Managing Injury: Conceptual Models that Guide Practice

Disability management is the overall process of preventing or minimizing the impact of impairment on a person’s ability to work or function. In this article, we look at conceptual models that influence disability management and service delivery.

A person who has been injured in an accident may require a range of medical and rehabilitation services and supplies to facilitate their recovery and minimize disability – for example, prescriptions, assistive devices, home or vehicle modifications, chiropractic treatment, psychological treatment or counselling, vocational counselling, training, workplace modifications and so on.

A medical healthcare provider will provide a diagnosis, recommend and provide treatment, and provide information on the person’s medical restrictions. An occupational therapist may be involved in assessing the person’s functional ability and arranging assistive devices; and a psychologist may be brought in to provide counselling or psychological testing connected with vocational rehabilitation. Depending on the circumstances, other service providers may also be called upon, such as ergonomists, physiotherapists, kinesiologists, employment counselors or labour market analysts.

To coordinate the supply of and payment for the various services, a case manager may be recommended.

Disability management models

The overall process of minimizing the impact of an impairment on a person’s ability to function is known as disability management. There are a number of models that guide professional practice in disability management, but the three main ones are the medical model, the environmental/social model, and the functional model. It is generally accepted that a combination of these three approaches is needed to address disability effectively.

In the medical model, the focus is on how the illness or disability resulting from a physical condition may reduce a person’s quality of life and cause them a clear disadvantage. Impairment is measured objectively based on clear medical criteria, and the goal is to identify the disability from an in-depth clinical perspective and invest resources in improving function.

Although determinations made under this model tend to be defensible because of the objective and measurable criteria used, the model takes no account of the person’s ability to actively influence his or her own rehabilitation, or of the potential impact of the person’s environment on his or her recovery.

In the environmental/social model, practitioners see a person with a disability, not a disabled person. This model takes account of the positive and negative impacts of a person’s environment on their disability. Factors that may be considered include access to services and support networks, access to suitable transportation, and barriers such as inaccessible buildings. These sorts of factors are considered for their potential impact (positive or negative) on the person’s rehabilitation.

Although this model takes a more comprehensive view of the factors that can affect rehabilitation, its emphasis on numerous and changing environmental factors can lead to uncertainty as rehabilitation goals become moving targets. In addition, the injured person may see the environmental factors as beyond their control, and may play a reduced role in their own rehabilitation as a result.

In the functional model, disability is viewed in relation to the person’s life roles: it arises from a mismatch between the person’s biological condition and functional capacities on the one hand, and his or her environmental and situational factors on the other. For instance, an inability to walk would affect an athlete differently than it would a clerk.

With its focus on the individual’s ability to work or to perform the activities of daily living, this model tends to emphasize treatment through services and supports aimed at making the person as functional as possible. This involves compensation rather than cure: The aim is for the individual to adapt and fit within the system, not for the system to accommodate the individual.

In its focus on the individual’s ability to function in his or her work and life circumstances, the functional model provides a tailored approach. Efforts can be focused upon those interventions with the greatest potential impact upon that particular individual’s actual functioning in daily life.

However, there is a tendency to focus on functioning that is directly relevant to earning capacity – performing essential job tasks, activities that permit the person to get to work, etc. But not all factors influencing rehabilitation are economic in nature. Psychosocial barriers, for example, can significantly impact rehabilitation outcomes.

Service delivery models

Just as conceptual models influence overall disability management, there are also models that influence how treatment and recovery services are delivered.

In the traditional model of service delivery, the treating physician leads the way in rehabilitation planning. As with the medical model of disability, this approach emphasizes objective medical diagnosis and tends to ignore environmental, functional and other factors. Active rehabilitation may be delayed in favour of waiting for a “full recovery.”

The job-matching model involves comparing an individual’s measured functional abilities with a job demands analysis to determine if there is a match. Measurable values are assigned to occupational factors such as required aptitudes, skills, educational requirements, physical requirements and tolerances, etc. A match can signal a viable option, whereas a mismatch can flag a poor choice or potential barrier.

However, this approach can lead to cookie-cutter solutions that are not individualized to the person. People and disabilities vary, and there is no one-size-fits-all solution.

Under the managed-care model, the client’s diagnosis is referenced against expected durations and other guidelines gleaned from medical research and insurance statistics. Reasonable estimates can be made about expectations for injury and disability, making time and cost projections possible. If a claimant’s disability experience significantly diverges from expectations, that may indicate that another factor, previously unaccounted for, is at play and impacting recovery.

On the other hand, individuals and therefore their disability experience can be unique. When the experience and duration of a claimant’s disability differs from what was expected, his or her case should be examined on its individual merits to determine next steps.

In the direct case management model, key stakeholders such as the employee and employer work together in the rehabilitation process, such as by developing a return-to-work plan. This multidisciplinary, multi-stakeholder model respects the privacy of the individual and the expertise of each stakeholder. It has a greater likelihood of resulting in a comprehensive rehabilitation plan that foresees and mitigates barriers from multiple perspectives. The case management approach ensures that the plan remains targeted and goal-focused.

This approach requires active case management, a role that is all too often left to a stakeholder who already holds another key role in the process or who may not necessarily be qualified to assume this responsibility. For the model to work, the role of each stakeholder must be clear to all parties, especially the injured individual.

This article is based on excerpts from the study material in the Understanding Serious Injury: Adjuster Training and Education program – a new program launching in November, developed by the Insurance Institute of Ontario in partnership with the Ontario Insurance Adjusters Association.