Disability Assessment & Management …. the context of the workplace

1. Disability Assessment & Management…..in the context of the workplace Dr. ‘LanreAjayi

2. Background….. Based on the WHO’s estimate, about 10 per cent of the world’s population has a disability, or 610 million people, of whom 386 million are between the ages of 15 and 64 years (United Nations: World Population Prospects, 1998 Revision, New York, 1999).

3. Background….. Disability is a complex phenomenon but so also is the definition of that word “DIS-ABILITY” The disability experience is unique to each person within a defined context. Indeed, that experience will differ from person to person as circumstances, internal make-up, life’s roles, cultures and contexts change; but can also differ greatly for the same person at different times under different set of circumstances A common definition is difficult.....

4. Why we need a definition for Disability Although a common definition is difficult, yet, it is essential to define disability for various reasons – - Legal (anti-discriminatory & equality laws, etc) - Policy & Planning (data gathering, administration, etc) - Social (grants, disablement benefits, etc) - Research & Epidemiological, etc

5. Background…..

6. Prevalence of Disability & impact on employment

7. Different Disability approaches..... Two major conceptual models of disability have been proposed – Individual & Social Individual Model (Moral model and Medical model) The moral model considers an abnormal or aberrant body structure or function as being made to befall a person usually as a result of their own (or their parents’) omission or commission. It is quite dominant in developing societies and often the most repressive. It is marked by pity, shaming and sometimes indignifying treatments. (John 9:2) The medical model views disability as a feature of the person, directly caused by disease, trauma or other health condition, which requires medical care provided in the form of individual treatment by professionals. Disability, on this model, calls for medical or other treatment or intervention, to 'correct' the problem with the individual.

8. Different Disability approaches..... Two major conceptual models of disability have been proposed – Individual & Social The Social Model The social model of disability, on the other hand, sees disability as a socially created problem and not at all an attribute of an individual. On the social model, disability demands a political response, since the problem is created by an unaccommodating physical environment brought about by attitudes and other features of the social environment. The Human rights model views disability as a human rights and diversity issue where PwDs are the oppressed minority. It also demands for a political and societal response for equal rights, equitable access, inclusion and protection. The UNCRPD is based on this approach.

9. Different Disability approaches.....

10. Impairment, Disability & Handicap Impairment Any loss or abnormality of psychological, physiological or anatomical structure or function Disability Any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being Handicap A disadvantage for a given individual, resulting from an impairment or a disability, that limits or prevents the fulfilment of a role that is normal (depending on age, sex, and social and cultural factors) for that individual (Int’l Classification of Impairments, Disabilities & Handicaps – ICIDH. WHO 1980)

11. Biopsychosocial Model of Disability The biopsychosocial model is more contemporary approach which embodies all the positive aspects of the earlier models but extends beyond each one in addressing all the elements that impact on the disability experience – health, emotional & psychological wellbeing, socioeconomic conditions, political factors including a person’s sexuality and spirituality This approach puts human activity at the core, with all interrelated elements at the periphery, without a break in the interrelatedness of each element

12. Biopsychosocial Model of Disability This is the model on which the WHO’s ICF is based

13. A Biopsychosocial example – The missing link

14. Biopsychosocial Model of Disability

15. Biopsychosocial Model of Disability - ICF

16. The Law, Disability & Discrimination Equality Act 2010 (UK) Under the Equality Act 2010 a person is classified as disabled if they have a physical or mental impairment which has a substantial and long-term(adverse) effect on their ability to carry out normal day-to-day activities (ADL). ADA, 1990 (Amended 2008 – USA) The ADA defines a covered disability as a physical or mental impairment that substantially limits one or more major life activities, a history of having such an impairment, or being regarded as having such an impairment. ADA examples of "major life activities" including, but not limited to, "caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working" as well as the operation of several specified major bodily functions.

17. The Law, Disability & Discrimination Remember, disability within the framework of the law is: - Set to prohibit discrimination in areas such as employment, education, provision of goods and services, transportation, etc - To regulate compensation and benefits (social or occupational) to people who may otherwise be denied these privileges - Is a legal judgement. OH will determine whether or not an impairment will likely qualify as disability under the law in the context of the workplace - Does not give consideration to whether or not the employee is able to perform his job tasks but whether the impairment imposes significant and long term adverse effects on his Activities of Daily Living (ADL)

18. Multilateral Intervention – A Modern Approach

19. Multilateral Intervention – A Modern Approach

20. Components of Fitness for Work Assessment

21. OR 1 MET = 3.5 ml O2·kg−1·min−1

22. Physical demand characteristics of work

23. Physical demand characteristics of work

24. Psychosocial Screening - Flags

25. Psychosocial Screening - Flags

26. Clinical Functional Assessment

27. Clinical Functional Assessment

28. Clinical Functional Assessment • WHO Disability Assessment Schedule 2.0 • WHODAS 2.0 covers 6 Domains of Functioning, including: • Cognition – understanding & communicating • Mobility– moving & getting around • Self-care– hygiene, dressing, eating & staying alone • Getting along– interacting with other people • Life activities– domestic responsibilities, leisure, work & school • Participation– joining in community activities

29. Functional Capacity Evaluation (FCE) • FCE is an umbrella term that refers to a set of (standardized) tests, practices and observations that are combined to determine the ability of the evaluated candidate in the areas of strength, endurance, speed, flexibility, and physical effort • Usually for the purpose of employment (workability) • Can be following an injury, accident, disease or intervention • Psychometric test can be included • Spinal Function Sort, Hand Function Sort, Ransford, McGill, Waddell, Dallas, Oswestry Low Back Questionnaire, Oswestry Neck Disability Index • Cardio-respiratory (aerobic) endurance testing • Modified Bruce, the Modified Balke, the Bench Step Test, or the bicycle protocol • Others • NYHA (cardiac), Barthel Index (CVA), MSE (psych), etc

30. Functional Capacity Evaluation (FCE) • The role of the Court vs. role of Occupational health • Occupational Health will: • Determine presence of impairment • Determine Fitness for Work (priority for safety) • Advise employer if impairment is likely to qualify as disability under law • Advise employer of reasonable adjustment and workplace accommodation (if req) • Advise on prognosis (with GP / Specialists) • Recommend Ill Health Retirement to employer if justifiable • Provide independent advice to courts as to presence and extent of impairment • The court will: • Determine presence of disability • Interpret provisions of the law and other relevant statutory requirements for benefits and compensation

31. Report Template - Sample

32. Return to Work (RTW) • Structured RTW must be the goal of OH following long-term sickness absence • 3 possible outcome for RTW assessment • Return to same job (with or without reasonable adjustment to the workplace or work process) • Alternative work • Ill Health Retirement (last resort. Not to be decided lightly) • The concept of reasonable adjustment: • A legal requirement, a duty of care • Biopsychosocial approach to RTW • E.g. adjustment to premises, allocating some duties to “able-bodied” employees, altering employees working hours, assigning employee to a different workplace, allowing employee time-off work for rehab, treatment, etc, assistive technology, etc

33. Barriers to RTW

34. Barriers to RTW • Physician Factors • Poor communications • Lack of understanding of stay-at-work/return-to-work principles • Misunderstanding of job requirements and limited duty programs • Lack of continuity in practice (multiple providers) • Tendency to give patients whatever they ask for related to work and time off • Employee Factors • Fear of re-injury • Thinking catastrophically • Tendency to feel depressed or anxious • Feeling mistreated • Belief that condition is disabling • Low self-efficacy • Organizational Factors • No workplace adjustment • No EAP • RTW approach is largely medical

35. Rehabilitation – Role of the workplace • The workplace is key to facilitating rehabilitation: • Reasonable adjustment / accommodation • Time off work for medical appointments / intervention, job redesign, role re-assignment, universal access in workplace, safety and emergency response, EAP, facilitating access to assistive devices, etc • Social interaction, financial independence, meaningful living • Fulfils the requirements of WHO’s CBR model • Equality and Human rights issue (UNCRPD) • Vocational Rehabilitation

36. Rehabilitation – Role of the workplace

37. Rehabilitation Goals – Landrum outcome Levels • Acute Illness / Injury • Medical assessment / treatment still on going • Included unmanaged medical problems presenting at a later stage • Mgt plan is in place to ensure ongoing maintenance of skin integrity, nutrition, ROM, and bowel & bladder care, etc • Basic functional goals at this stage may include bed mobility, self care and communication • Medical problems addressed and appropriately managed • Condition is stable. No longer requires acute care setting Level 0 – Physiological Instability Level 1 – Physiological Stability Level 2 – Physiological Maintenance • Functions appropriately in the community • Includes: self management, self-directed care of health, social functioning, community mobility, recreational activities, complex home management, financial management, safety in community, etc • Safe function at home • Includes self care, mobility around home, effective communication, simple house keeping, household planning and home management • Productive activities within patient’s level of ability. • Includes paid work, unpaid work, volunteer work and education / training Level 3 – Residential Integration Level 5 – Return to productive activity Level 4 – Community Re-integration

38. Rehabilitation Goals in a Stroke Survivor – A sample

39. Ill Health Retirement • Important considerations to bear in mind: • Medical retirement decision should not be reached casually without exhausting all reasonable options for work retention • Ill health retirement could be a justified next step when: • The candidate’s injury or illness excludes him from any form of work both now, and in the foreseeable future (Permanence) • The employer’s “best” efforts at reasonable accommodation falls short of accommodating the candidate at work and the employer cannot provide alternative work (Business needs) • The employee is unwilling to accept accommodation or any alternative work (Objective professional opinion vs. disciplinary HR measures) • Definition, qualifying criteria and administration differs from jurisdiction to jurisdiction • Inextricably tied to pension schemes in many jurisdictions • An employer should describe the process in its HR policies agreed by unions, and set within any local legal context • The role of the OHP is to • provide objective assessment of the case • pursue case management • promote work retention where possible (accommodation, phased RTW, etc) • determine if case meets requirements for IHR • Support the IHR application process when IHR decision has been made

40. Ill Health Retirement

41. Ill Health Retirement • Class Activity

42. Medical retirement - What is the key message…..? • Worklessness contributes to adverse health: • Reduced psychological well being with greater incidence of self harm, depression and anxiety • Increased smoking at onset of unemployment • Increased use of alcohol and other substances with unemployment especially in young men • Weight gain, reduced physical activity and exercise • Increased sexual risk taking in young men • Work is beneficial to health

43. Any Questions?