L & I’s Pilot Project

White Papers in Six Key Areas

Desired Practice Behaviors

As occupational health has evolved and matured as a unique specialty of healthcare practitioners, managers and legislators have struggled to determine the optimal environment for the delivery of healthcare to injured workers. It is a complex problem that involves the healthcare system as a whole, with insurers, employers, and the injured worker all playing roles that are sometimes in harmony but often in opposition. Repeated efforts at workers’ compensation reform have taken aim at this issue, but none has seemed to hit the target in the effort to design a model system.

L & I’s Pilot Project

In Washington State, the Department of Labor and Industries is preparing a model that may shed light upon the problem. The Pilot Occupational Health Program will designate two Centers for Occupational Health and Education (COHE) in two selected regions in Washington. The outcomes for three diagnosis groups will be studied for patients treated within the pilot system. The outcomes in those pilot regions can then be compared to outcomes in other regions of the state to determine if any part of the pilot model results in improvements. The development of the model has involved staff at all levels of the Department of Labor and Industries, a research team from the University of Washington, medical providers, and a project team from Occupational Health Research.

White Papers in Six Key Areas

The role of Occupational Health Research was to conduct research and develop white papers on six key areas of occupational health operations. The first paper on enhancing physicians’ occupational health expertise focused on the practice pattern differences between occupational health providers and general medical practice as a whole. The paper included suggestions on how to bridge that gap through education and the use of a respected medical peer at the COHE as a mentor for other community physicians. The second paper focused on the care coordination process, including patient tracking and the interactions among the COHE, payer, patient, employer, and community physicians. Paper three provided a discussion on quality assurance within the COHE and the overall delivery system. The fourth and fifth papers examined the information management needs of the delivery system and communication interactions among all the parties. One of these papers discussed communication of administrative information such as billing, initial claim reporting, and claim status. The other information management paper focused on the communication of medical information from the medical provider to all other interested parties. The sixth and final white paper evaluated different options for both financial and non-financial incentives for medical providers participating in the pilot program.

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Desired Practice Behaviors

The actual model to be implemented is in the final stages of design. The core concept behind the six papers as well as the design of the COHE was based upon several desired practice pattern differences between occupational health delivery systems and the general medical community. These desired behaviors were identified as being important components to the overall successful management of work injury cases. These behaviors were:

• Notification of the work injury to the employer by the treating provider

• Use of treatment guidelines or protocols in the care of the injured worker

• Use of standardized work restriction forms

• Ability to identify ergonomic job risks

• Ability to provide case management

• The absence of social decisions when determining a release to work

• Use of a specialized occupational medicine information system

Surveys were done to evaluate these desired behaviors and how much they are followed in both occupational health settings and general medical settings. The survey included 44 occupational health programs throughout the United States and 198 primary care physicians in the state of Washington. The occupational health clinics reported that 99.1% of their business was occupational health related. This is contrasted to the general medical community where only 12.6% of the medical practice is related to occupational health. The differences in practice patterns relative to the seven desired behaviors are summarized in the table at the top below.

The translation of most of these behaviors is clear, although one does require clarification. When asked about social decisions, the goal was to determine the behavior of providers when they are presented with an injured worker who is not able to perform his or her regular work, and it is unclear if the employer will be able to accommodate any modified duty. In the survey, the provider was presented with such a scenario and asked to choose between taking the person off of work or providing a work release and allowing the employer to make the decision regarding accommodations.

This survey demonstrates the size of the gap between occupational health and non-occupational health providers relative to the desired practice behaviors. The presence of a gap is not going to be a surprise to most people with experience in the occupational health setting. However, for the first time there is some measure of the differences and some validity for the channeling of work injuries through a medical practice that has an occupational health focus.

One other interesting finding in the surveys and subsequent white papers was the correlation between providers who exhibit the desired practice behaviors, their status relative to JCAHO accreditation, and the presence of a board-certified occupational health physician in the practice. It was found that, regardless of their status as an occupational health provider or a non-occupational health provider, a valid correlation exists between an increased demonstration of the desired behaviors and being associated with JCAHO-accredited organizations. However, there was found to be no correlation between the desired behaviors and the occupational health board certification of the provider in the practice.

The actual model for the Center for Occupational Health and Education is still being developed and deserves some attention over the next couple of years. Depending upon the outcomes that are experienced, the pilot may provide some validation of practices that have been common in the occupational health setting for years while also shedding some light on how occupational health providers nationally might modify their practice design to better serve their customers. Information about the project is being routinely posted on the Washington Department of Labor and Industries web page and can be accessed at www.lni.wa.gov/hsa/ohs/whitepaper.htm. 

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