Return to Work – What is Needed for “Success” for Workers?

Published By Categorized as Compensation Café

Returning to work after an injury is difficult at the best of times. 

Workers report that WorkSafeBC’s “Return to Work” (RTW) practices often fail, and sometimes even endanger them. Some employers complain that the Board’s “hands off” approach doesn’t help them either. 

So why does the Board pursue a RTW path that is problematic and wildly out of sync with best practices? The answer lies deep within the B.C. compensation system and its resistance to change.

A worker can begin a RTW when a serious injury is considered to have “plateaued” or stabilized. It starts when the Board makes a “plateau decision,” ending the worker’s “temporary disability” status (with wage loss benefits) and identifying the remaining restrictions and limitations. From this point on, the worker must follow the Board’s RTW plan to receive VR benefits (equal to wage loss benefits). If the worker does not (or cannot) follow the Board’s plan, they are cut off these benefits. 

So what is a “successful RTW”, exactly?

RTW “Success” for Workers:

From a worker’s perspective, a “successful” RTW can be measured by safe and sustained return to employment.

It starts with certain questions, best asked by a RTW specialist who consults with the worker, the employer and the worker’s doctor.

  • Is there a realistic and appropriate RTW plan? Is the employer supportive?
  • Is the RTW position suitable for the worker and available in the long run?
  • Are the RTW tasks and jobs safe and not harmful to the worker’s permanent condition?
  • Is the worker integrated into the workplace in a way which affirms their dignity?
  • Have barriers to the worker’s RTW been addressed?
  • Does the worker agree with the plan?

And the research is clear. Even with clarity and wide-spread agreement, a RTW experience can be rocky. The process needs a guiding hand to support the worker (and the employer) and trouble-shoot problems as they arise. The worker’s RTW also needs to be monitored until its on-going viability is ensured.

These questions are drawn from accepted best RTW practices, which endorse a “whole worker” perspective. See New Directions, pp. 145-147.

RTW “Success” for Worksafe

WorkSafe’s defines “RTW success” very differently.

The WCB defines RTW “success” as when a worker is “able” to RTW within 26 weeks [182 days or 6.5 months] without objection and can sustain the work for 30 days.1

The Board monitors such “successful RTWs” at the highest levels and uses the measurement as a Key Performance Indicator (KPI) of Board success.

But this definition of a “successful RTW” allows the Board to claim RTW success after a brief 30 days with no further responsibility for the worker’s experience of permanent injury. After this time, any RTW problems are treated as separate matters with higher bars for acceptance (re-openings or new injuries).

More destructively, this definition effectively injects bias into claims adjudication. Decision-makers are encouraged to “plateau” workers as soon as possible and achieve a “successful RTW”. Board policy2 enables “plateau” decisions to be issued before treatment is completed or before the worker is recovered as much as possible.3 In other words, workers can be “plateaued” and sent back to work in a brief RTW process before they are ready. They often are.

This rush to require a worker to RTW, before recovery and even before medical clearance, generates “success” under the KPI criteria. But from the real-world perspective of real workers, a premature RTW and quick sign-off is often the source of unfairness and harm.

Workers’ Voices on RTW

The dire consequences of the Board’s RTW failures can be seen in this brief sampling of Addendum cases in the New Directions report.

A young Construction worker was hit in the head with a hook. He was told to RTW but he struggled and then failed after some months of ongoing symptoms. (Case #1) He said that his case manager was really good until plateau and then is was “we’re going to cut you off or you’re going back to work…and “we know your doctor thinks you should stay off but we think you should go back…” The worker endured a RTW for a year with ongoing headaches and disturbing symptoms. Eventually, with the support of his union and his employer, his PTSD was accepted and treated. He is now back at work full-time with full duties.

A Health Care Assistant was told to RTW while she was still disabled from an ankle injury. The RTW decision was overturned on appeal, but the injury had deteriorated, ending her career. (Case #14) T. tore ligaments in her ankle when she tried to escape a violent patient. In her Graduated RTW, she could only do a few tasks but she was plateaued as “fit to RTW without limitations”. Six months later, an appeal body found that T. was still temporarily disabled, but by this time, she could barely walk. After many months on wage loss and another surgery, she had to change careers. She feels the premature plateau decision ended her career and that it could have turned out differently “with proper healing and care”.

A young construction worker with an unstable knee had to RTW and was catastrophically injured when he fell off a roof. (Case #15). M. had surgery for a work-related knee injury. After the surgery, he told the Case Manager (CM) his knee was unstable and he kept falling down. The CM did not accept this and said that he had to RTW. Three days later, M. was working on a roof when his knee gave out. He fell from the roof and almost died, breaking much of his spine and sternum.

In all of these cases, the RTW decision dismissed or ignored evidence about the worker’s actual condition. These RTW decisions are wrong and invite negative, sometimes horrific consequences for the workers. But can RTW decisions create an effective vocational path for injured workers? 

I believe they can if key reforms are made.

Problems in RTW

There is deep pressure within the compensation system to generate premature plateau and early RTW decisions. This pressure generates two simple but different RTW problems. Both are illustrated in the B.C. Ombudsperson’s scathing report on WorkSafe – Severed Trust: Enabling WorkSafeBC to do the right thing when its mistakes hurt injured workers.4 

A reminder:

Severed Trust presents the case of Mr. Snider, a cabinet maker, whose initial injury was a partial amputation of two fingers. He was told to return to his work with his impaired grip, even though he felt unsafe. He appealed the RTW, but to avoid financial disaster, he also worked. After 2 near misses and before his appeal was heard, Mr. S. lost his grip and had his hand pulled into an industrial sawblade. His catastrophic hand amputation required 26 hours of surgery and 10 days in the ICU. The Ombudsperson called the plateau/RTW decision “unjust”. 

Problem #1 – Quality and relevant medical evidence is needed for good RTW

The Ombudsperson has obtained WorkSafe’S agreement to develop and implement an “activities and limitations” form as proposed by Paul Petrie in his 2019 report, Restoring the Balance: A Worker-Centred Approach to Workers Compensation Policy.5

The significance of this “activities and limitations” form is that it requires the worker’s treating physician to specify the physical limitations of an injured worker with respect to the specific activities of their job – before the worker returns to work.

Mr. Petrie proposed this form as an effective way to get credible medical evidence, relevant to specific job duties, in a cost-effective way. The Board’s agreement to this is an important step.

Problem #2 – Good evidence-based RTW decisions must be ensured

However, even excellent evidence will improve a worker’s RTW experience only if the Board’s decision relies on that evidence. This difficult issue is present in most unjust decisions, including Mr. Snider’s.

The Ombudsperson concluded that the WorkSafe decision, that Mr. S. could return to work at full capacity was “unjust” and was made either “unsupported by evidence or in direct contradiction with that evidence.” 6

The related problem is timeliness. Waiting for justice is not an option for many workers. The reality is that an injury almost always brings financial insecurity. Workers comply with RTW decisions, even unfair and unsafe ones, because they must. The “whip hand” of economic hardship leaves no real choice. So until there is an immediate, fair and accessible remedy which allows workers to RTW safely while avoiding financial disaster, these RTW disasters will continue.

Recommendations for Worker RTW “Success”

The New Directions report makes a number of recommendations for better RTW outcomes for injured workers. For the two problems described above, the recommendations are:

  1. Adopt a patient-centred care model to Board health care. This means that the Board would only interfere with the decisions of the treating physician (or other carer) where the direction of care is likely to delay or impede recovery. This would specifically improve the quality of RTW decisions because:
    • The patient-centred approach aligns closely with the current best RTW practices endorsed by the Canadian Medical Association, where a RTW plan is incorporated into a treatment plan;
    • These and other best RTW practices have been developed in Canada and internationally.7 They are founded on an individual, collaborative, “whole worker” approach and good medical expertise. They simply cannot occur without the active involvement of treating health professionals.
    • Patient-centred care better aligns with section 160 [formerly 21(7)] of the Workers’ Compensation Act. 8
    • Patient-centred care would entirely integrate with the use of an “Activities and Limitations” Form as recommended by Mr. Petrie and the Ombudsperson.
  1. Adopt recognized “best RTW practices”9 with a different definition of a “successful RTW” 10 .
  2. Establish a Medical Services Office , offering non-binding medical case conferences to resolve RTW disputes (& other medical issues) in a timely way.11
  3. Provide better financial support for workers during RTW disputes. Finally, I make a new recommendation, based on research by Dr. Cecil Hershler, a specialist in Physical Medicine and Rehabilitation.12 The recommendation is that if a medical mediator from the Medical Services Office considers that a RTW decision is not supported by the evidence but the RTW decision is still issued, the worker can remain on benefits while an appeal is heard. This ensures that questionable RTW decisions will be scrutinized by all parties through the appeal process, without the worker being forced to return to unsafe work in the meantime.

Workers deserve a safe and supported RTW so they can resume a productive life. For RTW to benefit workers and their long-term health and dignity, RTW decisions need to be accurate, fair and based on quality medical information from health professionals that know them best. 

It is time to stop off-loading the high costs of unjust RTW decisions onto workers and their families.

  1. New Directions, page 101. ↩︎
  2. Policy #34.54 RSCM II. ↩︎
  3. New Directions, page p. 100-102. Recommendation #18 set out helpful changes to policy #34.54. There is also some problems in the role and quality of Board RTW programs. New Directions, Pp. 92-93. ↩︎
  4. Public Report No. 52, September 2021. See blog of September 22, 2021. ↩︎
  5. The Ombudsperson called on the Ministry to initiate changes to the Workers Compensation Act to allow special compensation in such cases where the Board’s decision has caused harm, (So far – there has been no response! NONE.) ↩︎
  6. Severed Trust, page 15. ↩︎
  7. See New Directions, “Best RTW Practices” pp. 145-147. ↩︎
  8. New Directions, Page 89. ↩︎
  9. New Directions, Recommendations #47 and #48. ↩︎
  10. New Directions, Recommendation #17. ↩︎
  11. New Directions, pp. 181-186 and Recommendation #71. ↩︎
  12. Dr. C.Herschler. “Work Injuries, chronic pain and the harmful effects of WorkSafeBC/WCB compensation denial” CCPA, 2015. This policy paper reviews the experiences of 9 patients and is an important contribution for understanding, from a medical case-study perspective, the impact of the claims process and the mental health problems (including suicide attempts) aggravated by the claims experience and financial insecurity.  ↩︎

Originally published on the Worker Education website by former WELLS Director Janet Patterson.