Author: Lai, Hon-sun
Title: Case management approach for return to work of injured workers : studies on effects on system and workers' readiness
Degree: Ph.D.
Year: 2008
Subject: Hong Kong Polytechnic University -- Dissertations.
Vocational rehabilitation.
Workers' compensation.
Work -- Psychological aspects.
Department: Department of Rehabilitation Sciences
Pages: xix, 260 leaves ; 30 cm.
Language: English
Abstract: Injuries in the workplace have a major social and economic impact in modern society. The existing Employees' Compensation Ordinance in Hong Kong does not lay down management or return-to-work (RTW) arrangements for injured workers. As a result, there is a lack of effective management of injured workers at both the system and the individual worker level. The present study explores the effects of implementing a case management system using the existing practices of handling occupational injuries in Hong Kong. At the same time, this study tests the potential benefits of applying prospect theory by communicating accurate and appropriate information to workers to enhance their RTW outcomes. This thesis is composed of three independent but related studies. Study 1 is an archival study that reviews issues associated with the current practices of handling injured workers in Hong Kong with a focus on insurance companies and rehabilitation service providers. Study 2 is a quasi-experimental study examining the effects of implementing a small-scale case management system dealing with the cases of injured workers with a view to their RTW. Study 3 is an experimental study testing the effects of using the framing techniques detailed in prospect theory, which considers how wage- and pain-related information can modify the intention of a worker to return to work. In Study 1, a total of 250 archived cases were extracted from the databases of six insurance companies. Demographic and individual factors such as work nature and income, and injury-related factors such as nature of injury, body parts involved, and types of treatment received were related to RTW outcomes-percentage of permanent disability, sick leave duration, and costs of compensation. The majority of the participants were male (80%) and the mean ages of the male and female participants were 40.3 years (SD = 9.9) and 41.6 years (SD = 9.4) respectively. Common occupational injuries were in the upper limbs (36.4%), lower limbs (30.8%), and trunk (28.4%). The mean rate of permanent disability was 1.1% (SD = 2.1), the mean compensation costs were HK$54,016.1 (SD = HK$113,183.7), and the mean sick leave duration was 78.8 days (SD = 133.9). The majority of the participants (80.8%) had utilized medical services in public hospitals. The work-related outcomes were found to be associated with various demographic, work-specific, and service-specific factors. Injuries to the trunk of cases in the construction industry and in manual work in general were significant predictors of longer sick leave duration and higher costs of compensation. Only a small number of cases had received specialist care, rehabilitation services, and case management. However, the negative outcomes of these cases, namely, higher permanent disabilities, longer sick leave, and higher compensation costs, were found to be attributable to long delays in referring patients for specialist consultation, rehabilitation and case management. These findings reveal the undesirable outcomes for injured workers under the existing practice in Hong Kong, which does not lay down a system for managing or caring for these workers. The findings also form the basis for Study 2 in this thesis. In Study 2, a protocol-based case management system was devised and implemented with a group of injured workers referred from a cleaning company between 2003 and 2004 (N = 296). The outcomes of the case management group were compared with those in a cohort group in 2002, who were under the care of the same company where the researcher worked in but did not receive case management (N = 137). Those in the cohort group received conventional medical specialist attention as well as rehabilitation services such as occupational therapy and physiotherapy. The affected outcomes of RTW were sick leave duration, costs of compensation, and rate of returning to work. The results indicated that the workers who had received the case management had significantly shorter sick leave duration (around 33.9%) and lower costs of compensation (which showed a reduction of an average of around 64.7%, i.e., HK$20,617.3, to HK$7,212.2) than those in the cohort group. However, no significant differences was revealed in the RTW rate between the two groups (94.2% and 96.9%). The results concur with those revealed in other studies of the implementation of case management systems. The main benefits of case management as identified in this study were better coordination of healthcare services by the case managers in order to reduce the time lag between the services provided by different medical specialists, diagnostic procedures, and rehabilitation. Case managers were also found to be effective agents for enhancing an early RTW. Good communication between the employers and those in the workplace, for example, in order to arrange modified or light duties for workers, was critical to the achievement of an effective RTW. Among all the factors, the age of an employee was revealed to be the most significant predictor of a successful return to work. Employees younger than 40 years of age were associated with significantly shorter sick leave duration and lower costs of compensation. Although workers who were between 41 and 50 years of age had longer duration of sick leave and higher costs of compensation, they appeared to benefit the most from the case management intervention. In Study 3, workers were invited to participate in an experiment in which wage- and pain-related information was presented in either a negatively or a positively framed format. Intention to return to work was measured in terms of perceived chance of RTW, confidence of RTW, and anticipated sick leave duration. It was hypothesized that workers would be more inclined to attend to information that was negatively framed. The loss in wages and the potential gain in pain would also exert differential effects on the intention of workers to return to work. A total of 141 injured workers were screened and attended one baseline assessment and one exposure session. They were randomly assigned to one of four groups: pain gain, wage loss, ambivalence, and control. The pain gain group was exposed to negatively framed stimuli on pain increase and positively framed stimuli on loss of wages if they had been asked to return to work. The wage loss group was exposed to negatively framed stimuli on wage loss and positively framed stimuli on pain gain. The ambivalence group was exposed to negatively framed information on both wages and pain, while the control group was given positively framed stimuli on both factors. Immediately after exposure to the stimuli, workers were asked to assign ratings to the three outcomes on a 10-point Likert scale. The same procedure was repeated 2 months after the baseline assessment and training for those who were still on sick leave. The participants were followed up after 6 months. At the baseline, no significant differences were revealed in the RTW outcomes among the four groups. The differences could be more readily seen when participants expressed a higher perceived improvement (60% or higher) or had shorter sick leave duration (60 days or less). Those who perceived themselves as making a better recovery from the injury but who received negatively framed information on an increase in pain perceived their chance of RTW as significantly lower than those in the other two groups that received positively framed information on pain. Similarly, the same effects of influence were found among those who were exposed to negatively framed information on both pain and wages. The findings further support the number size preference reversal proposed by Wong and Kwong (2005a), which is based on the framing effect as laid out in prospect theory. These results suggest that pain plays an important role as a defacilitating factor that influences the intention of workers to return to work. In contrast, employees who had shorter sick leave duration and were exposed to negatively framed information on wage loss were found to have a significantly higher confidence of returning to work than those who received positively framed information on wages. This suggests that workers would be more ready to take risks and commit to returning to work if they had been asked to do so. It is noteworthy that when workers were at an earlier stage in the workplace injury - that is, during the first 60 days in this study - they would be more responsive to messages related to loss of wages. When the workers were followed up at 2 and 6 months after the baseline -that is, those workers who had not at the time returned to work - the framing effect of both loss in wages and increase in pain did not show significant differences among the four groups. Nevertheless, it was found that the most non-RTW participants were among those who were exposed to negatively framed stimuli on increase in pain. In other words, those who had had longer sick leave, for example, 60 to 180 days or longer, were probably less responsive to the framed information than those who had had fewer than 60 days of sick leave. As this study used a single exposure method, the effects generated would be transient and relatively weak. The outcomes under study were related to the intention of employees rather than their actual RTW behavior. The results should therefore be interpreted with caution. It is recommended that future researchers use repeated exposure of negatively framed information and measure workers' actual RTW behaviors such as their resumption of duties carried out. Lastly, the results shed light on the potential benefits both of delivering early, accurate, and appropriate information that accompanies each stage in the recovery of the injured worker, and of the involvement of a case manager. Our findings further support the validity of applying prospect theory and number size preference reversal to employee compensation and occupational rehabilitation. The present studies examine both the overall injury management system and the individual's perspective in the occupational rehabilitation process. Problems in the current management approach have been identified that make it ineffective and conducive to delays in the diagnosis and treatment of injured workers. The results support the need for establishing a systematic approach involving case management and early intervention. A comprehensive case management system should ensure that injured workers receive timely and effective healthcare services and should ensure good communication among all stakeholders. In particular, the psychological aspects of the cases of injured employees and their decision-making processes can be managed appropriately at different stages in their rehabilitation. The use of appropriately framed information may be an effective way to enhance the motivation and confidence to return to work in employees with occupational injuries.
Rights: All rights reserved
Access: open access

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