Lucia London NP, Vail Health Occupational Health, is the latest practitioner featured in our series about best practices in workers’ compensation. Based on her performance in Pinnacol’s clinic profiling report, we asked her a few questions about educating injured workers throughout the workers’ compensation process.
What is your approach to educating injured workers during their first visit to the clinic?
Lucia: Many of our patients have never been in the workers’ comp system before, so they don’t understand how it works. I explain we are the authorized treating physician (ATP) and will be coordinating all of their care. They’re going to see us from the beginning to the end of their case. I explain there are medical treatment guidelines related to the injury, and we try to work within the guidelines as appropriate.
I give the patient an idea of how long the injury may take to resolve. I like to educate the patients and say, “If you have surgery, you’re going to be with us for a minimum of six months.” I explain that even though they’re with us for that long, it doesn't mean they won’t be working. I discuss their work restrictions. When a patient is worried about going back to work, I explain our job as the ATP is to gradually get them back to work. The ultimate goal is to get them back to their previous function level and back to their jobs. I explain that we may not get them back to their regular job during the in-between time, but they might be able to do something else within the business. And while they are recovering for the next six months, it doesn’t mean they will be out of work for six months. I will give them different scenarios of modified work I’ve seen other employers do.
How do you handle patients whose primary focus or complaint is their pain?
Lucia: We do see people who are afraid and focused on their pain. I discuss their fear. A big help is having the physical therapists explain to the patient they will not injure themselves further by starting to move. Movement is good for them, and sitting around makes them stiffer. Sometimes I have to get behavioral health involved. There are techniques therapists can use so the patient can learn to deal with the pain they’re feeling and put it into perspective. I have been using counseling more, especially with people I see as “failure to launch,” to help deal with their fears.
What do you see as some of the benefits to your early and repeated education to injured workers?
Lucia: Educating throughout the process sets the patient’s expectations of what will happen. For example, I explain that the treatment guidelines only allow for a certain number of therapies and how the patient will use therapy. The doctor ordered physical therapy (PT) three times a week, but that’s not realistic because it will not get the patient through to the endpoint. So we develop a plan on how to use therapy to get them through to the end. This works because they start going to therapy two times a week then cutting down to one time a week to stretch out their PT. And it is better than telling the patient they’ve used all of their PT, and they are out of luck.
If I put a little bit back on the patient on their education and make a plan, they appreciate the knowledge. I think it’s important to educate and validate what they’re experiencing and understand the difficulties they’re experiencing. So it’s education and listening to them and validating their fears.
What is your approach to return to work?
Lucia: I start by giving the patient some realistic ideas of weights. I’ll ask if they can lift a gallon of milk out of the refrigerator. If they say they can, I explain a gallon of milk weighs 8.6 pounds and point out they’re already lifting almost 10 pounds. I try to give them some real-life things they’ve done instead of saying you shouldn’t lift any more than 5 pounds. I use visuals they can understand.
I rarely take anybody off work unless it’s severe trauma. I explain to the patient that not every employer can meet their restrictions, but a lot can and will work within them. I write down everything the patient can or cannot do and explain that their employer will decide on whether they can accommodate the restrictions. Some patients fight me saying they can’t work or do their job. I explain they might not be able to do their regular job during the initial part of recovery, but that doesn’t mean they cannot work. And sometimes they don’t want to work and stay at home. You can’t fall into the trap of taking everybody off work.
The other thing I do to get my patients back to work is explain they don’t have to work a full eight-hour shift. With some injuries, they can only tolerate a four-hour workday initially. I’ll start them with half a day. It’s not just limitations of weight, sitting or standing. It’s also hours worked. If someone has a bad injury, they can’t go from not working at all then be expected to go back to working eight hours a day. I find most insurers and employers will work with you. I try to bring the patient back to work for an initial 10 days or two weeks at just four hours a day. Then move up to six hours then eight hours per day. It helps because the patient feels you want to help them get back to work, but you’re not rushing them back.
How do you handle patients who might be reluctant in accepting they have reached maximum medical improvement (MMI)?
Lucia: If I have somebody reluctant to be at MMI, I start discussing case closure early on. We start by making a plan. I tell them we’re discharging them within the next couple of months, which puts the idea into their head. You can’t tell somebody whose case has been open for several months that today is their last day. You have to prepare them. I’ll tell the patient we’ve tried every modality, and they aren’t getting any better. I’ll take out a piece of paper and pencil and say, “Let’s go over what we’ve tried. We tried physical therapy, massage therapy and chiropractic, and none of them helped you. I sent you to the orthopedic doctor, and you had injections. I sent you to get a second opinion. We’ve tried various medications. I have nothing left to offer.” I ask if there is something the patient feels I haven’t done for them. When the patient looks at the paper, they may understand we’ve tried everything and are more accepting of the fact. And as I’m going down the list, we may find one more thing to try.
Medical Director’s Note
Lucia London serves as a wonderful example of how a busy, well-versed, very thoughtful nurse practitioner can provide top-notch care to injured workers. We are proud that she is a member of SelectNet. Figure 1 summarizes some of Ms. London’s excellent quality of care outcomes.