Negotiating Successful Return to Work


View our on-demand webinar, Negotiating Successful Return to Work. During this informative presentation, our workforce health experts discuss why successful return to work requires negotiation and the role of the employer.

Our webinar includes information on:

  • Optimal management of the return-to-work process
  • The 5 “Ds” of danger to watch for in a work injury care
  • Best practices in return-to-work negotiation


Welcome to the webinar, "Negotiating Successful Return to Work with Dr. Maja Jurisic, Concentra vice president and medical director. Dr. Jurisic is board certified in emergency medicine and occupational medicine and, from 2008 to 2011, she chaired the Wisconsin Consortium on stay-at work/return-to-work. 

Dr. Jurisic has extensive experience in outlier case management and in helping employees return to work after an injury. Because of her expertise, the U.S. Department of Labor asked Dr. Jurisic to consult on the federal RETAIN initiative (Retaining Employment and Talent after Injury/Illness Network), which focuses on an important dimension of disability employment - that is, stay-at-work and return-to-work strategies. Dr. Jurisic will discuss optimal management of the return-to-work process, the anatomy of recovery for the injured employee, the five signs of danger to watch for, and injury care.  

We will return to the word, "negotiation," best practices, and key takeaways. At the end of this webinar when we will have a 20-minute question-and-answer session with Dr. Jurisic. If we run out of time before your question is answered, we will follow up via email. 

Dr. Jurisic:
Thank you to everyone for joining us. I think we can all agree that returning injured employees to normal work and life as quickly as possible is critical. That's actually our brand promise, that we help people renormalize their lives after the disruption of a work injury. 

So you might be wondering why we use the word "negotiation" when we're talk about optimal management because this is the kind of verbiage that's typically used in business and law. It's not usually used in medicine. When I first started as a newly minted physician, "negotiation" wasn't a word that I ever thought of using in the context of getting people back to work. But over time I realized that return to work really it is a negotiation. 

It's a coming-to-terms kind of dialogue intended to produce an agreement because, theoretically, the patient, the physician, and the employer all have the same goal, which is maximum restoration of function. The reality is sometimes that different patients sometimes feel that the employer or the physician is pushing them back to work too fast and if patients dig in their heels, the situation can become adversarial especially if the patient gets an attorney. So, whether we realize it or not, we really are in the middle of a negotiation every time we ask injured workers to do something and they do have power in this equation.

They decide how much effort to put into getting better and how much discomfort they are willing to tolerate as they are getting back to work.

During this process misunderstanding can potentially hinder progress. There are a lot of stakeholders in the workers' comp arena. There are doctors, therapists, supervisors, people in Human Resources, and maybe risk management. There are return-to-work coordinators. There are claims handlers and benefits administrators. Sometimes there are union stewards. 

There are lawyers, and case managers, and tens of state-specific workers' compensation systems that are all a little different. So all of this stuff can get confusing and can actually lead to confusion. Clarity is important, along with exchanging information to keep everyone on the same page. Collaboration is the way to get to the desired return-to-work outcomes for all of us.

There have been times when I have struggled with a difficult patient, and finally I feel like we're on the right track, I can see our destination like a light at the end of the tunnel, but then a supervisor says something very negative to the patient - something like, when I had a sprained ankle, I was better in two days and look at you, you're out two weeks, stomach-aching and whimpering. You know, something very derogatory. And then, the next time the patient comes in, we're two steps back from where we were. 

The patient is feeling worse. We have to kind of do this together and, hopefully, we can get that person back without any sort of barriers being raised. When somebody feels like they're being threatened unnecessarily, they feel more pain. Negative emotions feed pain. We know that from research in the neurosciences. Pain pathways are activated by both emotional pain and physical pain. Our body doesn't distinguish. 

Our brain doesn't distinguish either. So, when people are angry, upset, anxious, stressed, or fearful, they actually do feel more pain. 

At Concentra, our primary focus is getting people back to normal life and back to work. 

Optimal return to work requires defining the nature of the illness and determining whether or not something is work-related in the first place, which isn't always simple. Next is diagnosing the injury or the illness, prescribing a treatment plan, and then managing the return-to-work process.

The first three are things most physicians are used to doing, and they consider that part of their job. The part that sometimes is surprising to people is that they get engaged in managing the return-to-work process to help things move along more smoothly. That's where Concentra has revolutionized return to work by teaching clinicians. 

Hey, this is part of your job, and there are best practices you can follow. We tell them to communicate because it is paramount to keep everyone on the same page. After the initial injury visit, we expect our clinicians to call the employer contact. If no one's available, then they should leave the information on voicemail, if it's a private line. They should tell the employer, this is what I found, this is the treatment plan, let me know if you have any questions, etc. If there is someone on the other end of the line, the employer contact may have information we don't, and that can be very useful for us arriving at a better plan. 

The other thing we teach clinicians is that staying at work or returning to work as quickly as possible truly is in the patient's best interest. There are lots of studies that show this, and that's not always something that physicians have heard before. When I was an emergency physician, I truly did not know that. I thought that if I saw somebody with the work injury and I put them off work, it was quick, it was easy and the patient never complained. I thought I was being nice. 

I thought I was being kind to that person. It was only after I started at Concentra that I realized, oh my gosh, I could have been promoting a disability mindset and started that person down a bad path because that's not something that's typically taught in medical training. The third thing we teach clinicians about return to work is that the rejects schedule is important and every visit can be used to move the case forward. 

The fourth thing is that if there are functional deficits, and I'm emphasizing if here, the use of physical therapy really helps move the case forward and shortens case duration, rather than waiting to see if the person will get better on their own. And then the last thing is that the timing of testing and referrals also makes a difference, so if there are administrative barriers and we're waiting, we should reach out to either the adjuster or the employer to try to figure out how we can help things move forward. 

There are stages injured patients go through, from injury onset to claims resolution. The first one is the injury and its relationship to the workplace. That has to do with determining whether or not something is work-related. We teach clinicians to distinguish between causation and association. A lot of times, patients will assume that if a problem started bothering them at work, it must be work-related, and that's not necessarily true.

So we use things like the filter criteria thinking of biological plausibility, temporality, and how much exposure they've actually had to try to figure that out. The next stage really is the diagnosis and treatment stage and that actually is usually not too complicated in our setting. This is what clinicians are taught to do. You take a good history. 

You do a good exam. You perform any other diagnostic tests necessary, like an X-ray, perhaps. Frankly, in the work comp arena there are maybe ten diagnoses that we see most often. So it's not as tricky as some other fields. The third stage involves thinking about lost time and return to work.

There is a lot of medically unnecessary work disability. The Bureau of Labor Statistics data is that about 30 percent of work injuries have some lost time. There's a wonderful little book called, "Physician's Guide to Return to Work" that was edited by Drs. Talmage and Melhorn. They have one chapter where they look at this. They say that about 60 percent of lost time is not medically necessary. Every professional society, American College of Occupational Medicine, Orthopedic Internal Medicine, everybody says that physically, psychologically, and socially, a person is better off working rather than not working. 

It's better for people's well-being. So when patients sometimes say well gosh, I think I really need to be at home resting until I'm a hundred percent, it is part of our job to convince them that really truly that's not in their best interest. 

We're not putting you back to work because your employer wants us to. It is because we think that's going to help you more than anything else. The fourth stage then is consideration of impairment and disability. This happens in some cases where the injury is severe, and we have to identify any impairments that could affect performance, determine whether the impairments are permanent and whether they are a disability or not. 

The last stage is settlement and resolution. That's when impairment ratings have been provided, if there are any. They've been converted to a disability by the legal system and an offer is made of settlement to provide for resolution of the process. With this many things going on and this many different people involved, misunderstandings can occur, especially when everyone is not on the same page. We're all busy, and we all get stuck in our own silos without necessarily understanding what people in other silos need to know. There is no blame or shame here. We've all probably had some negative thoughts about other stakeholders at one time. 

Employees sometimes are the physician's only source of information, and they don't always have the words to describe their jobs. They can't explain to me in a way that I can understand what they do on a regular day. And again, this is when it's important to reach out to the employer and find that out. Sometimes, injured workers will use their words to mislead the doctor. 

I always remembered the guy who told me that he couldn't possibly go back to work because he lifted bags all day long. When I called his employer, I learned that it was true. He did lift bags, but they were six-ounce bags of snack items. He didn't bother to tell me that part. Claims administrators often request information from physicians to help them in managing their claims. Sometimes they use forms that don't really match the information requested and sometimes, they are too complex for what is needed. That can be annoying to clinicians. 

Physicians sometimes aren't aware that employers and benefits administrators actually need this information to handle the claim and to keep the case moving. 

So everyone can get exasperated by these types of situations. One of the best experiences I had was when I was in charge of this stakeholder summit that we were putting together in Wisconsin where I live. I worked with employers, adjusters, and some attorneys. There were a couple patients who were on the committee as well, but it was mainly employers, physicians, and therapists working together to pull this thing off and make it a worthwhile event for everyone. 

We all realized that we really do want the same things. You know, we sometimes have different ways of approaching or looking at the same situation. But our ultimate goal is the same. We really want to help this injured worker get back to a productive life. Once I realized that, I stopped having negative thoughts when things didn't go the way I thought they should. 

We can be quick to point fingers when the return-to-work process goes sideways, but that's not that helpful. Trying to understand that the other person might be looking at things from a different perspective and reaching out to that person is more helpful. 

Sometimes there's a negative perspective to return to work when the focus is on in capacity rather than retained ability. The glass is half empty rather than half full. So people focus their thinking on, you know, Joey shouldn't do this and that and the other thing instead of thinking about all the things Joey can still do. With most injuries, people can still do a lot of stuff.

They might not be able to do everything they normally do, but they can certainly do parts of their jobs. Even if they're doing a different job, they can still be productive. So return to work even in a modified position means a transition from the mindset of incapacitated patient to productive employee, and that definitely enhances recovery and reduces disability. The way we think about things and ourselves plays a huge role in how we're able to move forward in rapid recovery.  

Unfortunately, medical language is very negative. It's one of the only fields I know of where when you tell someone that their x-ray was positive, that's a bad thin. When it's negative, that's a good thing.  

Many stakeholders don't realize that factors other than tissue injury can profoundly affect an injured employee's recovery.

There's a neuroscientist at the University of Wisconsin in Madison named Richard Davidson who has been studying people's brains for several decades. He does this using deep brain EEG and functional MRI at the same time. What he has discovered is that the part of our brain we use when we're thinking about our situation, whatever it might be, makes a huge difference in how we are able to move forward or even whether we're able to move forward. What he's found is that when someone is thinking out of their right prefrontal cortex, it tends to be negative space. There are feelings of anger, sometimes feelings of victimhood. There's usually catastrophizing, meaning people are generalizing and thinking oh, this is the worst now that I've hurt my back. It's never going to be strong again. I'm always going to have back problems.

People tend to be very passive. When you encourage them to do more, they tend to be resistant. They are stuck. If people are thinking out of their left prefrontal cortex, it's a much more positive space. There's a broad and build attitude.

There are connections from that part of our brain to the amygdala, which is our emotional center that puts an emotional stamp on all information actually coming to our neocortex, the most sophisticated newest part of our brain. It quiets us down and makes us less reactive. So, I truly believe that when we are dealing with patients who are not progressing, and there doesn't seem to be a medical reason for it, it's because they're stuck in that negative part of their brain. Our challenge is to move them to the other side, and it's not that hard to do. If you're talking to one of your injured workers on the phone and they seemed to be stuck in that very negative place, you can help them move. I had one doctor who was good at this. He was dealing with a nursing assistant who had a kind of a garden variety of back injury, the kind of problem we'd expect to be better in a couple weeks. She was just not getting better. In talking to her, he realized how important it was to her to be a good parent. So he offered her the idea that as a parent, she is a role model for her children.

They watch how you handle the bumps that life throws in your path. And if you handle them, they learn from that, and they're more likely to be successful adults. That resonated with her. The next time she came back, she was a whole lot better. The visit after that she was discharged. It could have gone down a very different path. It could have gone down to you know, MRI, specialist referral, maybe even chronic pain. All he did was to shift her from the right side to the left side of her brain.

She went from thinking, poor me, my employer doesn't care. We were short-staffed. I should never have had to lift that heavy person all by myself. That's why I hurt my back. It's their fault. Instead, she started thinking that maybe she could teach her kids a life lesson with this experience. That little shift made all the difference to her. Knowing enough about the person you're talking to, in our case, the patient or, in your case, your employee, knowing what is important to them really helps because you can use that to help them make that shift.

The other thing that's important to understand is that pain is not necessarily related to tissue injury. The official definition of pain is that it's an unpleasant sensory experience that might or might not be related to injury. In our neural pathways, the same pathways are activated by both emotional and physical pain.

So if one week somebody's doing pretty well and next week, they come back and nothing's changed. They're not doing more. They didn't have a re-injury. They're just having a whole lot more pain.

Rather than doing what you typically do, what's taught in Western medicine - doing diagnostics, refer to a specialist, look for something to fix – take that step back and ask yourself, "What could be going on in this person's life that has increased their experience of pain?"

Maybe they had an argument with their supervisor or an argument with a spouse or maybe their kid did something that was upsetting to them. We can't assume that if someone hurts more, there's something more serious going on in their bodies because that just is not the case.

Another misconception is that the injured employee is going to do exactly what we asked them to do. The employee decides how much effort to put into getting better and how much discomfort to tolerate, as I mentioned before.

In study after study, the best predictor of returning to work is employee satisfaction with the job. People with high demands and little autonomy are far less likely to return to work after what should be a temporarily disabling injury than people who have a lot of autonomy. There are any number of studies that show that being a good employer who treats employees well and provides a work environment where employees feel their employer cares about them, the likelihood of people returning to work improves, and the bottom line improves. 

A supportive telephone call from the employee to the injured worker can be a strong force in motivating somebody to return to work. 

A recent survey of 200,000 employees showed that only 40 percent of them self-identified as being highly satisfied – and yet, that's what every company wants and needs. It needs satisfied and engaged workers because engaged employees are willing to do whatever it takes to help the company succeed. Organizations with high employee satisfaction have customer service ratings that are 20 percent higher than similar organizations with low employee satisfaction. They also have 50 percent less turnover. Seventy-nine percent of employees who quit their jobs cite a lack of employer appreciation as a key reason for their leaving. A Gallup poll found that 65 percent of Americans got no praise or recognition in the workplace in the last year.

As someone who treats workers from many different settings and many different employers, I can tell you that the more caring an employer is, the easier it is to get the injured person back to work. People know when they're treated like valued members of an organization, rather than as disposable parts, and they really do respond. 

Another challenge is that patients sometimes feel they're being pressured to return to work too soon. They can sometimes misinterpret the physician’s work activity status as pushing them back to work. In this situation, part of our job is to educate patients about the benefits of working and why it's in their best interest to do as much as possible, rather than as little as possible, during the healing process.

I like to talk about athletes. I point out how, after an injury, they don't suddenly take to their couch or take to their bed and rest, but they try to keep up with training as much as possible to avoid deconditioning and loss of muscle tone and muscle strength. I usually share a little study that was done by Texas A&M on their football team. After the season ended, they measured all the parameters, such as strength, flexibility and so on. 

Then they had the athletes go on bedrest for just a week. They could get up to go to the bathroom, and they could get up for meals. Otherwise, they had to stay in bed. After a week of bedrest, it took four months of training for them to get back to their previous fitness level. You lose conditioning fast. Patients are usually impressed by this and say, ‘Wow. Yeah, I didn't realize that!’ That's usually enough to at least make them willing to try to get back to work.

So again, if someone perceives being asked to return to work as a threat, if their brain interprets it that way, that can actually increase their experience of pain. One of our challenges and, I guess, your challenge is to make the person feel safe. We’re not doing this because your employer wants to make more money. We’re doing this because we think this will help you get back to normal more quickly.

With problematic injury cases, clinicians are taught to look for and respond to the five Ds of danger. And certainly I think other stakeholders can be aware of these, as well, because if you notice something that we don't, by sharing that, you help make sure that we have all the information we need to help this person move forward. This is very helpful.

The first D is dramatization. That's when patients complain of pain and suffering through very dramatic verbal and nonverbal displays.

Usually, you know, I'm just about to touch someone like this, and they're already moaning and groaning, sometimes so loudly that the medical assistant walking down the hall might get a little concerned, knock on the door, and peek in to see if everything is okay. This is when people demonstrate pain out of proportion to what one would anticipate, given the injury. Let's say it was an injury with no bruising, and no soft tissue swelling. It's not like there's a bone sticking up through their skin. It's just a minor strain or sprain. Yet, they are the very dramatic.

The next thing to look for is drug misuse. Usually, if a patient keeps asking for more and more opioids, that indicates a problem. Opioids are not that great for chronic pain. They can be very helpful if somebody has a severe, acute injury, but other medications can help with that, as well.

There's a Cochrane study that shows if somebody takes one over-the-counter ibuprofen and one over-the-counter acetaminophen – so an Advil and a Tylenol – at the same time, that actually is more effective for pain than taking a hydrocodone. When I tell people that, most of them are more than happy to try it, given how much news there is now about the dangers of opioids. My husband did this when he had a root canal, and he was very comfortable. He didn’t have any issues. In Europe, it’s actually sold as a single pill because it is so effective.

But, in the United States, both of these medications are cheap and don’t provide a big profit margin. Here, you have to take them both because they don’t come as one pill.

Another big tip-off – and the next D in our five Ds of danger – is dysfunction. By that, I mean a withdrawal or an unwillingness to function in normal personal, social, and occupational roles. These are people who withdraw from the fabric of their lives, and that’s a bad thing.

Next is dependency. By that, I mean the patient adopts a passive attitude and isn’t really doing much to further the recovery process. The patient just sits there and waits passively for someone to do healing. 

I wish I had a magic wand and could do that, but I don't, and neither do our therapists. So, we encourage patients to be active participants in their own recovery. That moves them forward much more quickly. Passivity, often accompanied by depression, are signs of dependency. And then the last D is a disability mindset. This is when a person becomes a professional patient and shows an unwillingness to return for productive life.

They keep complaining of pain or discomfort beyond the expected healing time or the recovery period.

When several of these Ds are found, Period And so when several of these Deeds are found, usually you have a case that has issues other than tissue injury. Unfortunately, medical training does not give us good tools to deal with that. We've spent several years at Concentra trying to help people deal more effectively with these kinds of cases and not just chase pain symptoms because that's usually not very helpful to the problem. Usually the problem is elsewhere and not the fact that they have tissue injury.

Toward the end of 2017, Concentra started an outlier management process where cases in our system that are outliers go in a special file. It's a six-week process. For two weeks, the center-level medical director and therapy director, if the patient is having therapy, look at the cases on file. These are cases that, according to our usual case progression, are not progressing that quickly. They have three options. They can decide the case is the kind that just takes longer. It could be a rotator cuff tear. Those take longer. Or, they can decide this is a case where there are some barriers to recovery, and we need to take action. In this instance, they will indicate what action they're taking to try to move things forward. Or, they can conclude the case is highly complicated, and they are not sure what to do, and they turn it red. 

The next two weeks, it goes to the next level for the director of medical operations and the director of therapy for that market or region to look at the cases. First, they look at the red cases and work with their clinicians to figure out what might be done to help the patient move forward. In the last two weeks, the cases go back to data analytics, which puts the whole file back together again, and resends it.

We've been doing this now for 24 cycles. We’ve seen that we have made a difference with these outlier cases. These are the cases everyone remembers. They are atypical for us. Our average case length is just 17 days. That's great. But everyone knows, there are some cases that do not go as well. They're not average. We're trying to get a handle on these other cases. This is part of what we do to help that. 

In these kinds of cases, we emphasize with our clinicians that can’t always be the healer. You are the rehabilitator. What you need to focus on is restoring function rather than eliminating every last pain complaint. In fact, studies have shown that even just mentioning the word pain to somebody who is overly focused on it, increases their experience of pain. 

So, we focus on how much are you doing? Are you walking? We praise the patient and celebrate every increase in what they can do. Patients understand that this is what's important to their well-being. I think patients logically assume that, if we keep asking about pain, pain must be what's most important, and really it's not. 

Developing a successful strategy is both a skill and an art. It demands clear communication among all stakeholders involved in return-to-work decisions. 

There's an acronym that helps summarize the different strategies to use. The first one is setting the stage. That's letting the patient know where you stand, where he stands, and who the other players are. When I see a patient, I usually let him or her know that I'm going to be talking to their employer about the treatment plan. One of doctors called the employer contact right from the exam room after the initial injury visit with the patient so the patient could hear what the employer was told. So the patient didn't think there was any behind-the-scenes “collusion” between us and the employer, which helps create a feeling of trust, that we are all in this together. 

The second step is uncovering issues. Sometimes people have hidden agendas. Sometimes they have fears that they are too afraid or embarrassed to express. It's important to listen to not just the words the patient is saying, but to listen for any undercurrents and to get them out in the open because you can't resolve a problem if it stays buried. If I sense that someone might be worrying about something but not expressing it, I ask the patient if there is something they are wondering about or worried about that we haven’t discussed yet. This gives them an extra chance to confide or to share what is really bothering them, and that’s helpful. 

The third step is confining the issues. When people are fearful or thinking out of that negative space in their brain, they tend to catastrophize and generalize. They start having unhealthy thoughts like, ‘This will ruin my whole life,” and there is this whole cascade of horrible events that they're picturing. So. it's important to help them confine the issues.

If you're talking to somebody who you think is catastrophizing, please help them confine the issues. The more they worry, the more they catastrophize, and the more pain they're actually going to have. I try to stress that this is an episode; we’re going to get through it together. I also let them know that some patients use the injury as a starting point for change, and they start making different lifestyle choices. Sometimes, after they've had physical therapy, they incorporate the exercises and stretches that they learned into their life going forward, and they end up being stronger and more flexible than they were before their injury. 

The fourth step is confirming intent and authority. I let the patient know what my role is and what steps I will and can take to help the patient move forward. Sometimes people try to draw the physician into personnel issues or workplace struggles. We can't go there. That's your bailiwick. For example, they might complain, ‘My employer is not following the restrictions. That's why I'm not getting better. Sometimes they ask to be taken off work. Again, communicate. There was one guy who was sitting across from me, ranting for probably about a good couple minutes about how he had to do this and that and the other and the employer wasn’t following restrictions. I picked up the phone while he was still there and called the employer. I said I've heard from Joe and there are a couple points I wanted to touch base with you on. As it turned out, he hadn't even been back at work since his last visit with me. His entire complaint session was a tissue of lies. And once he realized that the game was up, I returned him to work and he was fine. 

We can't let ourselves be drawn into issues that really are not ours. I also have to let some patients know that I'm their doctor, not their mother. At my age, I guess I could be their grandmother, too. But as competent adults, they are responsible for their own recovery and staying within the appropriate activity parameters. If someone asks them to work beyond their restrictions, they need to speak up. If they don't feel comfortable, doing that, they can ask their employer to call me, their physician or another doctor who is taking care of them. But they need to be responsible. They need to make sure they are taking care of themselves. 

The fifth step is evaluating the issues. The worst thing we can do when somebody has a complaint is to blow them off or sidestep the issue. 

That's usually when people are motivated to get an attorney because they feel they're not being heard. Feeling heard is one of the things that makes people feel safe. The safer we make people feel through this whole return-to-work process, the faster they get better usually. The sixth step is solving the problem. Sometimes there are barriers that are logistical. Maybe the person has transportation issues and can't get to clinic visits. We have a program where we will give people rides or use Lyft or other services to do that. These are all things that we can work on with the patient. 

The seventh step is a satisfaction check. That’s important at the end of the whole process, at the last visit. I usually ask what went well and were there any frustrations for you as you went through this process? That helps us get better, if we realized that there were certain things that maybe are not enhancing the patient experience. Like most other systems, we do have patient satisfaction surveys and since you are our partners, we have employer surveys that we do, as well.  

Along with negotiation, reaching a good outcome means that we have to understand normal human reactions. We should be prepared to address common patient concerns. If somebody is afraid, ‘Gosh. I'm going to hurt myself if you make me go back to work,’ we can reassure them. 

Sometimes I have to talk about the fact that hurt does not necessarily equal harm. I let the patient know that when starting to use muscles that maybe you haven't used in a while, those muscles will make themselves heard by hurting. Something new, but not necessarily something bad, is happening. When they're just getting back to a job after an injury, they will have some aches and pains at the end of the day. The same thing holds for employer concerns. If you have any questions, issues, or concerns, feel free to call us.

You can call the clinic talk to the doctor. We have directors of medical operations in every market who also are available and very responsive. I work with our strategic accounts team who are the go-to people for those clients. We're more than happy to talk about any concerns, issues, or even just questions that you have. 

The key takeaways. A successful outcome for a work injury requires more than treating pathophysiology. It requires negotiation as well. There are a lot of stakeholders involved.

This means that there can be some misunderstanding, at times, if we're not communicating clearly, which is why we emphasize collaboration and communication. Education is very effective for good outcomes. Injured employees go through five stages of recovery. As they do that, we need to be attuned to signals that might indicate they are at risk for delayed recovery – things like dramatization, drug misuse, dysfunction, dependency, and disability mindset.

And then setting the stage. Covering issues, confining them, confirming authority, evaluating issues, solving the problem and a satisfaction check at the end. I'll help with the return-to-work negotiation. Again, taking a strictly biological approach can fail to help injured employees who have a dysfunctional way of dealing with their post injury situation.

Fortunately, that's a very small percentage of injured workers. You always hear about the difficult ten percent. Really and truly, it's a small percentage, but these are the people who use up most of the resources. So, even though it's a small number, we are learning to identify them and to develop strategies to help them, to be a rehabilitator, rather than somebody who's just going to chase a paint complaint they have. This really is the way to help them move forward.