Is work hardening dead? What is the difference between work hardening and work conditioning? I have been teaching the concept of advanced work rehab lately. What is that and where did it come from? Do insurance companies even pay for these programs anymore? Are the heydays of work hardening programs over or is there a resurgence happening?
During the 1980’s and 1990’s work hardening was booming. Hospitals for the most part began providing CARF accredited work hardening programs. This included an interdisciplinary team that provides functional, physical, behavioral and vocational return-to-work needs. Rehabilitation practices including hospitals, private practices and physician owned practices began offering work hardening and some of them provided good to great programs, however, there were many practices that did not provide the value of getting the injured workers back to full duty work. Many rehabilitation clinics said they did work hardening, billed the work hardening codes, but kept patients in their program for weeks on end without progressing them to return-to-work levels.
Thus came the advent of work conditioning. This was more general strength and conditioning exercises in an effort to get the injured worker conditioned for return-to-work. The clinics that said they did work hardening just switched and said they did work conditioning. Their program format and whether they did or did not get the patient back to work did not change. The CPT code they billed out, 97545 and 97546, remained the same since it is the same code for both work hardening and work conditioning in most states.
In 2011 the Occupational Health Physical Therapy Advanced Work Rehabilitation Guidelines were published and adopted. One of the goals of this guideline was “Each person has individualized needs and it is not appropriate to separate physical and behavioral aspects of care through artificial program distinctions.” Since work hardening programs are less and less, work conditioning programs by definition tend to be the trend. However, it does not matter what you call your program since the goal is getting the injured worker back to work. Thus the Occupational Health Special Interest Group of the American Physical Therapy Association has termed Advanced Work Rehabilitation as a combined work hardening/conditioning approach.
Some of the program elements associated with Advanced Work Rehabilitation include:
- Addressing physical, functional, behavioral, vocational needs within a multidisciplinary model that includes medical and workplace stakeholders
- Requiring examination and evaluation with testing and communicating/coordinating with all stakeholders
- Utilizing therapeutic interventions with a functional emphasis, emphasizing the role of the worker/work activities
- Hours required in program to be determined by situational analysis, may extend from hour/multi-hour sessions depending on evaluation plan of care and options/availability for work reintegration
The program elements as a whole are a combination of the previous program elements of work hardening and work conditioning. Interestingly, you do not see any rehab practice changing their signage on the front of their practice saying they have an Advanced Work Rehab program.
This is however exactly what a work hardening or work conditioning clinic should be doing from a programmatic perspective. It does not matter what you call your program. Your primary goal should be to provide rehabilitation, strengthening, conditioning, behavioral coaching and functional testing that gets a person back to full duty work.
The other important trend is that your work conditioning or hardening program should not just be a dumping ground for the most difficult return-to-work patients. Many times physicians run out of options on what to do with the challenging workers’ compensation patient. Their final attempt in regards to return-to-work is to have the patient enter a work hardening or conditioning program. Your program then becomes the dumping ground for the most challenging patients and in a sense you become a pain management program.
There is no better medical professional who knows if a workers’ compensation patient needs work hardening/conditioning/advanced work rehab as compared to a therapist. The therapist treats them three times per week for weeks and each therapist should have documentation at discharge that says whether that patient can or cannot perform the physical demands associated with the essential functions of a job.
When an outpatient therapist discharges a workers’ compensation patient, there are programs, calculations, and algorithms on the market that could help a therapist document the following: “Mr. Smith demonstrated the ability to perform 72.6% of the physical demands of their job as a Police Officer at discharge from outpatient therapy.” This objective and evidence based documentation approach specifically suggests the workers’ compensation patient requires Advanced Work Rehab because the client can only perform 72.6% of their full duty job.
Documenting function with our Medicare patients in today’s medical climate is required to get paid. Documenting function is not required in workers’ compensation however, many of the best workers’ compensation practices across the country document exactly what their patient can and cannot perform related to the essential functions of their full duty job during outpatient therapy so more efficient return-to-work decisions can be made.
Documentation of function in outpatient rehab, as well as defining the exact percentage of the job a workers’ comp patient can perform, assists in providing objective documentation in regards to which of your patients need work conditioning/hardening/advanced work rehab and which are able to perform 100% of their jobs physical demands.
Claims managers tend to be very picky in regards to verbal authorization when a physician has ordered work hardening/conditioning. I would scrutinize a request as well when someone wants me to pay them $5,000 to $10,000.00 for a rehabilitation program! A rehab practice has to provide value when the expense to the insurance company is so high. Here are some strategies to be considered the best work hardening/conditioning program in your market:
- Your initial evaluation, in a work hardening/work conditioning/advanced work rehab program, should never be a full functional capacity evaluation. It should be a baseline psychophysical based evaluation focusing on return-to-work function, used to determine the most appropriate strength and conditioning starting points
- From outpatient initial evaluation all the way through work conditioning discharge display on a line graph table the return-to-work progress your patient has made throughout rehabilitation
- Many practices say the initial evaluation is a work hardening/conditioning evaluation but then the document they send the insurance company or third party company looks like a classic Physical Therapy initial evaluation. The initial evaluation needs to be a job match evaluation that shows exactly what percentage of the full duty job the client can or cannot perform
- Make sure you document functional improvement on a weekly basis and communicate this with the case manager, claims adjustor, physician, patient, and employer
- During your initial evaluation determine an exact length of stay in your program and stick to that. If you get to the end of your initial length of stay decision and the worker is not ready to go back to work only ask for more visits if the worker continues to make functional improvement
- If after one week the worker is not progressing specifically in regards to return-to-work function call the insurance and the Dr. to communicate that the worker has not progressed functionally. If after two weeks there is no progress, discharge that patient as you are wasting the insurance carrier’s money
- Determine and promote your clinics full duty return-to-work percentage for workers that have successfully completed your Advanced Work Rehab program
Strategy number seven is your primary marketing tool. Every work hardening/conditioning program should know what their full duty return-to-work percentage is. What percentage of your work hardening/conditioning/advanced work rehab patients who completed your treatment plan returned back to full duty work? Once you know this percentage, and if it is 60% or higher, promote it to the world. Mention it in every piece of marketing collateral and every conversation you have about your clinics program. If you are lower than 60% you need to figure out how to improve it.
Work hardening is not a dead in the water program. It has just evolved and there is a resurgence in these programs. No matter what you call your program you need to make sure that your focus is on full duty return-to-work by showing the exact improvement a worker makes weekly in your program and communicate with all of the stakeholders involved in that workers’ compensation patient.
Jim Mecham, MSIE, OTR/L, CPE is the primary developer of OccuPro’s Work Hardening/Conditioning Software which is used throughout the world and greatly assists clinics with disseminating evidence based documentation to workers’ compensation stakeholders. Jim also teaches medical providers around the world how to implement or enhance these programs within their medical practice.