ABSTRACT. The purpose of this study was to examine the case manager's role in a return-to-work programme in Sydney, Australia. The investigators examined the case manager's role assumed by occupational therapists, physiotherapists, psychologists and rehabilitation counsellors when providing occupational rehabilitation services. Files of closed cases (n= 172) were examined to investigate the relationship between the case manager's profession and return-to-work outcomes. It was found that the provider of occupational rehabilitation examined in this study achieved above-average return-to-work rates (83%), with no significant difference between case managers. There was, however, a significant relationship between the client's type of injury and the case manager (p<O.001), and case length was significantly different between case managers (p=0.004). The occupational therapist had the largest case management load (43%), followed by the rehabilitation counsellor (23%). There were trends (0.05<p<O.I) between the case manager's profession and return to the same employer, and return to pre-injury, modified or new duties. The provider allocated cases on the basis of professional expertise and skill, which proved to be successful. The provision of workplace-based occupational rehabilitation services combined with case management provides a comprehensive and attractive package to employers and other referrers. Further research is required to investigate factors associated with case management that improve return-to-work outcomes.
Key words: case management, occupational rehabilitation, return to work.
Introduction
In Australia, each state and territory has its own compulsory workers' compensation system, with federal government employees being covered by a separate system. All systems, however, highlight the need for appropriate return-to-work programmes for injured workers, with an emphasis on workplace-based rather than clinic-based rehabilitation. This workplace-based approach is termed occupational rehabilitation in Australia, whereas in North America the term disability management is more commonly used (Shrey, 1998; National Institute of Disability Management & Research, 1999).
Occupational rehabilitation is defined as:
[A] managed process involving early intervention with appropriate, adequate and timely services based on assessed needs, and which is aimed at maintaining injured or ill employees in, or returning them to, suitable employment (National Occupational Health & Safety Commission, 1995: 2).
The essential principles of occupational rehabilitation (CCH Occupational Health & Safety Editors, 1990; WorkCover Authority of NSW, 1993; National Occupational Health & Safety Commission, 1995; WorkCover NSW, 2000a) include:
1) Early intervention;
2) Commitment by all interested parties to the rehabilitation process;
3) Maintenance at work, or early and appropriate return to work as the primary goal;
4) Recognition that the workplace is usually the most effective place for rehabiltation to occur;
5) Rehabilitation should ensure that the dignity of employees is retained and that they actively participate in the process;
6) Consultation and communication between all interested parties should occur at all stages of the process;
7) Return-to-work programmes should aim to return workers to the highest level possible with regard to the following hierarchy:
a) same duties/same job, same employer;
b) modified duties/similar job, same employer;
c) alternative duties/new job, same employer;
d) same duties/same job, different employer;
e) modified duties/similar job, different employer;
f) alternative duties/new job, different employer;
8) Duties assigned through the rehabilitation process should be meaningful to the worker;
9) Graded return to pre-injury levels of work in terms of duties and time, permanent part-time work or reduced hours should be considered when planning and implementing return-to-work programmes; and
10) Rehabilitation is most effective when linked to workplace-based occupational health and safety programmes.
The employer is responsible for the provision of suitable duties for injured employees. Employers are also required to appoint accredited rehabilitation providers, who assist in the development and implementation of the occupational rehabilitation programme, including the identification of suitable duties, when necessary. Rehabilitation providers work in multidisciplinary teams that provide occupational rehabilitation services. They usually consist of occupational therapists, physiotherapists, psychologists and rehabilitation counsellors (Innes, 1995). Other healthcare professionals, such as medical practitioners specializing in rehabilitation or occupational medicine, occupational health nurses and audiologists, may also be involved. `The rehabilitation provider assists with the assessment of workers and workplaces, and treatment of injured workers, as well as developing return-to-work programs in consultation with the rehabilitation coordinator' (Innes, 1995: 150).
Rehabilitation providers assume a case-management role and offer a range of occupational rehabilitation services (initial rehabilitation assessment, functional assessment, vocational assessment, assessment for adaptive equipment, workplace assessment, job analysis, advice concerning job modification, rehabilitation counselling, advice or assistance concerning job-seeking and arranging vocational retraining, work conditioning, functional education, and monitoring return-to-work plans) (WorkCover NSW, 1998).
Case management in occupational rehabilitation is defined as `the coordination of functional rehabilitative services result[ing] in a return to work and/or vocational independence' (Maki, 1998). A diverse range of skilled and experienced health professionals, including nurses, therapists and rehabilitation counsellors, have been identified as performing case management services (Maki, 1998). Successful case management requires skills in `communication, diplomacy and relationship building', as well as assessment, planning, implementation, coordination, monitoring and evaluation of a rehabilitation plan (Maki, 1998: 326).
In NSW the minimum qualifications for case managers in occupational rehabilitation are 'a degree or graduate diploma in Applied Health Sciences, Behavioural Sciences, Medicine, Social Work, Nursing, Rehabilitation Counselling, or equivalent qualifications, AND at least 6 months experience in occupational rehabilitation' (WorkCover NSW, 1996: 4). Case managers provide services such as an initial rehabilitation assessment, advice or assistance in arranging vocational retraining, monitoring return to work, and preparation of rehabilitation reports (WorkCover NSW, 2000b).
Minimum qualifications have also been identified for health professionals providing other specific occupational rehabilitation services (WorkCover NSW, 1996, 2000b). Occupational therapists and physiotherapists with at least three months' occupational rehabilitation experience are able to provide functional and workplace assessments, job analysis, advice concerning job modification and assessment and organization of aids and equipment. Rehabilitation counsellors and psychologists with at least three months' occupational rehabilitation experience are able to provide vocational assessment and counselling. Rehabilitation counsellors can also provide advice or assistance concerning job-seeking. Workers with psychological injuries must have specific assessment services undertaken by a relevant health professional, such as a psychologist or a rehabilitation counsellor. Physiotherapists also frequently provide `hands-on' treatment, as distinct from occupational rehabilitation services, for injured workers.
The outcomes of Australian workplace-based occupational rehabilitation programmes have been reported from the perspective of either the employer or the workplace rehabilitation coordinator (Hocking, 1989; Ferguson and Talbot, 1992; Yates, 1992; Hocking et al., 1993), or the rehabilitation provider working with a specific employer/company (Johnson, 1993). Over the threeyear period 1994/95 to 1996/97 the average rate of return to work for accredited rehabilitation providers was 70% (WorkCover Authority of NSW, 1996b, 1997b). Of those injured workers who returned to work in this period, an average of 84% returned to the same employer, and 63% returned to work performing the same duties for the same hours (WorkCover Authority of NSW, 1996b, 1997b).
Nationally, there was a durable return-to-work rate in 1997/98 of 74% (Workplace Relations Ministers' Council, 2000), which included injured workers who were not assisted by rehabilitation providers. In fact, only 39% of injured workers who were surveyed in 1997/98 had a return-to-work plan (Workplace Relations Ministers' Council, 2000), presumably developed by a rehabilitation provider or workplace rehabilitation coordinator. In Australia in 1997/98, 76% of surveyed injured workers experienced a full return to work (that is, receiving income from employment and not from workers' compensation benefits); 70% undertook alternative duties when they first returned to work, which reduced to 17% after six months (Workplace Relations Ministers' Council, 2000).
The average length of time off work for all people with employment injuries in NSW (1995-96) was 18.5 weeks, with a national average of 15.1 weeks (National Occupational Health & Safety Commission, 2000a). Only 10-13% of people with employment injuries in NSW were off work for more than 26 weeks (WorkCover Authority of NSW, 1996a, 1997a). For cases requiring rehabilitation, however, the average case length was 26 weeks, with a median of 17 weeks (Kennedy, 1997).
Although it is recognized that multiple factors, such as individual worker, job, organizational and rehabilitation programme characteristics, affect returnto-work outcomes, most variables have been studied only for their effect on return-to-work status and length of time off work (Russo, 1998).
This study aimed to investigate the outcomes of one occupational rehabilitation provider in the south-western Sydney region (New South Wales, Australia) and to determine variables affecting a broad range of return-to-work outcomes. One of the variables investigated for its effect on return-to-work outcomes and reported here, was the case manager's professional designation, as this had not previously been investigated.
Method
The investigators used a non-experimental ex-post facto design to examine 335 client files, which had been closed during 1994 to 1996, of a south-western Sydney accredited occupational rehabilitation provider. This type of research design was used because the purpose was to examine the `relationships among variables, based on data that have already been collected' (Portney and Watkins, 2000: 744), as was the case when examining closed client files.
Of the 335 files examined, 267 had a compensable employment injury covered under either the Commonwealth or New South Wales (NSW) workers' compensation systems. The 68 files excluded were non-compensable (n=29), private (n=14), road traffic accidents compensated under compulsory third party insurance (n=13), compensated by a workers' compensation system other than the Commonwealth or NSW (n=7) ones, or where the compensation status or system was unknown (n=5). Ninety-five files with non-relevant return-to-work outcomes (that is, assessment only (n=87), referred on (n=l), no action taken (n=3), not applicable (n=2) or return-towork status unknown (n=2)) were also excluded from the study. Only those files with a compensable employment injury covered by Commonwealth or NSW workers' compensation systems and with a relevant return-to-work outcome (that is, `return to work' or `no return to work') were included in this study (n=172).
The data reported here are part of a larger study that investigated the factors affecting the return-to-work outcomes of an accredited rehabilitation provider (Russo, 1998). Only those results relevant to addressing the question `what is the relationship between the case manager's profession and return-towork outcomes' are presented here.
The return-to-work outcomes investigated were:
1. Case length - the time from referral to case closure, where case closure was after a maximum improvement had occurred and been maintained for one month (WorkCover NSW, 1998); and
2. Return-to-work status - whether the client returned to work or not.
For those clients who returned to work, the following factors were examined:
3. Employer status - whether the client returned to the pre-injury employer or a different wmployer;
4. Duties status - whether the client returned to pre-injury/same, modified, or new duties; and
5. Hours status - whether the client returned to pre-jury/same, or reduced hours.
The client's type of injury was coded using the Type of Occurrence Classification System (National Occupational Health & Safety Commission, 1990) based on the primary diagnosis recorded. Secondary diagnoses were not considered for coding purposes and so the distribution of diagnostic groups among case managers may not reflect the influence of differing combinations of primary and secondary diagnoses.
In this study the `case manager' was identified by the professional designation of the health professional assigned by the provider to coordinate the rehabilitation of a particular client. All health professionals, however, also provided profession-specific services to clients when requested by the case manager. At the time of the study (1994-96), the rehabilitation provider employed one occupational therapist, one physiotherapist, two clinical psychologists (one full-time and one part-time) and one rehabilitation counsellor, who were all case managers. They also provided profession-specific services to clients when required.
The allocation by the rehabilitation provider of referrals for case management attempted to match clients with the case manager's clinical experience and expertise. This enabled case managers to provide the majority of profession-specific services deemed appropriate for their clients. Other health professionals provided services as requested by the case manager. The provider reported allocating referrals to case managers as follows:
* The occupational therapist was allocated clients whose injury or illness was predominantly soft tissue (for example, sprain/strain; muscle, tendon and soft tissue), or who had both physical and psychological components to their disability.
* The physiotherapist was allocated clients whose injury was clearly and primarily physical (for example, fractures).
* The psychologists were allocated clients with mental disorders (for example, traumatic stress), clients who were unable to perform pre-injury duties, and clients who had been terminated from their pre-injury employer.
* The rehabilitation counsellor was allocated clients who had been terminated from their pre-injury employer, and/or those with soft tissue injuries.
As a result of this allocation process, a bias in the diagnostic groups associated with particular case managers was expected.
The client file data were analysed using SPSS (v. 7.5). Descriptive statistics, including mean and standard deviation (where relevant) and/or percs were reported for all variables. Chi-squared ()CI) statistics were percentages were reported for all variables. Chi-squared statistics were calculated when comparing categorical data (for example, case manager and injury type), and one-way analysis of variance (ANOVA) with a post-hoc Student-Newman-Keuls test was used for comparison of continuous data (for example, case manager and case length).
Ethical approval for this study was obtained and all indentifying information was removed from data proir to statistical analyses in order to ensure client and employer anonymity.
Results
Return-to-work outcomes
This rehabilitation provider was effective in returning injured workers to their pre-injury employment (Tables 1 and 2). Overall, the provider achieved a return-to-work rate of 83%. When more detailed outcomes were considered, the provider returned 88% of clients to their pre-injury employer, 69% to preinjury duties, and 88% to pre-injury hours of work.
Nature of injury
The two largest injury groups were `sprains and strains' (31%), and `disorders of muscle, tendon and soft tissue' (19%) (Table 1). The former group included all clients with a diagnosis of non-specific `back pain' or `back injury', and the latter included cumulative trauma disorders (CTD), also known as repetitive strain injuries (RSI), or occupational overuse syndrome (OOS). Other injury groups were `mental disorders' (13.5%), 'dorsopathies' (disorders of the spinal vertebrae and intervetebral discs, including prolapsed discs) (12%), 'fractures' (8%), `multiple injuries' (3.5%), and other injury types (13.5%).
Nature of injury and return-to-work outcomes
There was a statistically significant relationship between injury type and the number of hours worked (xz (df=2, n=143) = 7.275, p=0.026). Clients with mental disorders and disorders of muscle, tendon and soft tissue had aboveaverage return-to-work rates on the same hours, whereas those with multiple injuries and dorsopathies were more likely to return to work on reduced hours (Table 1). The nature of the injury was not significantly related to case length, return to work, employer or types of duties performed.
Case managers' lad
Of the 172 cases included in this study, 43% (74) were managed by the occupational therapist (Table 2). The remaining 57% (98) of cases were distributed between the physiotherapist (15%), psychologists (19%) and the rehabilitation counsellor (23%). If the cases had been evenly distributed, each full-time case manager would have had 22% of the total, or 38 cases.
Injury type and cam
There was a significant relationship between injury type and the case manager's profession (XI(df=6, n=172) = 77.00, p<0.001). The most notable associations between injury type, when considered as a percentage of case management load, and the case manager's profession were as follows (Table 3):
1. `Sprains/strains' were more likely to be allocated to the rehabilitation counsellor;
2. `Disorders of muscle, tendon, and soft tissues' were more likely to be allocated to the occupational therapist; and
3. `Mental disorders' were more likely to be allocated to the psychologists.
Other associations that were noticeable but not as strong: 1. 'Fractures' were more likely to be allocated to the physiotherapist; and
2. `Multiple injuries' were more likely to be allocated to the psychologists.
Overall, however, the occupational therapist had the greatest number of each injury type, except mental disorders (Table 3).
Case manager's profession and return-to-work outcomes
Return-to-work rate
All case managers achieved high return-to-work rates. Overall, there was no significant difference between case managers regarding whether or not clients returned to work (xz(df=3, n= 172) = 5.88, p=0.117). The occupational therapist (89%) and physiotherapist (88%) attained similar return-to-work rates, as did the psychologists (76%) and rehabilitation counsellor (74%) (Table 2).
Employer status
There was a trend for the case manager's professional to be related to employer status, but this was not statistically significant (chi^sup 2^(df=2, n=143) = 5.42, p=0.066). Whereas the occupational therapist managed clients who were more likely to return to work with the same employer, hte rehabiliation counsellor manged clients who were more likely to return to work with a different employer (Table 2).
Duties status
Duties status
Table 2 illustrates the pre-injury, modified and new duty rates among case managers. Although not significant, there was a trend towards a relationship between case manager and type of duties (XI(df=4, n=143) = 7.93, p=0.094). The physiotherapist and psychologists managed clients who tended to return to work on pre-injury duties. The clients managed by the occupational therapist, however, were more likely to return to work on modified duties, and the rehabilitation counsellor managed clients who were more likely to return to work on new duties.
Hours status
The number of hours clients worked was not significantly related to case management (chi^sup 2^(df=4, n=143) = 1.38, p=0.503). The physiotherapist, however, managed the highest percentage of clients returning to their pre-injury hours of work (96%).
Case length
The median case length for this provider was 23 weeks, with an average of 29.2 weeks (SD=21.6). For clients who returned to work, average case length was 28 weeks, while those who did not return to work averaged 32 weeks.
Case length was significantly different between case managers (F(3, 169) = 4.55, p=0.004). Cases managed by the physiotherapist and psychologists had the shortest mean lengths (21 weeks), whereas the occupational therapist (34 weeks) and rehabilitation counsellor (32 weeks) managed cases that were longer than average (Table 2). A Student-Newman-Keuls post-hoc test showed that the mean length for cases managed by the occupational therapist and rehabilitation counsellor was significantly longer than for cases managed by either the physiotherapist or psychologists (p<0.05).
Discussion
This is the first study we are aware of that has examined the effect of case managers' professions on return-to-work outcomes. For this rehabilitation provider, all case managers, regardless of profession, achieved positive returnto-work outcomes. Results indicated that the case manager's profession was not significantly related to whether or not clients returned to work (p=0.117) or the number of hours clients worked (p=0.503). There was, however, a significant relationship between the profession of the case manager and the length of the case (p=0.004). There was also a significant relationship between the case manager and the nature of a client's injury (p<0.001). A trend was found between the case manager's profession and whether clients returned to their original employer or a new employer (p=0.066). This was also the case for whether clients returned to pre-injury, modified or new duties (p=0.094). There was no significant difference in the return-to-work rates achieved by case managers, but there was an uneven allocation of cases to managers, with the occupational therapist having twice the average number of cases, and the physiotherapist and psychologists having below-average case management loads.
Return-to-work outcomes
Overall, the provider was very successful and achieved an above-average return-to-work rate of 83%, compared with 70% for all accredited rehabilitation providers in NSW for the same period (1994-96) (WorkCover Authority of NSW, 1996b, 1997b). This provider also returned more clients to their preinjury employers (88%) than the state average (84%), with return to pre-injury duties (69%) and pre-injury hours (88%) also higher than the state average (63%) (WorkCover Authority of NSW, 1996b, 1997b).
Nature of injury and return-to-work outcomes
The distribution of injury types managed by this rehabilitation provider was different from the distribution of employment injuries in NSW (1995-96). In NSW sprains and strains accounted for 46.5% of all employment injuries, while fractures were less than 8%, mental disorders less than 4%, OOS and other soft tissue disorders 2%, and multiple injuries less than 0.5% (National Occupational Health & Safety Commission, 2000c). All clients with these types of injury had longer than average periods of time off work (National Occupational Health & Safety Commission, 2000b), indicating a more severe or complex injury.
When compared with the general distribution of employment injuries in NSW, this provider had greater percentages of each injury type, except sprains and strains and fractures (Table 1). This is not surprising, since it has been estimated that only 5-10% of injured workers actually require referral to a rehabilitation provider (CCH Occupational Health & Safety Editors, 1990; Yates, 1992) and, therefore, those injured workers referred to a provider could be expected to have injuries requiring more extensive intervention.
The type of injury was not significantly associated with case length, overall return-to-work outcome, return to original or new employer, or return to preinjury, modified or new duties. The only significant relationship was between injury type and the number of hours worked (p=0.026). This would suggest that any variations in these specific return-to-work outcomes may be due to factors other than the nature of the injury.
Case managers' load
There was an uneven allocation of cases, where the occupational therapist managed twice the average number of cases (43%), the rehabilitation counsellor had an average caseload (23%), and the physiotherapist (15%) and psychologists (19% total) had below-average case management loads. This may be due to the physiotherapist and psychologists spending more time providing clinic-based treatment services to clients, as opposed to providing case management and other related occupational rehabilitation services. It has been noted that physiotherapists `essentially utilise "hands on" methods to increase and maintain joint mobility and muscle strength' (CCH Occupational Health & Safety Editors, 1990: 108), which is consistent with the provision of clinic-based treatment services. Details of treatment services were not available, however, so we were unable to examine the provision of profession-- specific services in further detail.
It is also possible that the occupational therapist and rehabilitation counsellor had professional skills and expertise that were more closely associated with the requirements of case management (CCH Occupational Health & Safety Editors, 1990; Fisher, 1996; Hafez and Brockman, 1998; Australian Society of Rehabilitation Counsellors, 2000). Recognition of these skills would result in a greater number of cases allocated to the occupational therapist and rehabilitation counsellor for management. It would seem that this was the case for this provider.
Based on the qualifications required to provide occupational rehabilitation services, all case managers were able to provide 36% of identified occupational rehabilitation services (initial rehabilitation assessment, assistance arranging vocational retraining, preparation of rehabilitation reports, functional education, and monitoring return-to-work plan) (WorkCover NSW, 1996).
Occupational therapists and physiotherapists were able to provide a further 43% of services (functional assessment, workplace assessment, job analysis, advice concerning job modification, assessing for aids/equipment, and work conditioning). Psychologists and rehabilitation counsellors were able to provide these services for workers with psychological injuries (WorkCover NSW, 1996). Psychologists and rehabilitation counsellors were also able to provide vocational assessment and counselling, and rehabilitation counselling (14% of services), whereas rehabilitation counsellors also provided advice or assistance with job-seeking (WorkCover NSW, 1996).
While the occupational therapist and physiotherapist were both permitted to provide up to 79% of occupational rehabilitation services, the occupational therapist had a much higher case management load. We suggest that this may be a reflection of the occupational therapist providing workplace-based services (for example, workplace assessment, job analysis, advice concerning job modification and on-site work conditioning) in conjunction with case management, whereas the physiotherapist tended to provide clinic-based treatment services. The provision of workplace-based services is consistent with occupational therapy's emphasis on obtaining an optimal fit between the person (injured worker), the occupation (job duties) and the environment (worksite) (Cooper et al., 2001). When combined with case management, the provision of workplace-based occupational rehabilitation services enables health professionals to develop and monitor return-to-work plans, and liaise effectively with employers, while also coordinating necessary input from others.
There was a significant relationship between the nature of a client's injury and the case manager (p<0.001). This reflects the rehabilitation provider's deliberate strategy of allocating cases on the basis of professional expertise in order to maximize efficiency and effectiveness. The different return-to-work outcomes between case managers, therefore, cannot be compared based only on the face values of either the varying case lengths or the differences in same employer and duties rates. We must take into account how cases were distributed to case managers.
When the distribution of injury types to case managers was considered as a percentage of caseload (Table 3), biases in allocation of cases were apparent. The psychologists were allocated 83% of clients with mental disorders, which comprised 58% of their case management load. This result was expected and consistent with WorkCover requirements (WorkCover NSW, 1996).
The rehabilitation counsellor and occupational therapist managed 80% of clients with sprains and strains. This accounted for 51% and 31% respectively of these professionals' case management loads. This group of clients included all those with non-specific back injuries and back pain. Rehabilitation of individuals with back pain is complex and requires consideration of psychosocial factors as well as physical factors (Gibson and Strong, 1998), and a multidisciplinary approach to intervention (Carosella et al., 1994; Greenberg and Bello, 1996). The case management skills of both the rehabilitation counsellor and the occupational therapist would enable an effective multidisciplinary approach to intervention to be coordinated, and an understanding of the psychosocial factors associated with disability would further assist with managing these clients (Fisher, 1996; Hafez and Brockman, 1998; Australian Society of Rehabilitation Counsellors, 2000).
The occupational therapist was allocated 58% of all clients with muscle, tendon and soft tissue disorders, which accounted for 26% of her case management load. This injury group included clients with CTD/OOS. Clients with CTD/OOS benefit from interventions at the workplace where the work environment and job duties and tasks are analysed and modified appropriately (National Occupational Health & Safety Commission, 1986; Drake and Ferrano, 1997; Hanson et al., 2001). These workplace-based strategies are often provided by occupational therapists (Drake and Ferrano, 1997; Innes, 1997; Hanson et al., 2001). The large number of clients with this type of injury allocated to the occupational therapist is consistent with this professional's expertise and skills.
Case manager and return-to-work outcomes
There was no significant difference between case managers for return-to-work rates, which were all above the NSW average (70%) (WorkCover Authority of NSW, 1996b, 1997b). This was also the case for clients returning to the same hours of work, which were also all above the NSW average (63%). This would indicate that all case managers were equally successful in returning clients to work, and all were able to upgrade clients' work hours to pre-injury levels.
Although not statistically significant, there was a trend (0.05<p<0.1) for the case manager's profession to be associated with clients returning to their original employer, and returning to their original, modified or new duties. All, except the rehabilitation counsellor, returned clients to their original employers more successfully than the NSW average (84%) (WorkCover Authority of NSW, 1996b, 1997b). Rehabilitation counsellors returned 76% of clients to their original employers. This is not surprising, given that the rehabilitation counsellor was specifically allocated clients who had been terminated from their original employer.
The physiotherapist and psychologists returned clients to their original duties more successfully than the NSW average, and the occupational therapist and rehabilitation counsellor achieved the NSW average (63%) (WorkCover Authority of NSW, 1996b, 1997b). The occupational therapist had the highest percentage of clients on modified duties (20%), whereas the rehabilitation counsellor had the greatest percentage of clients returning to new duties (28%).
The high use of modified duties by the occupational therapist suggests that there was adaptation of the job duties and tasks and the work environment in order to maintain injured workers at work. Occupational therapists consider adaptation of the person, the task or the environment in order to facilitate task performance (CCH Occupational Health & Safety Editors, 1990; Christiansen and Baum, 1991), and it would seem that this occurred with this provider.
Rehabilitation counsellors provide vocational counselling to assist injured workers in acquiring new skills, or in using existing skills for the purpose of gaining a new position of employment (CCH Occupational Health & Safety Editors, 1990; Australian Society of Rehabilitation Counsellors, 2000). These services are consistent with the results obtained in this study, where the rehabilitation counsellor assisted clients to obtain new duties with their original employer or a new position with a different employer.
The average case length for this provider (29 weeks) was slightly longer than the NSW average for cases requiring rehabilitation (26 weeks) (Kennedy, 1997). Although there were no significant differences between case length for different types of injury, there was a significant difference between case managers (p=0.004). The physiotherapist and psychologists had average case lengths (21 weeks) that were significantly shorter (p<0.05) than those of the occupational therapist (34 weeks) and rehabilitation counsellor (32 weeks).
Although there was no significant difference in case length between individual types of injury, it is possible that when injury types were pooled in the form of case managers' caseloads, the effect resulted in significant differences in case length between case managers. Mental disorders (23 weeks), fractures (25 weeks), and sprains and strains (26 weeks) had the shortest case lengths, whereas muscle, tendon and soft tissue, dorsopathies, multiple injuries and other injury types all had case lengths over 30 weeks (Table 1). Sixty-four per cent of the psychologists' caseload consisted of mental disorders and sprains and strains, and 48% of the physiotherapist's caseload consisted of fractures and strains and sprains. The injury types managed by these clinicians tended to have shorter case lengths. On the other hand, 60% of the occupational therapist's caseload consisted of injury types with lengthier cases, and onethird of the rehabilitation counsellor's caseload consisted of injury types with lengthier cases, combined with clients who had been terminated from their original employer, who also experienced longer cases.
It would seem that the difference in case lengths between case managers was the result of differences in the types of injury that constituted each clinician's case management load.
Limitations of the study
There are a number of limitations associated with this study that should be acknowledged. The results of this study pertain only to compensable clients with a relevant return-to-work outcome of one Sydney-based rehabilitation provider. As a case study, it is not possible to generalize the results to other providers, particularly those outside Australia. Different workers' compensation legislation and clinic-based rather than workplace-based rehabilitation approaches preclude drawing any extensive conclusions beyond the observations made. Despite this limitation, we have attempted to highlight some case management practices that could be considered for their influence on returnto-work outcomes.
It is recognized that multiple factors affect return-to-work outcome. This study is part of a larger study that examined many different variables associated with return-to-work outcomes (Russo, 1998). Only those variables related to the case manager's professional designation, however, have been presented here.
Conclusions
Although legislative systems, case management practices and approaches to returning injured workers to work may differ between countries, there are several aspects that can be considered from this case study. By maximizing the expertise of different health professions, in terms of matching effective case management and professional skills, it is possible to provide an extremely effective occupational rehabilitation service. The provider in this study had a multidisciplinary approach to rehabilitation, employing case managers with a diverse range of professional expertise. While all case managers were successful, some had a closer association between profession-specific and case management services than others. This resulted in larger case management loads for some, whereas others provided more clinic-based hands-on treatment services.
We suggest that, when combined with case management, the provision of workplace-based occupational rehabilitation services enables health professionals to develop and monitor return-to-work plans, and liaise effectively with employers, while also coordinating necessary input from others. This provides a comprehensive and attractive package to employers and other referrers.
Further research in this area is needed to investigate the various factors associated with case management, including the case manager's profession, which influence return-to-work outcomes.
Acknowledgments
This research was completed by the first author for the degree of Bachelor of Applied Science (Occupational Therapy) Honours. It was funded in part by a grant from the School of Occupation and Leisure Sciences, Faculty of Health Sciences, University of Sydney. The authors wish to thank the rehabilitation provider for the provision of research data for this study. We also wish to acknowledge Peter Choo for his advice regarding statistical analysis of the data, and Kristan Baker for his assistance with data entry.
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Address correspondence to Dr Ev Innes, Lecturer, School of Occupation and Leisure Sciences, Faculty of Health Sciences, University of Sydney, PO Box 170, Lidcombe NSW 1825, Australia. Emial: [email protected]
DOMENICA RUSSO locum occupational therapist, UK
EV INNES School of Occupation and Leisure Sciences, Faculty of Health Sciences, University of Sydney, Lidcombe NSW 1825, Australia
Copyright Whurr Publishers Ltd. 2002