Advice re: RTW Coordinators - location & backgrounds

Jennifer Christian MD

A state asked for my advice about who the RTW coordinators should work for and what kind of professional backgrounds they should have.  Here are my observations and professional opinions on the matter.   I have provided some big picture for some very important context, and then directly answered the questions. 

CONTEXT:   The COHE model revolves around  (and three kinds of important services are delivered by)  an actual organizational "center" – thus the name:  CENTER for Occupational Health & Education.  In my view, an absolutely essential  and strategically BRILLIANT part of the COHE model is that the CENTERS are ALL housed/operated by entities INSIDE the healthcare delivery system.  

Please really try to get your whole team to grasp / buy into this concept:   You DO want to this program to look as medical as possible  –and keep it organizationally and culturally as tightly connected to the healthcare process as possible.   The goal is to make the SAW/RTW process appear to be (and have it actually become) part of the caring and healing process and thus more culturally palatable to doctors and to workers – and even to those employers who want to help their employees get better.  If they see the RETAIN effort as an integral part of the healing/caring process, they will be 1,000% more likely to refer, cooperate, actively participate, etc. etc. etc.   One can look at COHE / RETAIN as an effort to “package” SAW/RTW as part of the overall benevolent effort to help working people keep the the rhythm of everyday life as normal as possible, right?  

In fact, the Washington state agency ONLY sent the RFP to establish COHEs to healthcare delivery organizations – they were the only ones eligible to bid.  The COHEs were then established as standalone organizational units within healthcare delivery organizations.  (There are often multiple discrete business units within what is branded as one organization, each with its own separate budget, administration, etc:  the inpatient hospital,  the lab, the outpatient clinics, the remote primary care sites, etc. etc.   Many healthcare delivery systems were built through mergers and acquisitions.  So adding the COHE as another unit wasn’t too foreign to them. )

Who works for the COHEs?

  1. COHE management staff who oversees and ensures that all three parts of the program are operating as intended:   (a) medical community relations; (b) RTW coordinators; (c) medical direction and specialty  consultants.   
  2. The medical community liaison staff (who are on the road much of the time recruiting new doctors (to keep growing the membership – and thus increasing the fraction of the physician workforce that buys into the COHE concept), educating, and building/maintaining/trouble-shooting relationships with community doctors)
  3. Physicians:
  • Medical directors (most likely contract part-time) are occupational medicine physicians or have similar expertise in functional recovery and the SAW/RTW process.   
  • Specialist consultants (also contract and very part-time)  in medical / surgical specialties that are frequently needed, especially orthopedics.  They are rarely on site.
    • In RETAIN, I think you'd want at least one orthopedist, one neurologist, one psychiatrist, and one psychologist with expertise in behavioral medicine / cognitive behavioral therapy (who would have to have had -- or agree to get -- special training in two area:  work and pain).   
    • You might also want them to have a contracted Occupational Therapist on staff who can be the first line resource for HSCs and community physicians regarding adaptive techniques/equipment/ accommodations that permit SAW/RTW.
  1. The “healthcare service coordinators” (HSCs) who are actually care/communications coordinators.  I believe Washington INTENTIONALLY chose HSC as the term for the coordinators – in order to be consistent with their STRATEGY to make this whole issue of restoring/preserving the normal rhythm of life ASAP and preventing needless work disability LOOK LIKE A NATURAL PART OF THE MEDICAL TREATMENT PROCESS.    But in RETAIN they are referred to as RTW coordinators**. 

** SIDE NOTE:   Calling the coordinators “RTW coordinators” may actually IMPERIL the success of your project.  Outside the world of “disability employment advocates” prompt RTW is OFTEN NOT considered a worker-friendly / patient-oriented outcome.  Many people think that time away from work is a “benefit”.   They see RTW as what the EMPLOYER wants or the GOVERNMENT wants.  Going right back to work may not be seen as safe for the patient or the discussion may seem “unfeeling” if brought up “too early” in the patient's or doctor's view.   So, the term RTW coordinator will completely turn off /alienate some workers and their doctors.  Thus, you probably want to call these staff people something else. 

    • In the COHE model, the HSCs work at the COHE center.   They spend most of their time on the phone or email or using a centralized IT system.
    • They must be comfortable working BOTH with doctors AND with employers – AND aware of the types of issues that arise early in a health episode.   
    • The HSCs use their discretion on how much effort to put into individual cases.  They become familiar with the local medical and employer community, and start to see patterns.  One of them told me that she can usually tell whether a case is going to need extra attention based on the name of the doctor and the name of the employer.   There are other triggers, of course.  But, the HSCs interact more frequently with the doctors and employers who are less experienced or less “enlightened” and thus need more reminders/help/suggestions than others). 
    • The HSCs go out on the road to MEET ANNUALLY with the doctors they are connected to, providing feedback and doing some training at each visit.  
    • Many of the HSCs I encountered in the COHEs had originally been trained in vocational rehabilitation AND had years of experience.  So they are familiar / comfortable dealing with people who have health problems AND their need to make emotional as well as tangible adjustments in order to work.   The new part for the HSCs to learn – which is required in order to be effective in COHE -- was the specific types of SAW/RTW issues that arise and must be managed EARLY in health episodes, while the health condition is still evolving.
    • The list of potentially appropriate professions to serve as HSCs include:  Occupational Therapists, Vocational Rehabilitation professionals, Physical Therapists, Nurses, and Social Workers, especially LCSWs.   There are potential difficulties with all of those professions.  The key questions are:
        1. Whether they are familiar with the functional impact / medical care process for the most common medical conditions workers are likely to have  (Social workers are least likely).
        2. Whether they have had any special training or prior work experience in SAW/RTW –  Nurses are least likely, and many OT’s / PTs may have specialized in hospitalized patients, children or the elderly.
        3. Their overall philosophy – their awareness of and beliefs about the dynamics of injury and recovery, the negative impact of having life in limbo / worklessness, and the positive impact that SAW/RTW will have on people’s futures.   We do not want the HSCs/RTW coordinators to be so tender-hearted they end up “enabling” failed recovery, over-impairment, and needless work disability.   
        4. their INTERPERSONAL SKILLS – the ability to rapidly create and maintain a purposeful relationship of trust and good communications with ALL THREE PARTIES:  workers, doctors and employers.    MOST of the IMPACT the RTW Coordinators will deliver is going to be due to their ability to inspire trust, to communicate clearly and persuasively, to change how people think / see a situation, and increase confidence and willingness to try things, go along with proposed solutions.
    • Pitfalls for RTW Coordinators.   In my personal years of experience supervising and training case managers, and from what I have observed in our consulting projects, I have found that any one of the professionals above MAY or MAY NOT be appropriate to work at the health/work interface.  Problems arise if they:
        1.  Would rather back seat drive treating physicians instead of partner with / support / develop the doctor’s abilities (this is common among nurses who have worked in managed care – roughly half of them in my experience.)
        2. Have had little or no training or experience in understanding the implications of health conditions for FUNCTION, and
        3. Have had little or no detailed knowledge or actual experience in workplaces other than their own;
        4. Tend to see medical and healthcare delivery issues as the most important, so get sucked in by them -- and neglect RTW issues with which they feel less comfortable.
        5. They over-medicalize things, sympathize with workers as “victims,” and see it as “the system’s” (everyone else’s) responsibility to get them better (so the patient becomes passive), agree that is pain a reason to stop living and sit around, and have difficulty remembering that life is often unfair and that the real purpose of healthcare is to get people functioning, back on their feet, out in the world living the fullest possible life again.
    • I suspect that your occupational medicine physician advisor / COHE medical director can help you identify which of the candidates you find is best qualified – and can help train them.  Also, the Technical Assistance contractors will be helping with training.

I hope this information is helpful


Jennifer Christian, MD, MPH

President / Chief Medical Officer

Webility Corporation

95 Woodridge Road

Wayland, MA 01778

Office:  508-358-5218 (preferred)

Mobile:  617-803-9835

Email: jennifer.christian@...