Disability Management

Introduction

Even though the general health of people aged 15–65 is improving in Europe, public spending on disability benefits continues to rise. Many countries are facing an urgent need to tackle sickness and absenteeism. With an ageing workforce, this need will only increase ^[1]. 

Health problems and/or functional limitations that cause disability are not the only factors that determine sickness absence. The persistence of the disability is mostly due to psychosocial and environmental factors, factors that are unrelated to the initial medical health problem^[2][3]. A well-planned, systematic, and structured approach – “disability management" – allows a company to proactively respond to these factors that may impede return to work (RTW)^{[4][5][6][7][8]}.

What is disability management (DM)

Background

Due to the increased expenses on disability benefits, the policy development with regard to this subject is rapidly moving to the centre stage of the economic policy agenda. The ageing workforce will only increase the need for attention, as the prevalence of chronic conditions within the workforce is higher in an ageing population^[1].

In the past, individuals with disabilities who did not return to the workplace were categorised based on medical diagnoses, associating their conditions with physical pathology^[9]. The belief was that returning to work would automatically follow their recovery. Only those facing  severe health problems, functional limitations, or those feigning illness, were considered exceptions to this expectation^[10]. However, the biomedical model received criticism for disregarding the broader context of disease and disability. This context includes personal and psychological aspects, social and environmental factors^[11], as well as political and economic influences^[12] that play important roles. These criticisms arose because the models were too theoretical and failed to explain the dynamics of social relations and interactions within the RTW process^[13]. Furthermore, these models did not adequately address the relationship between the individual and their environment ^[10].

Based on these findings, the Sherbrooke model was developed that discussed disability from both a biomedical and social position. In this bio-psychosocial model the RTW-process is considered as an interaction between biological, psychological and social conditions that determine the working capacity of an individual (Figure 1). This model explains the RTW process in a systematic context that takes into account the macrosystem (social environment, culture and policy), the mesosystem (work environment, health care, legal framework and insurance system) and the microsystem (the individual). The model also considers the fact that multiple stakeholders are involved in the process, each with their own vision and expectations^[14].

Figure 1. Sherbrooke model

Figure 1. Sherbrooke model

Source: ^[10]

Absence due to health problems and/or functional limitations has a significant impact on individuals, organisations and system agencies^[15]. However, health problems and/or functional limitations that cause disability are not the only factors that determine sickness absence. Research shows that the majority of employees who do not return to work (RTW), can be explained by determinants that are unrelated to their initial medical health problem ^[2][3]. The persistence of the disability is mostly due to psychosocial and environmental factors^[16]. Examples of these factors are the lack of a common vision shared by the actors involved in the reintegration process, fear of new working conditions, or psychological thresholds. A well-planned, systematic, and structured approach however, allows a company to proactively respond to these factors that may impede RTW^[4][6][7][8] .

At company level, strong evidence suggests that two factors have a significant impact on reducing the risk of leaving work due to a health issue or disability. Firstly, the frequency of interaction between the care provider and the workplace plays a crucial role: the more frequent the contact, the higher the likelihood of the individual returning to work. Secondly, multi-domain interventions including multiple components aimed at service coordination, work modification and improving worker health tend to increase return to work^[17].

Studies have shown that a pro-active disability management on the company level can be associated with reduced frequency and duration of disability ^[4][6][7][8] and that the benefits from assisting people to return to work outweigh the costs^[18].

Definition

Disability management (DM) is a proactive process that aims to minimise the impacts of an impairment (that results from injury, disease or illness) on an individual’s capacity to participate in the work environment in a competitive way^[19]. DM focuses on three basic objectives: (1) reduce the magnitude and number of illnesses, (2) minimise the impact of disabilities on work and (3) decrease lost time associated with injuries, illnesses and resulting disabilities. DM is a systematic and goal-oriented approach at the workplace which aims to simplify the return-to-work process for persons with disabilities through coordinated efforts, taking into account individual needs, workplace conditions and the legal framework^[20]. DM has a dual approach: individual employees confronted with prolonged absence from the job market due to health problems or disabilities are coached along with a structural implementation of a reintegration policy within the company.

The ultimate goal of DM is twofold: the strategies and interventions are used to promote sustained employment of workers with injuries and disabilities and also used to control unnecessary workers’ compensation and disability cost^[21].

Policy overview at EU level

Promoting equal labour market participation for individuals with disabilities is a top priority outlined in the Commission's Strategy for the Rights of Persons with Disabilities 2021-2030^[22], which was adopted alongside the European Pillar of Social Rights Action Plan^[23]. This strategy aims to enhance the quality of life for people with disabilities in the EU and seeks to support Member States in implementing the United Nations Convention on the Rights of Persons with Disabilities^[24]. Within the strategy, the Commission is committed to increasing European efforts, with a particular focus on promoting the employment of individuals with disabilities. One of the strategy's key initiatives is the Disability Employment Package, introduced in September 2022^[25]. This package consists of six key areas including ensuring reasonable accommodation at work, retaining persons with disabilities in employment (preventing disabilities associated with chronic diseases), and securing vocational rehabilitation schemes in cases of sickness or accidents.

In most European countries, policy makers are searching for answers on the current challenges in the labour market. Two important bottlenecks are recurrent in most countries with regard to long-term health problems or physical impairments. Firstly, the employment rate for people with disabilities shows to be very low. The average employment rate of people with disabilities in the OECD countries is 44% compared to 70% for those without disabilities (2019, data covering people aged 15-69)^[26]. The gap between the employment of persons with disabilities and the employment of persons without disabilities is known as the disability employment gap. Eurostat data from 2020 show that the average disability employment gap in the EU27 was 24.4 percentage point (pp). The highest disability employment gaps were in Ireland (38.6 pp), Belgium (36.3 pp), Bulgaria (33 pp), Croatia (32.9 pp) and Germany (32.4 pp). The lowest employment gaps could be found in Italy (14.9 pp), Latvia (16.7 pp), Denmark (18.1 pp) and Portugal (18.2 pp)^[27]

A second major focus is the outflow from the labour market into benefit systems. The average number of working-age people who receive a disability benefit, is almost 5% in the EU^[28]. 
In many OECD countries, reforms took place at social security level. Overarching, the reforms in most OECD countries can be framed within three main objectives: (1) activation rather than benefits, (2) involve the care sector and employers in the RTW-process and (3) create a more accessible and transparent service regarding RTW (the right people in the right place). Especially the Netherlands, Denmark and Sweden conducted thorough reforms (or are implementing them). With regard to the inflow into compensation systems, the Netherlands, Switzerland and Germany managed to reduce these figures. In a lot of these countries a large number of requests for sickness benefit were rejected. This suggests that a lot of people (mostly unemployed) seek to achieve sickness benefits.

Over the past decade, many countries have introduced reforms to their disability benefit systems, but the effects have been limited. These reforms mainly involve limiting the generosity of the disability system and strengthening employment-oriented programmes. The reforms do not sufficiently translate into changes in the employment rate of people with disabilities. The limited impact of strengthening employment-oriented programmes is due to the fact that these efforts are generally still too small and too late. Too small because the share of employment-related measures in total disability spending has barely increased in all OECD countries from 9% in 2007 to little over 10% in 2017. Too late because when people apply for disability benefits, they have usually been out of work for a long time or experienced significant periods of unstable work. Even the best programmes or incentives make little difference at such a late stage^[26].

Facts and figures

One of the key outcomes in the sickness and disability field^[1] is the insufficient labour market integration of persons with a disability. In the EU, data from 2020 show that on average 51.3% of persons with disabilities are employed, compared to 75.6% of those without disabilities^[27]. Additionally, the employment rate of women with disabilities is significantly lower compared to women without disabilities in all Member States. At the EU level, the employment rate of women with disabilities is 47.8 % and the rate for women without disabilities is 68.8 %^[28].

A second key outcome is the poor financial resources of households with disabled persons. In 2021, 29.7 % of the EU population with a disability was at risk of poverty or social exclusion, compared with 18.8 % among people with no limitations^[29].

All countries are confronted with high costs of sickness and disability benefit schemes. On average, OECD countries spend 1.6% of GDP on disability benefits and sickness benefits. Overall, this percentage has remained more or less stable between 2010 and 2019^[30].  In virtually all OECD countries there is a big shift in the medical causes underlying the disability benefit claim. Mental health problems are becoming (or have become) the most important cause. One-third of all new disability benefit claims are due to mental health conditions and these figures do not reveal the full extend of the problem yet: there is also a frequent co-morbidity of certain physical and mental conditions^[1].

Key concepts

Different key concepts should be taken into account when implementing a DM programme^[20]. First, it is important to ensure that there is an early contact between the employer and the employee who had to leave work due to an injury or illness. Studies show that early contact between the worker and the workplace reduces the length of the sick leave ^[31][32][33].

Next, providing accommodations within the workplace is important. Accommodations or adjustments refer to changes to the work and workplace which can be provided to overcome barriers to work for people with disabilities. The rate of employees returning to the workplace is higher for those who are provided with modified jobs than for those where no accommodations are made. Similarly, modified work programmes cut the number of lost workdays in half^{[33][34][35][36]}. Furthermore, it is necessary to stimulate contact between the care sector and the work floor. Research states that contact between the workplace and health provider is important in reducing the duration of work disability ^[33].

To obtain an effective return-to-work programme a high level of internal (worksite) coordination and communication is required, as well as the coordination of activities among external (community) medical services, rehabilitation providers, and others ^[20]. This coordination can be taken up by a Disability Case Manager. A Disability Case Manager reduces work disability ^[33]by coordinating and facilitating access to necessary services, resources, and support systems and promote the overall well-being of the worker. 

A Disability Case Manager plays a crucial coordinating role and particularly by (a) establishing communication lines, (b) explaining the objectives of the return-to-work programme to the worker, (c) developing and implementing the return-to-work plan with the worker and others, and (d) monitoring the worker's progress and coordinating additional services or interventions, as required.

DM, OSH (incl. ergonomics) and WHP

Based on occupational safety and health (OSH) regulations, and voluntary workplace health promotion campaigns organisations put a lot of effort into keeping their employees healthy at work. Interventions may focus on the three levels of prevention: 

• Primary: Improving the quality of work. Examples are ergonomic adaptations, changes in the organisation of work, and preventing work-related health complaints or accidents.
• Secondary: Paying attention to early detection and solutions for problems that occur during work. Examples are career counselling and explaining the temporary work possibilities.
• Tertiary: A supportive return-to-work policy to get dropped out workers back on board. An example could be the shift from an absence policy to a return-to-work policy.

In practice, many organisations act on the primary prevention level. Here the focus mainly lies in preventing risks in the workplace that could lead to injuries or health problems for employees. A multidisciplinary approach encompassing all three levels of prevention is needed when striving for an overall wellbeing policy for workers with functional limitations or long-term health problems. Return-to-work policies are an integral part of such a comprehensive wellbeing policy.

In addition to creating awareness, it is also important to support organisations in providing jobs adapted to the evolving capacities and needs of their employees. A well designed job enables sustained employment throughout the career. Therefore, it is essential for organisations to systematically incorporate job design in their policies and consider the following aspects: (1) the physical and mental workload, (2) the organisation of work, and (3) the general health of employees. A well-balanced business policy not only enhances employee well-being but also contributes to a positive work environment. In this regard, it is crucial to set up collaborations between the human resources (HR) department and OSH services. The OSHwiki article Ill health, disability, employment and return to work provides an overview of EU-OSHA’s resources related to returning to work and working with an ill-health condition or disability. These resources include reports, factsheets, practical advice, tools, etc. The article also features key resources from other organisations.

Conclusion

The current work environment increasingly emphasises the importance of disability management. Statistics show that injured and/or sick workers are insufficiently integrated in the labour market and are more likely to live in households with poor financial resources. According to research, social and environmental factors play an equally important role next to the obvious medical aspects. This finding has been integrated in the Sherbrooke Model (see figure 1), which also incorporates the different stakeholders: individuals, organisations and system agencies. By taking all these aspects into account a disability management programme can be developed. Key components will be early contact, adapted work accommodations, and high-level internal coordination and communication. A Disability Case Manager will help to establish the necessary communication lines and will develop and implement these programmes. However, it is just as important for organisations themselves to develop a health policy with interventions focussed on all three levels of prevention. These measures aim to achieve both goals of disability management: promote sustained employment of workers with injuries, diseases and disabilities and control unnecessary workers’ expenses concerning health issues.