Return to work (RTW) is a documented plan/strategy to accommodate an injured worker with temporary restrictions while receiving treatment or rehabilitation.
The return-to-work plan is a collaboration between the worker, the employer, the care provider and the WCB. The return to work will be monitored and progressed by the care providers based on objective clinical findings. It should have a defined start and end point that may include a combination of a gradual increase in hours of work and/or work activities designed to return the injured worker to the pre-injury job.
It is expected that the majority of RTW programs will be less than four weeks in duration, unless there are unusual circumstances such as unusual shift length, heavy to very heavy industrial DOT, a highly repetitive job or a post-surgical worker.
A RTW Plan should include:
• The week it should start, the total hours of work, the days, and a list of restrictions to job duties; and • Any comments or concerns regarding job duties in the comments section.
A RTW may exceed four weeks on occasion. After the four weeks have been completed, the practitioner should:
• Submit the remainder of the RTW for the final stages;
• If a graduated RTW of greater than 4 weeks is required, provide a rationale in the restrictions section below; and
• Provide an anticipated end date. When a RTW plan exceeds 4 weeks, please indicate the actual week when the worker can be expected to return to work, i.e., week 5, 6, 7. This is particularly important when the return to work is exceeding 4 weeks because the worker’s case manager uses this information for payment of wage loss.
Practitioner’s Return to Work Report WCB Claim No.: ______________________________
Clinic # ________________ Billing # ______________ Personal Health # _______________________ Phone # _______________ Fax # _________________ Date of Birth _____________ Phone # ____________
Practitioner’s Name, Address, Postal Code Employer Name ______________________________
Worker Name, Address, Postal Code Clinic Name ___________________________________
Memo to: _________________________________ (employer/primary practitioner/WCB)
Please forward any requests for changes to the RTW plan to the therapist, who will monitor the worker’s progress, evaluate any suggested changes, adjust the RTW plan if required, and forward amendments to all parties. The WCB will also adjust the level of income replacement as the worker’s duties and hours of work change.
Return to Work Start Date: DD/MM/YY Anticipated End Date: DD/MM/YY
Employer Contact Name: ______________________________________ Contact Phone # _____________
22 Calendar of Hours and Restrictions
Month Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Week One
Date 21/10/07
Hrs 4 4 4
Restrictions: Mr. Smith should avoid lifting greater than 25 lbs. and above shoulder activity.
Comments: Mr. Smith requires alternate modified work than his construction job as a framer. He should be accommodated in the shop until he begins his GRTW.
Week Two
Date 28/10/07
Hrs 4 4 4 4 4
Restrictions: Mr. Smith can begin lifting above shoulder while under treatment. Comments: Continue accommodation in the shop while under treatment. Week
Three Date Hours Restrictions:
Comments: Please explain need for RTW longer than 2 weeks Week
Four
Date Hrs Restrictions:
Comments: Please explain need for RTW longer than 2 weeks
Signatures: Care provider may sign all three as verification that all parties are aware of, and have agreed to, the RTW plan.
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Appendix VIII: Risk Factors for Chronic Disability
Injured Worker
Age – older workers may have difficulty finding jobs because of their age.
Place of residence – rural workers may have more difficulty finding other employment if they are unable to return to their pre-injury jobs.
Education – jobs with fewer educational requirements usually involve more physical activity.
Language – English as a second language may limit their ability to find work.
Lack of mobility – if their spouse has a job in the community, or if they have lived there a long time, they may not want to move and this will limit their ability to find work.
Opinion as to the degree of disability is out of proportion to the nature of the injury.
History of drug or alcohol abuse.
Financial problems reduce the ability to focus on return to work as a priority.
Family problems such as separation, divorce, serious illness or death.
Injured worker cannot be reached when Case Manager calls or tries to arrange a meeting.
Injured worker relies on a third party (spouse or parent) to communicate with the WCB.
Injured worker has a significant number of prior claims with the WCB.
Employment
Employment history – length of employment with employer of record, seasonal work, issued a layoff, uncertainly about having a job to return to.
Nature of employment – no light duties available, employer small in size.
History of poor performance on the job – employer doesn’t want worker to return to work.
Excuses for not returning to work – no transportation, unreasonable demand for light duties.
Little or no contact with employer after injury.
Rate of compensation provides a sense of security, especially if pre-injury income was uncertain, sporadic or seasonal.
Dissatisfaction with the job.
Lack of job opportunities because of economic conditions within usual field of employment.
Health
Period of disability exceeds expected recovery time for the injury.
Injured worker has other health problems at the same time as the injury.
Lack of physical findings on health care reports to support a delay in returning to work.
Injured worker frequently changes primary care providers.
Past related problems in same body area of the injury.
Expansion or change in location of symptoms from those of the original injury.
Injured worker does not participate in treatment, misses appointments, makes excuses for nonattendance, and has only vague recollection of primary care provider’s advice.
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Appendix IX: Lower Extremity Functional Scale (LEFS)
Go to the next page to see the Lower Extremity Functional Scale, which you can print off to use with a patient.
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THE LOWER EXTREMITY FUNCTIONAL SCALE
We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your lower limb problem for which you are currently seeking attention. Please provide an answer for each activity.
Today, do you or would you have any difficulty at all with:
(circle one number on each line)
ACTIVITIES Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty
a. Any of your usual work, housework, or school activities.
0 1 2 3 4
b. Your usual hobbies, recreational or sporting activities.
0 1 2 3 4
c. Getting into or out of the bath. 0 1 2 3 4
d. Walking between rooms. 0 1 2 3 4
e. Putting on your shoes or socks. 0 1 2 3 4
f. Squatting. 0 1 2 3 4
g. Lifting an object, like a bag of groceries from the floor.
0 1 2 3 4
h. Performing light activities around your home.
0 1 2 3 4
i. Performing heavy activities around your home.
0 1 2 3 4
j. Getting into or out of a car. 0 1 2 3 4
k. Walking 2 blocks. 0 1 2 3 4
l. Walking a mile. 0 1 2 3 4
m. Going up or down 10 stairs (about 1 flight of stairs).
0 1 2 3 4
n. Standing for 1 hour. 0 1 2 3 4
o. Sitting for 1 hour. 0 1 2 3 4
p. Running on even ground. 0 1 2 3 4
q. Running on uneven ground. 0 1 2 3 4
r. Making sharp turns while running fast. 0 1 2 3 4
s. Hopping. 0 1 2 3 4
t. Rolling over in bed. 0 1 2 3 4
Column Totals:
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Appendix X: Neck Disability Index (NDI)