director and Appellate Division Judge for the Board, appointed by former Governor Nathan Deal in July of 2017. In addition to hearing Workers’ Compensation cases on appeal, Chairman Vinson shares responsibility with Judges McKay and Bahl for governing the state agency, which includes regulatory, policy, and operational matters.
STATE BOARD OF WORKERS’ COMPENSATION (404) 656-3875 270 Peachtree Street, NW Atlanta, GA 30303-1299
www.sbwc.georgia.gov
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Workplace Health Magazine gets around the WC Community!
GWCA Conference in Athens Chairman Eddie Kinnard, Judge Ben Vinson, Judge Frank McKay
Thanking John Poole for 29 Years of Service at the GWCA Conference
GWCA fun in Athens, GA
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Translation vs. Interpretation Aruna Rao-McCann, MS, CRC, CCM Hola! Namaste! Howdy! Habla Ingles? Sprichst du Englisch? Do you speak English? Many of us who have traveled the world or are from another country understand the nuances of not being able to communicate in our own language with a physician, a physical and occupational therapist, Uber driver, or shopkeeper. As an immigrant from India, I had the privilege of speaking and communicating in English, both written and oral. However, I learned Spanish on my own and it has been very useful in my role as a nurse case manager in assisting injured workers who only speak Spanish. That being said, I believe in a patient’s right to have a private, physical examination with the physician at any given time. When this is done, I ensure that I have a certified interpreter present at the appointment who communicates on behalf of the patient. They also accurately relay and clarify what the physician recommends for them. The physician also has the assistance they need in correctly understanding the patient’s symptoms and concerns in order to confirm a correct diagnosis and identify a treatment plan. The importance of sending a certified interpreter is important on multiple levels. They need to: • Speak English • Speak the language they are interpreting fluently • Understand medical terminology • Have the ability & confidence to ask the treating providers if they don’t understand any term Here’s the crucial difference between an interpreter and a translator: An interpreter merely interprets oral language and does not make notes of what transpired during the visit because their job is not to be subjective, rather it is to interpret for the moment at the appointment or when an interaction is taking place. Please do not ask agencies to have their interpreters send you a written report of what transpired as that is illegal. Additionally, the interpreter’s job is completed once they have helped out the person and others in communication and should leave after the appointment is done. They should not stay back and engage in social bantering, exchange of phone numbers, or render advice on the case. A translator translates written documents from one language to another language. I know it is catchy to say, “We need Transportation & Translation,” or “T&T.” However, please be mindful of what you are requesting at any given time to help people who do not speak English as a first language or at all. Multiple agencies provide certified interpreters, both medical and legal and I am happy to make recommendations and share information.
Aruna Rao-McCann, MS, CRC, CCM, holds a Bachelor of Science with Honours in Psychology from Delhi University in India. She received her Master’s in Rehab Counseling from Georgia State University in Atlanta. Aruna is multi-lingual. She is an Independent Case Manager and owns ARM Case Management Solutions.
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Return to Work Decisions: Restrictions, Limitation, Capacity, and/or Tolerance Shane Mangrum, M.D. “In the sweat of thy brow shalt thou earn thy daily bread: it was not a curse upon mankind, but the balm which reconciled it to existence.” ~ W. Somerset Maugham The process of facilitating the return to work for an injured employee can be complicated to navigate as a treating physician. In school, doctors are educated on how to treat injury and illness. Little heed is given in the physician molding process for how to fill out return to work forms and the functional issues that surround the care of injured workers. From a practice perspective, the terms “restriction,” “limitation,” “capacity,” and “tolerance” are essential to the communication that moves the process of return to work forward. In a colloquial sense, these terms are used loosely or interchangeably. However, in an occupational medicine sense, these terms each have a very specific meaning imbued that can encourage clear, consistent communication for all parties with a stake in the process. The American Medical Association (AMA) guides to the Evaluation of Work Ability and Return to Work defines these critical terms as follows: • Restriction = activity advised against because of harm • Limitations = activity cannot be performed due to ta lack of physical or psychological capacity • Capacity = current ability as measured in concept like strength, flexibility or endurance • Tolerance (defined as “the ability to tolerate sustained work at a given level”) ≠ equivalent to a limitation. In certain situations, a worker “may have the ability to do a certain task (no limitation or restriction), but not the ability to do it comfortably.” A treating physician must consider these terms carefully when filling out the seemingly ceaseless flow of forms that go along with the return to work process for an injured worker, as well as asking the proper questions when necessary. The first question he/she must consider: Whether there is a risk of substantial harm with work activity (and not just an increase in symptoms)? If there is a risk of substantial harm, the restrictions are indicated. The second question to consider: Is the worker actually able to physically do the task in question (again, not considering symptoms, but ability)? If no, then the reason can be stated as a limitation. If the answer to this question is yes, then consider issues of tolerance. The wise George Herbert once said, “Good words are worth much but cost little.” The words we physicians choose to communicate the roadmap for return to work are worth much. And they don’t have to cost anything more than a careful moment of consideration.
Shane Mangrum, M.D., is an experienced, board-certified physiatrist at Axion Spine & Neurosurgery in Alpharetta in the Atlanta, Georgia metropolitan area. He is double boarded in physical medicine and rehabilitation, as well as sports medicine. Dr. Mangrum earned his undergraduate degree in organismic and evolutionary biology from Harvard College in Cambridge, Massachusetts. He completed medical school at the University of Utah in Salt Lake City and finished medical training with residencies in physical medicine and rehabilitation at Mayo Clinic and the University of Utah. Drawn to the climate and culture of Atlanta, Dr. Mangrum now resides in Milton with his wife and four beautiful children. 26
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Stress Management in the Workers’ Comp World Karl Kirkland, Ph.D. Workers’ Compensation (WC) claims are challenging for everyone concerned: the patient, their family, the adjusters, the case managers, the employers, and the attorneys. As a retired psychologist, I spend thirty-six years evaluating and treating Workers’ Compensation claimants, so I know firsthand how the process works and the potential negative impact on the parties. Even cases that “go right,” can be extremely stressful. In my experience, knowledge, and research of Workers’ Compensation, here are some ideas as to why the process goes wrong, as well as things that can make it better. First, there isn’t just one factor to the stress of the situation, rather there are several sources such as: injuryrelated pain, depression, anxiety, fear of the future, to name a few. On the other side of the coin, there is the push for adjusters to do more with less. They suffer from high caseloads, a lack of training resources, high turnover rates among adjusters, as well as pressure to keep costs as low as possible. These two “sides” have very different motivating factors and goals in the process of managing a claim. One of my main frustrations as a treatment provider was once a plaintiff’s attorney entered the case, all parties retreated to their corners and stopped talking. From then on, it was as if all parties were functioning in their own silos. The lack of direct communication causes paranoid thinking, which often increases hostility and anxiety for all. I spent many years studying claimants and the process on a case-by-case basis through evaluations. Stress, anxiety, and depression were always present. On the job injuries naturally cause disruptions for the injured worker. However, the same goes for the claims adjuster or case manager. With help from the Alabama Department of Labor, I recently completed a research study on claims adjusters and stress. We surveyed forty-six Workers’ Compensation adjusters attending a mandatory continuing education conferences in Alabama. The adjusters were asked to respond to questions concerning their perceptions of work stressors. Results revealed seventy-four percent (74%) of adjusters reported they were overburdened with too many claimant files to manage. In addition, adjusters listed their stressors as managing claimant relationships like dealing with anger and fear, handling complicated settlements, high turnover rates among their peers, time management, and the challenge of working with multiple jurisdictions concerning Workers’ Compensation laws and regulations. My research and experience in the field have led to a set of proposed solutions. These include: • More training for new adjusters • Peer mentors within companies to shepherd new hires • Early involvement of psychologists in the claim • Avoidance of the “silo effect” by having open conference calls between adjusters and all parties at the beginning of a case and mid-stream during case management We also asked about positive coping strategies of adjustors. Stress management is “in the eye of the beholder,” so use what works for you. Common strategies included: • Setting boundaries • Exercise • Effective time management • Walking away from your desk • Taking breaks • Developing protocols so cases are uniformly handled with the same processes and actions by the adjuster to increase control
Karl Kirkland, Ph.D., is a retired clinical psychologist, who regularly evaluated and treated workers’ comp cases in central Alabama for 36 years. He earned a doctorate degree in Philosophy. He is a Forensic Consultant with MPA Legal, the Forensic Services Division of Montgomery Psychiatry & Associates.
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Rehabilitate, Recover, and Restore Randy F. Rizor, M.D. He was a former U.S. Marine who had herniated a lumbar disc six years earlier lifting luggage. I watched him from the window as he got out of his transportation service and walked through the front door into the lobby. He was bent forward at the waist about forty-five degrees, his elbows resting on a rolling walker. He was wearing a back brace as well as braces on both ankles. He walked slowly, shuffling his feet. He had constant pain in his back and both legs, despite having had two back surgeries, an implanted spinal cord stimulator, and taking two opioids equivalent to over 50 mg of morphine a day. He required transportation and attendant care. His case had been designated as catastrophic. After walking about thirty feet, he sat down, out of breath. His shoulders slumped and his arms shook as he signed the consent for treatment. Six weeks later, I watched him again as he walked through the lobby; this time on the way out. He had no braces. The rolling walker had been replaced by a single-point cane. His left foot drop was barely noticeable. The day before, he had walked over a mile on an outside track and had performed a plank for over sixty seconds in the gym. He had not taken an opioid in four weeks. Before he left, we talked about the future – moving into his own apartment, enrolling in classes, and looking for a job. Between those two occasions, he had been a patient at the Rizor Institute, our interdisciplinary residential rehabilitation program. Six days a week, he participated in structured, goal-oriented physical and occupational therapy four hours a day. Opioids were weaned as his activity level was increased. He had individual behavioral therapy and rehabilitation coaching sessions twice a day by telemedicine link in his room. At night, he did homework studying self-management techniques. His catastrophic thinking was replaced by proactive planning and problem-solving. He had nutritional counseling and lost weight. Our program—treating chronic pain by focusing on function—is new, but the principles of comprehensive treatment of all components of chronic pain—biological, psychological, and social—date back fifty years. In the 1970s, centers created by Dr. Hugh Rosomoff in Miami and Dr. John Bonica in Seattle, each treated hundreds of patients a year. Dr. Rosomoff, a neurosurgeon, started his program to “prehab” patients scheduled for back surgery. Often the treatment was so effective that the anticipated surgery was never performed. In the 1990s, theories on pain treatment changed. Chronic pain was considered to be like acute pain arising solely from a biological cause that could be located and treated. Opioid medications were considered a safe, effective, and economical way to treat all pain. Between 1997 and 2002, the number of prescriptions for oxycodone increased from 670,000 to 6.2 million. At the same time, the proliferation of easily placed implant systems for spinal fusion contributed to the belief that back pain had a primarily mechanical cause that could be corrected. Between 2004 and 2015, the rate of spinal fusions increased by thirty-two percent (32%). During this time, the availability of comprehensive interdisciplinary treatment all but vanished as programs across the country, including the ones in Seattle and Miami, closed. The resulting epidemics in opioid addiction and failed back surgery with their devastating financial and social cost have brought attention to the flaws in the medical evidence that produced those problems. Today, the focus in treating chronic pain is returning to rehabilitative strategies. At the Rizor Institute, our results speak for themselves. Please call 404-443-8484 or visit rizorinstitute.com for more information. Randy F. Rizor, M.D,. is president and a founding partner of The Physicians Spine & Rehabilitation Specialists and practices in the Sandy Springs and Stockbridge offices. Dr. Rizor has been named one of Atlanta’s top doctors by Atlanta Magazine and one of the top doctors in the country by US News and World Report. He is a member of the Chairman’s Advisory Council of the Georgia State Board of Workers’ Compensation. He currently serves as President of the Medical Association of Atlanta, as well as with the Board of Directors of the Medical Association of Georgia. 30
The 5-Year Rule for a Georgia Workers’ Compensation Case Todd Ross, Esq. Because the Workers’ Compensation Act in the State of Georgia is derived from legislative statutes and Board Rule implementation, there are numerous deadlines throughout the process of each claim. For example, there are deadlines associated with each of the following: timely payment of indemnity benefits; timely payment and approval of medical care; filing of a controvert; filing of the WC-1, WC-3, WC-2, WC-4, WC104, etc. There are also deadlines for timely notice and filing of claims by an injured employee. Additionally, all of the deadlines from Georgia’s Civil Practice Act also apply. Additionally, there is a critical deadline to the Board’s jurisdiction to even hear a claim which has not been accepted as compensable. That deadline is referred to as the 5-year rule. At O.C.G.A. § 34-9-100(d)(1), the Georgia Legislature wrote the most recent version of the 5-year rule: “For injuries occurring on or after July 1, 2007, any claim filed with the Board for which neither medical nor income benefits have been paid shall stand dismissed with prejudice by operation of law if no hearing has been held within five years of the alleged date of injury.” Here, the Legislature set a finite amount of time for the Board to hear a claim of occupational injury. Other provisions of the statute specifically exclude occupational disease claims from this 5-year rule. A specific claim assigned to me illustrates an application of the 5-year rule. In January 2016, former counsel for an injured employee filed a WC-14 request for a hearing and alleged an injury date from December 2015. The Board scheduled a hearing. Next, counsel for the injured employee withdrew and new counsel was obtained by the injured employee. Counsel for the injured employee voluntarily removed the claim from the Board’s active hearing calendar several times. Throughout the claim, a total of four different WC-14 filings requesting a hearing were voluntarily withdrawn from the hearing calendar. Across seven calendar years, a hearing was scheduled seventeen different times. Importantly, this was an alleged date of the accident for which neither medical bills nor income benefits had ever been paid. Over the life of the claim, the employee was scheduled for a deposition on multiple occasions and eventually provided deposition testimony twice. After I asserted the 5-year rule as a defense and statutory bar to the Board’s jurisdiction to even hear the case, counsel for the injured employee voluntarily dismissed the claim. Application of the 5-year rule to any claim is certainly rare. However, the specific example provided demonstrates that the deadline to have the Board hear a claim is equally as important as every other deadline contained within Georgia’s Workers’ Compensation system.
C. Todd Ross serves on the Legal Committee for the Georgia State Board of Workers’ Compensation’s Steering Committee. He has presented on workers’ compensation topics to numerous claims associations, TPA’s, employers, insurers, self-insured, and at State Bar of Georgia seminars. He is also very active with the Georgia Association of Manufacturers.
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Home Care Workforce Impacts Georgians Dave Lamb Workforce, workforce, workforce… it is a theme facing healthcare providers across Georgia and the nation. Providers have been encountering a growing workforce issue for several years, an issue that has been dramatically enhanced by the stresses of the pandemic. The Georgia General Assembly held joint appropriations hearings January 18-20, 2022, with an agency theme of Workforce Shortages Throughout All of State Government. Last November, the House Human Relations and Aging Committee held hearings on the healthcare workforce shortage, hearing the concerns of a wide range of providers seeking nurses and caregivers. For healthcare, the workforce shortage is complex, involving pressures both within and outside the industry. We are all indebted to the effort of our healthcare workforce who has been serving the needs of Georgians during the pandemic. Now, we must all work to stabilize that workforce into the future. The pandemic changed the delivery of patient care, ushering in a new appreciation for the patient’s house as more Georgians opted to remain in their residences to receive more of their care. While the home does not replace the need for facility care, it does augment total patient care and contentment. An October 2021 Kaiser Family Foundation study examined the care delivered in the home and community, finding that five percent (5%) of the adult population is receiving paid care by caregivers and nurses in their homes. In our state, that translates to more than 400,000 Georgians who are receiving care in their homes. The Georgia Chapter of the Home Care Association of America (HCAOA) represents many of the more than 2,000 licensed home care provers across the state who provide a wide range of skilled and unskilled care. In a survey conducted in October 2021 concerning the home care workforce, eighty percent (80%) of the providers surveyed had insufficient applicants to meet their hiring needs while more than sixty percent (60%) could not meet the pay rate needs of the applicant. Caregivers represent the largest segment of the home care workforce. During the first eighteen (18) months of the pandemic, the Georgia CNA Registry lost over twelve percent (12.7%) of listed CNAs. While this overall drop is concerning, more troubling is the loss of CNAs in nine years in 112 Georgia counties. All Georgians deserve CNA coverage; many counties have a critical need. Echols County in south Georgia had only three (3) CNAs on the registry in November 2021. While some may discount Echols as a small county, we cannot and will not discount those in Echols County that need care. The caregiver role is critical for the unskilled care needs of Georgians. Unfortunately, the competition for caregivers is often with non-medical opportunities outside of caregiving. These opportunities come at your local Wal-Mart, Hobby Lobby, or nearby Amazon warehouse, and come in the $15 - 20 per hour pay range, a level current healthcare reimbursement rates prevent providers from matching. Caregivers are critical to the healthcare continuum and the overall care of Georgians. We need reimbursement rate support, but we also need assistance building a true caregiver career path in Georgia that addresses all aspects of the caregiver role and recognizes the caregiver heart Georgians see every day. Dave Lamb is the Director of Governmental Affairs for CareMaster Medical Services. He also serves as the Legislative Chair for the Georgia Chapter of the Home Care Association of America (HCAOA.) He can be reached at davelamb@caremastermedical.com.
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Taking the Risk Out of Light-Duty Work Dustin S. Thompson, Swift, Currie McGhee, Hiers, LLP One of the most effective ways to mitigate exposure and accelerate resolution in a Workers’ Compensation claim is an employer’s ability to safely return injured workers to light-duty work. Despite the favorable impact of light-duty work, employers are often wary of bringing injured employees back to work. Moreover, once income benefits are commenced, Georgia law, in particular the WC-240 process, requires a rather rigorous and, at times, complicated procedure to bring injured workers back to a light duty. Although perceived as risky and complicated, establishing light-duty positions and safely bringing injured employees back to work does not have to be. Procedures to bring employees back to light-duty work should be in place in advance of any work accident. The employer’s ability to immediately offer light-duty work following the assignment of work restrictions is crucial because it bypasses the WC-240 process. Statistics further show claims are open longer when light-duty work is not available or utilized. If possible, employers should have established light-duty positions ranging from sedentary to those with lifting limitations. Once income benefits are paid, Georgia law requires employers to follow the WC-240 process to return employees to light-duty work and suspend income benefits. The process can be found at O.C.G.A. §34-9-240. A written description of the offered light-duty position must be sent to the authorized treating physician (ATP). This is typically performed by the employer completing a WC-240a job analysis form. It is more effective to provide as much detail about the position on the WC-240a, which includes dedicated space to address standing, sitting, lifting, carrying, pushing, pulling, etc. When sending the WC-240a to the ATP, the injured worker and the injured worker’s attorney must be copied. The ATP will then indicate whether the claimant is released to the described job, is unable to perform the described job, or is instead released to a job with modified restrictions. The WC-240a form must be executed by the ATP within 60 days of treatment. Once the WC-240a is signed by the ATP, a WC-240 (notice the missing “a”), which details the authorized light-duty job and provides a date to return to attempt the position with a minimum of 10 days’ notice, must be provided to the injured worker and their attorney. If there are issues with obtaining the ATPs authorization of the described light-duty job, it may be helpful to provide more details about the position. A creative solution to help the ATP better understand the light-duty position is for the employer to film the actual work area and job being performed and then provide the video to the ATP for review. On the date the light-duty job is set to begin, employers must ensure the supervisors and workers in the area understand the restraints of the position and avoid asking the employee to perform work in excess of those parameters. It is also prudent to instruct the employee to immediately report issues with performing the light-duty job. If issues are reported, have the employee provide a written statement about any inability to perform the job. The employee, coworkers, and supervisors being on the same page about the parameters of the light-duty work creates a higher probability for the job to be performed safely and longer, and thus reduces the risk of liability for the employer. When the employee returns to the authorized light-duty job or if the employee refuses to return on that date, a WC-2 should be filed with the State Board attaching the WC-240a and WC-240 noting the suspension of income benefits. If the employee works more than eight cumulative hours or one scheduled workday, whichever is greater, but less than 15 days, income benefits must be reinstated immediately. Otherwise, the employer waives the defense the employee unjustifiably refused to perform the light-duty position. The employer should maintain an open line of communication with the employee to ensure the safe performance of the light-duty job and to ensure the job is modified as treatment progresses and work restrictions change. The employer should further ensure the employee is providing copies of every new work status report to confirm the light-duty job remains appropriate. Ultimately, the employee’s performance of light-duty work should benefit their medical treatment and potentially provide a quicker return to regular duty. To avoid the time and complications of the WC-240 process, the most effective avenue to navigate light-duty work is for employers to establish light-duty positions before work accidents occur. With a range of light-duty positions readily available to injured workers, the employer can immediately offer light-duty work following the assignment of work restrictions and avoid the hassle of the WC-240 procedures. When such positions are not immediately available, the employer can follow the foregoing steps to meet the requirements of the WC-240 process once income benefits are commenced. If in the WC-240 process, the best strategy for success is to provide the ATP with detailed information about the position and maintain an open line of communication with the employee and their supervisors about the parameters of the light-duty job. 36
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Summertime Leads to an Increase in Workplace Hand and Upper Extremity Injuries Sonya Khurana, M.D. According to a Bureau of Labor and Statistics study, there is an increase in work-related injuries and fatalities during the summer, with the peak month being July. With warmer weather just around the corner, employers and employees must remain vigilant to help prevent hand and upper extremity injuries. Reasons for such increased work-related injuries include, but are not limited to: hot weather leading to increased fatigue and loss of focus, increased construction activities, summer storms, insect bites, gardening wounds, and inexperienced seasonal workers. Working in extreme heat can cause workers to fatigue quicker and lose focus. This combined with sweaty hands that cause slippage of instruments can lead to lacerations, amputations, open fractures, sprains, and strains. Most superficial wounds can be treated with local wound care and sutures, if necessary. The worker should be evaluated if there is a concern for injury to any of the “white structures” of the upper extremity such as tendons, ligaments, or bones. Allowing employees to take breaks from the heat, utilizing cooling stations, and stressing the use of safety gloves when using sharp instruments or machinery can help prevent these injuries. Increased construction activities are often accompanied by the expanded use of vibratory instruments. Frequent use of vibratory instruments can cause damage to nerves in the hand and upper extremity, trigger finger, and lateral epicondylitis (tennis elbow). Employees need frequent breaks from the vibratory tool and varied upper extremity tasks to perform to help prevent these conditions from forming or becoming exacerbated. Heavy manual overhead labor during construction can cause shoulder and elbow pain. Those who work outside during summer storms are at risk for hand and upper extremity fractures, sprains, strains from slipping and falling during the rain, and/or electrical burns from lightning storms. Employees need to seek shelter and cease outdoor work activities during summer storms. Insects are more active in the summer and bee stings and insect bites to the hand and upper extremity are common. Some plants, like roses, have sharp thorns that can get lodged in the skin of the upper extremity. Most of these gardening wounds/bites may be treated with local wound care, but there is also a risk of a secondary infection. Employers and employees should seek care for these if there is a concern for infection, including redness, drainage, swelling, and increased pain. Wearing gloves while working, clean light-colored clothing, and using insecticides can help stave off insect bites and stings. Inexperienced seasonal workers may not be familiar or comfortable with machinery around the workplace or protocols that are in place for the protection of the workers. The employer should review safety information with all workers, including the seasonal ones, and ensure they are properly trained on how to use the equipment. Even though data shows an increase in worker injuries in the summer months, with the proper vigilance, training, and work equipment, the number of workplace injuries can be reduced or even prevented. Sonya Khurana, M.D., is a hand, wrist, elbow, and shoulder surgeon at Perimeter Orthopedics in Atlanta and Woodstock. She is double fellowship-trained in hand and microvascular surgery as well as upper extremity and shoulder surgery. Dr. Khurana is a member of the American Academy of Orthopaedic Surgeons, the American Society for Surgery of the Hand, the American Association of Hand Surgery, and the Ruth Jackson Orthopaedic Society for female orthopaedic surgeons. 39
Enhanced Recovery After Surgery and the Rationale for Using Non-Narcotic Alternatives Kim Duggan, MHA, BSN, RN-C Corporations strive to improve customer satisfaction and retain valuable employees. Healthcare similarly aims to deliver clinical excellence and exceed industry standards. The value proposition becomes a partnership to effect change and increase profit margins and reimbursements through the delivery of high-quality and efficient health care. Businesses are being challenged to secure qualified employees. Particularly since COVID, companies struggle to employ and retain a competent workforce. Employers are facing constant staffing issues that affect their ability to keep normal business operations. Many times, patients receive opioids after surgery which can lead to downstream side effects and adverse events. Such events may include increased risk of dependence and addiction, delayed recovery, and missed days of work. Consequently, when a staff member goes out for surgery, their position remains vacant or becomes the responsibility of other employees. As a result, company managers are anxious for the safe and speedy return of the employee back into the workforce. Much like in business, to increase revenue without compromising value, healthcare must deliver quality care at a low cost. This is achieved by reducing care variation and providing clinical excellence through best practice programs. For surgical patients, utilizing evidenced-based protocols, create abundant downstream rewards by meeting the quadruple aim. An example of this is an Enhanced Recovery After Surgery (ERAS) program. A complete ERAS program delivers evidenced-based enhancements throughout all phases of care to mitigate the consequences seen with archaic surgical methods. Healthcare also seeks to find cost savings wherever possible; the surgical arena tends to be a hotbed for costsaving opportunities. Frequently, decisions are made to eliminate “expensive” items from surgical cases and replace them with cheaper alternatives without understanding the clinical rationale. At first glance, the use of opioids to manage postsurgical pain may appear to be the more cost-effective method due to its inexpensive upfront cost. However, the truth is that opioids may lead to future costs resulting from associated adverse outcomes such as bowel paralysis, leading to longer lengths of stay which increases overall costs. The better option is to use a high-quality, opioid-sparing medication, that is non-narcotic, non-sedating, and long-acting which provides extended pain coverage. This enables patients to quickly begin their recovery journey which has shown to greatly reduce, or in some cases eliminate the need for opioids. By using a high quality, opioid-sparing medication patients can begin meeting discharge criteria hours, not days after surgery, thus returning to baseline, and allowing faster recovery. With its many benefits and limitation of harmful adverse events, multimodal analgesia is essential to any ERAS program. Healthcare organizations and employers experience plentiful rewards through providing quality and improving the delivery of care, but the real winner is the patient.
Kim is an author and national subject matter expert on the Perioperative Surgical Home (PSH) and Enhanced Recovery After Surgery (ERAS) programs. Kim is the owner of IMPACT Surgical Consulting. With two decades in the surgical arena, Kim was one of the primary architects for establishing 18 complete ERAS surgical service lines for New Hanover Regional Medical Center in Wilmington, North Carolina. 40
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Chiropractic for Work Injuries Dr. Chris Connelly In spite of the fact that millions of Americans successfully treat with chiropractors every year, chiropractors remain underutilized in the workers compensation system. Unfortunately there are many assumptions and stereotypes about chiropractors in the worker’s compensation community that have caused insurers and claims management personnel to unreasonably avoid chiropractors, even those who understand the issues in worker’s compensation and are able to treat effectively to reduce costs, encourage early return to work, and help avoid the use of drugs or surgery. The purpose of this article is to introduce you to chiropractic care and give you some guidelines for how to choose an effective chiropractor to be a part of your team. With the present opioid epidemic and recent medical research in Journal of the American Medical Association (JAMA), as well as, Annals of Internal Medicine supporting the use of spinal manipulative therapy as a first line treatment for acute low back pain, it’s a great time to take a second look at including knowledgeable chiropractors in the care of injured workers. In fact, after an extensive study of all available care for low back problems, the federal Agency for Health Care Policy and Research (now the Agency for Health Care Research and Quality) recommended that low back pain sufferers choose the most conservative care first. And it recommended spinal manipulation as the only safe and effective, drugless form of initial professional treatment for acute low back problems in adults. The evidence supports that doctors of chiropractic are well suited to diagnose, treat, and manage the treatment of patients with low back pain disorders. Low back pain initiated with a doctor of chiropractic (DC) saves 40 percent on health care costs when compared with care initiated through a medical doctor (MD), according to a study that analyzed data from 85,000 Blue Cross Blue Shield (BCBS) beneficiaries in Tennessee over a two-year span. (Liliedahl et al (2010), Journal of Manipulative and Physiological Therapeutics) In a sample of 1,885 workers there was a very strong association between surgery and first provider seen for the injury even after adjustment for other important variables. Approximately 42.7% of workers who first saw a surgeon had surgery, in contrast to only 1.5% of those who saw a chiropractor. (Spine. 2013;38(11):953-964) It’s important to note that none of the researchers of this study are chiropractors. This study is a great reminder that provider selection (even within the same specialty) is an important and often missed factor in a successful outcome. It also leads us into my top 6 tips for a successful outcome in a work injury: 1. Identify more serious injuries early. 2. Identify and address apportionment, catastrophizing, malingering and symptom amplification early. 3. Provider selection. 4. Patient selection for testing and treatment. 5. Return to normal activities and work as soon as possible. 6. Patient education and reassurance. These tips will be the topics for future articles but hopefully this article will open the door for specialize chiropractors in the work injury arena. Dr. Chris Connelly is a chiropractor from Atlanta, Georgia who is a Certified Brain Injury Specialists by the Brain Injury Association of America. He has been in clinical practice for 25 years and has treated over 20,000 trauma cases. “A good diagnosis is the first step to a great treatment” and “working together to get patients better” are two mantras for good patient care in his office. 42
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TPA Adjuster
Home Health
Risk Manager
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Urgent Care/Occupational Medicine Defense/Claimant Attorney Pain Management Practice Safety Professional Transportation Surveillance Broker DME
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Nominations: FEB 7 - APR 1 Voting: APR 4 - JUN 1 Winners Announced: JUL 2
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Whose Employee Are They Anyways? Lexi Laufer, Attorney Few topics have spurred more debate in recent years than the ever-changing definition of “employee” and the requirements necessary to establish an employment relationship. At the forefront of this debate are organizations such as temporary help contracting firms, employee leasing companies, and professional employment organizations. In practice, these overlapping relationships can lead to scenarios where a worker receives wages from one company that is insured through another company, but performs work on behalf of yet another company. When a worker is injured, confusion arises about which company is responsible for Workers’ Compensation coverage. As a result, understanding the various types of employment relationships is an integral first step to determining which company covers the injured worker. Leased Employees Leased employees are direct employees of employee leasing companies or PEOs which lease the employee to client companies to perform labor. 1. Employee Leasing Companies - Definition: Defined by O.C.G.A. § 34-8-32, an employee leasing company is a business entity that supplies workers to a client company on a temporary basis or for a specific project with a start/end date. Coverage: During the temporary employment period the leased employee remains a direct employee of the staffing company. Example: Feyonce’, a wedding dress designer, needs thirty (30) seamstresses to make dresses for a special order. Feyonce’ calls ShortNSweet, a temporary employment agency, that provides thirty (30) workers. If one of the workers supplied to Feyonce’ is injured, ShortNSweet is the employer. 2. Professional Employer Organization (PEO) - Definition: An employee leasing company that enters into a contractual agreement with the client company to undertake certain employer responsibilities, resulting in a coemployment relationship. The PEO handles human resource responsibilities of the client company but does not provide workers. Coverage: The PEO is the leased employee’s “Administrative Employer” and the client company who hired the PEO is considered the “Worksite Employer.” The worksite employer maintains full control and direction over the leased employees’ day-to-day operations. Example: Due to the sudden surge in weddings, Feyonce’ needs help managing payroll, benefits and other human resources functions. Feyonce’ hires IDo, a PEO, to manage these employee-related tasks. Feyonce’ and IDo enter into an agreement which establishes a co-employment relationship. Statutory Employees When a worker’s immediate employer is not covered under the Act or becomes insolvent, O.C.G.A. 34-9-8 attaches secondary liability to a principal, intermediate, or subcontractor who had control over the project/premises where the laborer was working. Coverage: The contractor, the employee leasing company or the PEO are considered the statutory employer and are therefore the injured worker’s employer. Example: PartyBus, a transportation rental business, hires Rider to provide busses. Rider then hires Driver to perform the work PartyBus hired Rider to perform. Driver gets hurt. Shortly thereafter, Rider’s insurer becomes insolvent. PartyBus may be considered Driver’s statutory employer. As you can see, determining which company employs an injured worker is not always an easy feat. Fortunately, there are cases pending before the State Board that could provide clarity on how to determine who the employer is for coverage purposes in unconventional-multi-employer situations. Lexi earned her Bachelor’s in Business Administration from Stetson University, summa cum laude, in 2016 and was recognized as one of the two top students in her major. She later received her Juris Doctorate from the University of Florida Levin College of Law in 2019. While in law school, Lexi was a member of the Florida Moot Court Team and served on the Justice Campbell Thornal Executive Board as the activities chair assistant. Lexi also had the opportunity to work with the inhouse counsel of a Fortune 500 company, as well as the Georgia Office of the Attorney General’s commercial transactions and litigation team. Lexi now focuses her practice on the defense of workers’ compensation claims in Georgia. 48
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Streamlined Protocols for Treating Injured Workers John McCormick, Jr., MD Low back pain is a common injury seen in orthopedic practices. Up to seventy percent (70%) of the general population may experience back pain at some point throughout their life and the majority of the back pain resolves without treatment. The goal of every physician is to provide quality care for the patient and return them to work as quickly as possible. However, the challenge in a Workers’ Compensation injury is seeing patients in a timely matter and creating a pathway to treatment that is cognizant of the patient’s problem and factors in their job description. Industry greatly benefits by having clearly-defined options for their employees to perform work when they have work restrictions. Difficult scenarios arise when a spine surgeon is seeing patients twelve (12) weeks out from their injury and/ or the injured party has been out of work for twelve (12) weeks and the individual has tried minimal treatment modalities regarding the lumbar spine. It is also crucial to create an environment that keeps spine surgeons actively engaged and willing to care for “low back” Workers’ Comp injuries. With that in mind, it is not feasible for a spine surgeon to see every low back injury. Because of that, we have trained our physician assistants to follow a special spine protocol to evaluate the spine injury and provide treatment that focuses on helping the injured worker. This special protocol, developed by our team, will help the injured worker return to the highest level of function possible. Traditionally, injured workers have received delays getting medical care, including physical therapy. Our team has streamlined the process of getting an injured worker into the right type of treatment quickly, thereby reducing lost days of work and improving patient outcomes. The protocol was designed to be flexible in regard to the industry and the physician practice. It assists the Workers’ Compensation office in scheduling the patient with the right personnel regarding the patient’s previous appointments with outside providers, current imaging studies and subjective complaints of the patient. It is meant to be used as a tool to aid front office staff with scheduling patients the appropriate provider. Future work will be to streamline care in regards to low back pain. The benefits of beginning therapy early in the injury treatment process are numerous. Physical therapists are trained to evaluate and treat a wide range of spinal problems. At Optim Orthopedics, our highly trained therapists are board-certified in orthopedics and/or manual therapy certified which gives the specialist a better understanding of spine problems as a whole. Additional training provides the clinician with an in-depth understanding of the mechanical nature of the patient’s problem. Through understanding the injury process and the mechanism of the injury, the therapist can identify the underlying structures involved so they can provide considerable relief to the patient—promptly. Studies show that decreasing the delay time from injury to treatment improves a patient’s long-term outcomes. The negative psychological component associated with delayed treatment—thus delayed relief from pain—has a large effect on the success of any treatment, including physical therapy. By getting the patient into therapy quicker, there’s a possibility of avoiding the physiologic effects of prolonged pain such as medication dependency, and depression. Utilizing therapy early in the treatment process has also proven to be more effective in return to work and decreased medication dependency. Physical therapists are also trained in work ergonomics and injury prevention so they can assess job descriptions and work with patients to improve movement patterns and teach safe lifting techniques to reduce future injury.
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Greg Scott, Risk Manager for Chatham County, Georgia, weighs in that the development of these early intervention protocols was a collaborative effort between the employer, orthopedists, and the TPA, to solve two outstanding issues facing the medical provider and the employer: 1) the need for the medical provider to have early and quick approval of the treatment; and 2) the need for the injured employee to be treated in a timely manner. Here’s an example of how the new protocols could work: The Optim WC Team will meet with the employer to tailor a Spine program to streamline the care for their injured workers. This program will consist of pre-authorized office visits, PT, diagnostics and surgical review if needed. Working with a Physiatrist can be crucial depending on the diagnosis. This is done within a 6 week or less time frame. These protocols would allow the injured worker to be triaged swiftly and streamline the treatment process. Employers also want a diagnosis as soon as possible to determine the nature of the injury, and help the adjuster set the reserves more accurately. The feeling all around is these protocols would lead to a better outcome for the employee. In an article by Jason Pesche, accredited exercise physiologist of Absolute Balance Exercise Physiology Group, he indicated how studies have shown that with acute lower back injuries, early intervention is effective in leading to more rapid involvement in function, mood, quality of life, and overall general health. An important point found was the timing of intervention impacts the development of psychosocial features, which are very common in the Workers’ Compensation system. If treatment is provided later, the same psychosocial benefits are not achieved. Therefore, early intervention is a necessity for improving an individual’s function, mood, quality of life, general health, and, thereby decreasing the development of biopsychosocial features which can hinder an injured worker’s engagement in a return-towork plan, treatment compliance, and their return to pre-injury function. John D McCormick, MD is a board-certified orthopedic spine surgeon with Optim Orthopedics, providing patients with all spine disorders, including cervical spine and minimally invasive procedures. He earned a bachelor’s degree at the University of Georgia before attending medical school at the Medical College o f Georgia. Dr. McCormick spent his childhood on a family farm and understands the value of hard work. He uses these principals to guide him in patient care with the goal of returning patients to work and activities outside of work with as little pain and discomfort as possible. 51
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