Canadian Underwriter

Decision Time Week 104

July 31, 2010   by Frank Malito and Angela Veri

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When a client reaches the week 104 mark, it is decision time — about functional status and what further action to take. Information gathering before a client reaches week 104 is the most effective approach, as it provides an independent adjuster with the kind of up-to-date, accurate, and objective information required to make critical decisions. Preparation leads to peace of mind in the 104-week decision making process.

Forward thinking in three steps

As week 104 approaches, if a client was employed at the time of the accident and is an Income Replacement Benefit (IRB) recipient, follow these steps to ensure preparedness for the 104 week mark:

Step 1: Develop a profile of your client

As the IRB client approaches week 104, look for the following signs that it is time to take action:

• Age
• High income/low education
• Lives in a remote area
• Performing physically demanding job
• Lack of English language skills
• Limited mobility/driving
• Low motivation
• Lack of transferable skills
• Pre-existing medical conditions
• Financial incentive exists
• Unsuitable accommodations for restrictions
• Lack of support from family/friends

Step 2: Check the client’s medical status and return to work status

If the IRB client shows any of the signs described in Step 1, check whether:

• medical condition has stabilized, and/or
• client cannot return to regular employment

Step 3: Arrange for the appropriate functional and/or vocational assessments

Based on steps 1 and 2, arrange for the appropriate functional and/or vocational assessments. Taking a proactive approach in coordinating the assessments assists claim resolution in many ways, including establishing realistic goals and minimizing — or even eliminating — the amount of benefits payable at the 104-week mark. In addition, being proactive can help address motivational issues and facilitate skill enhancement, such as worksite training, computer skills upgrading and English language development. There are a variety of functional and vocational services that provide a thorough assessment of the types of employment a client is physically able to perform while taking into consideration education, interests, and experience. Services that are effective for assessing IRB clients include:

Job site analysis / work site evaluation: An objective evaluation of the physical, environmental, cognitive and ergonomic factors related to a specific job. It assesses the client’s abilities and limitations in performing the job so an effective return to work program can be developed addressing these issues. This assessment should be done early in the claim. Waiting can result in its own set of problems, for example, whether the employer is still in business, or are the essential tasks of the client’s position the same as they were prior to the MVA.

Physical demands analysis: Used when the goal is to assess a client’s existing job. It is the process of examining the client’s job by breaking it down into specific tasks and then measuring the client’s ability to successfully complete the tasks. It should include the job’s physical, environmental and organizational components, as well as its cognitive demands. It should include:

• Physical components (e. g., standing, walking, sitting, lifting, pushing, pulling, carrying, fingering, gripping, pinching, twisting, kneeling, bending, reaching, climbing, crawling, crouching)
• Environmental components (e. g., dust, vapour, moving objects, hazardous machines, electricity, sharp tools, protective equipment, congestion)
• Organizational components (e. g., shift length, breaks, pace of work, position title, when the job was previously assessed, how the job is set up, pay structure, etc.)
• Organizational demands (e. g., vision, perception, feeling, reading, writing, hearing, speech)

Functional abilities evaluation: Used when the goal is to assess the client’s ability to perform tasks that could be related to a range of different jobs. It is the process of measuring, recording and analyzing the client’s ability to safely perform a number of job-related functions, such as lifting, lowering, pushing, pulling, and carrying weights, stair climbing, sitting, standing, bending, stooping, crouching, kneeling, crawling and fine motor manipulation. It can be facility-based or home-based. If facility-based, it specifically tests the job-related functions the client must perform to provide “baseline” functional information for all parties (i. e. insurer, employer, treating practitioner, and rehabilitation facility). Whereas, if it is home-based, it assesses the client’s functional abilities in his/her home to make recommendations about whether he/she can complete daily activities.

Transferable skills analysis: Identifies transferable skills for clients who need to find a new vocation and provides recommendations of suitable alternative jobs/occupations. It takes into consideration the client’s educational background, work history and special skills. It does not include psychometric tests so information about aptitude and interests is not included. Computerized formats are available and, depending on the situation, an in-person meeting with the client may or may not be necessary.

Vocational assessment: Necessary when the client needs to investigate alternative employment options either through directly entering a new type of work or via formal re-training. It identifies suitable jobs or occupations by identifying the client’s personal vocational characteristics through evaluation of learning ability, academic achievements, vocational aptitudes and employment history. It also incorporates medical, social and, at times, psychological information. All of this information is taken into consideration while assessing the suitability of different types of jobs/occupations. This process also helps the client better understand his/her skills and to take a more realistic approach to potential employment opportunities. Referral for a vocational assessment should be made:

• once the client has met his/her maximum medical recovery
• if it has been medically determined that the client is no longer able to perform his/her job due to ongoing functional limitations
• if there are no transferable skills that can be applied to another physically-suitable job

Psychometric tests: Used as part of the vocational assessment, to assess the client’s general intelligence, achievements, aptitudes, vocational interests, personality traits and dexterity to help assess vocational options. Types of psychometric tests include:

• Intelligence tests: measure learning potential and reasoning in verbal and non-verbal areas through individual and group tests.
• Achievement tests: measure level of acquisition of various skills and reading, spelling and arithmetic abilities.
• Aptitude tests: measure characteristics that indicate the ability to gain skills related to a particular job/occupation.
• Interest tests: determine high, moderate and low interest areas and assist in linking areas of interest with appropriate vocations.
• Personality tests: measure emotional state, attitudes, values and motivations.
• Dexterity tests: measure manual and motor co-ordination responses when manipulating various materials.

Psychological vocational assessment: Should be considered when there is a diagnosed or suspected diagnosable psychological condition that may interfere with the client’s return to work program becaus
e its purpose is to determine the presence and severity of psychological issues that may be influencing the return to work plan. Although a client may have the skills to perform a specific job (or is training for a well-suited position), there may still be difficulties in returning to work. To help establish realistic vocational goals, the psychological vocational assessment specifically focuses on not only determining whether a psychological impairment exists, but also whether it is affecting the client’s ability to return to work. The assessment may identify a range of psychological impairments such as depression, adjustment disorder and post traumatic stress disorder that could inhibit job performance. For example, certain psychological conditions like depression and anxiety are known to affect motivation, memory and the ability to concentrate.

It includes a standardized cognitive assessment, psychometric testing, aptitude and ability testing, academic achievement testing and a vocational interest survey including a Transferable Skills Analysis (TSA). A TSA identifies transferable skills and provides recommendations of suitable alternative jobs/occupations. It takes into consideration educational background, work history and special skills, but does not include psychometric tests (i. e., aptitudes and interests are not included). Computerized formats are available and an in-person meeting with the client is sometimes necessary.

Neuropsychological vocational assessment: Combines neuropsychological and psychological vocational evaluations to address both diagnostic issues and vocational questions in the context of a confirmed or suspected traumatic brain injury or other neurocognitive pathology. It identifies the client’s personal and vocational characteristics by assessing general learning ability (intelligence), academic achievement levels (reading, spelling, arithmetic), emotional status, personality characteristics and vocation-related aptitude/interests. Current vocational aptitude is compared to prior occupational history to determine the most appropriate basis for the transferable skills.

Labour market survey: Involves surveying potential employers specific to the client’s identified job/occupation. This outreach is combined with additional research via databases, the internet and employment periodicals about potential employers, job availability in desired geographic region(s) and salary information to provide a comprehensive overview of the job market specific to the client’s identified job/occupation.

Job search training programs: Teach the necessary skills to secure employment, such as developing a resume and networking list, as well as contacting potential employers and interview skills. The goal is to provide the client with the skills and confidence to be marketable. Individual and group instruction is implemented as appropriate, depending on the client’s specific issues/needs.

Job placement services: Provide direct recruitment to potential employers to help the client secure and maintain employment. Job placement specialists are in continuous contact with potential employers to obtain up-to-date information about job opportunities, market trends and salary ranges. Upon successful job placement, the job placement specialist conducts follow-up calls to both the client and employer to monitor progress and enhance job success.

In-home/ Activities of daily living assessment: Determines the client’s ability to care for him or herself, as well as conduct activities of daily living such as dishes, laundry, etc. It includes a client interview, history, observation of self-care and homemaking tasks, as well as a physical assessment of strength and range of motion.

Caregiver assessment: Determines the client’s ability to look after dependents (e. g. children, seniors) in the client’s home. It includes a client interview, observation of tasks involved in caring for self and dependents, as well as assessment of the level of care needed for the children/senior(s).

Three steps forward, leaps and bounds ahead

The 104-week mark is critical — preparation is the most effective strategy. Being proactive ensures the most accurate and defensible information possible about a client’s functional and vocational status. In turn, it ensures the most accurate and defensible information to make critical decisions that will affect a client’s future and file outcome. In addition, having a complete and accurate medical evaluation enables an adjuster to appropriately reserve a claim file.

Frank Malito is national director of government services and Angela Veri is national director of customer relations at Sibley and Associates.

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