Disability Management

Even though the general health of people aged 15–65 is improving in Europe, public spending on disability benefits continues to rise ^[1]. Many countries are confronted with an urgent need to deal with sickness and absenteeism. The ageing workforce will only enlarge this need ^{[2] [3]}.

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 ^{[4] [5]}. A prepared, systematic, and structured approach – “disability management" – allows a company to proactively respond to these factors that may impede return to work (RTW) ^{[6] [7] [8] [9] [10]}.

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 enlarge the need for attention, as the prevalence of chronic conditions within the workforce is higher in an ageing population.

As mentioned, the ageing workforce will enlarge this need, as the prevalence of chronic conditions within the workforce is higher in an ageing population ^{[11] [12]}.

Until recently, people with disabilities who didn’t return to the workplace were labelled with medical diagnoses and their diseases were linked to a physical pathology ^[13]. This way, recovery should automatically lead to work resumption. Only workers confronted with severe health problems or functional limitations, or people who fake their illness, should not return to the workplace ^[14]. However, critics noted that such a biomedical model ignores the broad context of disease and disability where also personal and psychological history, social and environmental factors ^[15] and political and economic factors ^[16] play an important role. These models, in turn, were criticized because they were too theoretical and failed to explain the subtle differences in social relations and interactions in the RTW process ^[17]. Furthermore, the relationship between the individual and the environment was not sufficiently addressed in these models ^[18].

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.

Recently, researchers accept that the RTW process is influenced by multiple determinants. This vision is presented in the Sherbrooke model (Figure 1). This model tries to explain 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 ^[19].

On a company level, there is strong evidence that two factors significantly reduce the risk of acquiring disability. Firstly, the frequency of contact between care provider and the workplace plays a role: the higher the frequency, the less risk of acquiring disability. Secondly, work accommodation offers such as alternative duty, graded work exposure, work trials, workstation redesign, activity restrictions, reduced hours or other efforts to temporarily reduce physical work demands ^{[29] [30]} intend to decrease the risk.

Studies have shown that a pro-active disability management on the company level can be associated with reduced frequency and duration of disability ^{[31] [32] [33] [34]} and that the benefits from assisting people to return to work outweigh the costs ^[35].

Definition

Disability management (DM) is a proactive process that aims to minimize 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 ^[36]. DM focuses on three basic objectives: (1) reduce the magnitude and number of illnesses, (2) minimize 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 occupational disabilities through coordinated efforts, taking into account individual needs, workplace conditions and the legal framework ^[37]. 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 ^[38].

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. For most of the OECD countries, the employment rate is approximately 40% to 50% ^[39]. Additionally, employment rates are dropping in most countries, not only in the current period of recession, but also in the preceding period of economic prosperity. 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 6% in the OECD countries. Denmark and the Netherlands score above average with respectively 7% and 8%.

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.

In general we can state that an increase in the employment rate of people with disabilities cannot solely be reached by providing incentives or by raising responsibilities of key actors (employer, employee and public services). A strong regulatory fragmentation (and poor internal communication) leads to an important threshold in the RTW process. Essential elements for both the employer and the employee however are good prevention, health and illness policies and rapid intervention. The OECD ^[40] combines the various initiatives that are taken in different countries into the three challenges mentioned above. This leads to the following summary: - Creating disability benefits aimed at work: o Evaluate abilities instead of limitations; o Strengthen individual responsibilities; o Make work (financially) attractive. - Employers and medical professionals need to be involved in the solution: o Make job retention (and recruiting) of people with occupational disabilities financially attractive for employers; o Support employers in taking up their responsibilities; o Increase the focus on work in the care sector. - Ensure the right people at the right time: o Increase cooperation and coordination of different services; o Provide systematic and individual support; o Provide incentives for private service providers in the field of RTW.

The impact of the reforms that countries made in their social security system was particularly evident in the annual figures with regard to new applications for disability benefits: these often dropped spectacularly. However, few countries have succeeded in increasing the employment rate of people with a work disability.

One of the key outcomes in the sickness and disability field ^[41] is the insufficient labour market integration of persons with a disability. Across the OECD countries, the employment rates of people with health problems or a disability, on average, are just over 40% compared to 70% for people without disability. Additionally, people with health problems are significantly more likely to work part-time. One in four people do so compared to one in six or seven among those without disability. There is also a higher level of unemployment. In the mid-2000s, the OECD average of unemployed people with disability was twice as high as those without disability.

A second key outcome is the poor financial resources of households with disabled persons. The income of people with a disability is 15% lower than the national average. In turn, households with a disabled person are at significant higher risk of relative income poverty.

All countries are confronted with high costs of sickness and disability benefit schemes. On average, countries spend 1.2% of GDP on disability benefits alone, when including sickness benefits, the number rises up to 2%. In 2007, about 6% of the entire OECD working-age population received a disability benefit. Overall, the disability benefit rates have increased only slightly over the past 10-15 years, but this masks substantial differences across countries. 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.

Different key concepts should be taken into account when implementing a DM programme ^[42]. 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 ^{[43] [44] [45]}.

Next, providing accommodations within the workplace is important. 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 ^{[46] [47] [48] [49]}. Furthermore, it is necessary to stimulate contact between the curative sector and the work floor. Research states that contact between the workplace and health provider is important in reducing duration of work disability ^{[50] [51]}.

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 ^[52]. Indeed, the presence of a Disability Case Manager (DCM) reduces work disability ^[53].

Essential coordination roles of the DCM are to (a) establish communication lines, (b) explain the programme's objectives to the injured worker, (c) develop and implement the return-to-work plan with the injured worker and others, and (d) monitor the worker's progress and coordinate additional services or interventions, as required.

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, we see that many organisations act on the primary prevention level. Here the focus mainly lies in preventing risks in the workplace that could lead to health problems for employees. When striving for a general welfare policy to include employees confronted with functional disabilities or long-term health issues, a multidisciplinary approach is needed, which incorporates all three levels of prevention. A proactive approach to prevent further disability or injuries of disabled workers but also of other employees is essential. This so called disability prevention should be added to return-to-work policies.

Next to creating awareness, it is also important to support organisations in creating jobs with a workload adapted to the changing capacities and desires of their employees. Adapted workload enables a healthy and motivated career path. Therefore, organisations should foresee to systematically embed this in their policy. It is important that on all prevention levels, the following aspects are considered and deployed: (1) the physical and mental workload, (2) the organisation of work, and (3) the general health of employees. This is because a suited health policy not only contributes to greater employee health, but to a better work atmosphere in general. In this regard, it is crucial to set up collaborations between the human resource (HR) department and OSH services.

The current work environment increasingly emphasizes 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, the 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 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 and disabilities and control unnecessary workers’ expenses concerning health issues.