Do you have patients who aren't sure if they can stay employed after an injury or illness?

RETAIN California is here to help you and your patients achieve the best possible recovery. We want to collaborate with you to minimize the impact of your patients’ medical problems on their future well-being and their livelihoods.

There is no cost to you or your patients to participate in our program. RETAIN California is voluntary for you, your patient, their employer, and other involved parties.

Why Should My Practice Get Involved?

Job loss is a devastating outcome of health conditions that can have a long-term negative impact on your patients’ health and well-being - whether physical, mental, familial, social, or financial. So, it makes sense for people to keep working when medically feasible.

The seeds of stay- at-work or return-to-work (SAW/RTW) goals are often planted in the office by a physician, but by collaborating with RETAIN California, you won't have to manage that aspect of your patient’s recovery alone. By serving as a trusted intermediary, we’ll lead you to solutions to common problems that needlessly prolong work absence. RETAIN California assists to:

  • Speed up and improve the quality of information flowing between your office and the patient’s employer, and other involved organizations   
  • Minimize hassles and save you time
  • Open doors for your patients that lead to a faster and better recovery

How Can My Practice Get Involved in RETAIN California?   

  • You will automatically become involved in RETAIN California once you refer a patient 
  • We will collaborate with your clinic on an ongoing basis to optimize and expedite your patient’s’ functional recovery

Who is Eligible for RETAIN Services?

Working patients who may be unable to work due to a new injury, illness, surgical procedure, or change in a chronic condition may qualify for our services

To meet enrollment criteria patients must: 

  • Currently be under medical care
  • Live or work in Sacramento or San Diego County
  • Speak English or Spanish

And have one or more of the following:   

  • Clinical nomination (clinician determines the patient to be at risk for prolonged work disability)
  • 2 injured body parts
  • Any surgical consult
  • 7+ physical therapy visits   
  • Off duty for any amount of time   
  • Any MRI, EMG   
  • Modified work - is being accommodated, any amount of time
  • Modified work - is being accommodated for a minimum of 3 weeks
  • Any "no-show" appointments without cancellation
  • The date of onset of primary injury/illness should be the date on which the worsening occurred rather than the date in which the pre-existing condition began

Best Practices

RETAIN California is modeled after several promising SAW/RTW programs, including one operating in Washington State called the Centers of Occupational Health and Education (COHE). COHE  identified four best practices that resulted in a quicker return-to-work of participating employees. These include:

  1. Completing a report-of-accident form and sending it to the state’s Department of Labor and Industries within two business days.
    Physicians receive about $20 extra per case if they meet this goal. Before this program, it usually took between 7 and 21 days for a form to be submitted for an employee with an injury. Currently, roughly 87 percent of forms are returned within the two-day period.
  2. Submitting an activity prescription form that outlines the employee’s physical limitation.
    Physicians receive an additional $50 for completing the form.
  3. Making a phone call to the employer to discuss the case and potential RTW options.
    Physicians are compensated on a sliding scale based on the length of the phone call with employers.
  4. Identifying and documenting non-medical barriers to RTW.
    Examples include alcoholism, exaggerated illness, and employer-employee relationship. The goal is to identify any nonmedical reasons for a worker’s failure to return to work. The physician receives an additional $150 for this task.

These four desired clinician best practices are strongly encouraged and rewarded: 

  1. Timely notification to Labor and Industries (within 36 hours) that a new episode has begun.
  2. Providing newly injured workers with explicit guidance recommending appropriate levels of activity and work as part of the medical treatment, using an activity prescription form and a conversation "script" with four key informative messages.
  3. Actively communicating with other parties, especially with the health service coordinator and employer to discuss work capacity, return to work plans, and how to move things forward.
  4. If recovery seems delayed (typically if return to work has not occurred by four weeks), deeper analysis and thinking about possible causes and remedies. 

ACOEM Guidelines

ACOEM has released a set of guidelines that describes the Stay-at-Work/Return-to-Work (SAW/RTW) process and presents recommendations to improve the process

What is the SAW/RTW Process?

  1. Triggered when a medical condition or another precipitating event occurs raising the question whether the worker can or should do his or her usual job today.
  2. The worker's current ability to work is assessed on 3 important dimensions:
    1. Functional capacity
      • What can they do today?
      • Has the infection made him or her so sick he or she cannot function at all? If not, what can they do in their current condition?
    2. Functional impairments or limitations
      • What can the worker not do now that they normally could?
    3. Medically based restrictions
      • What they should not do lest specific medical harm occur?
  3. Demands of the usual job and/or available temporary alternative tasks are compared with the worker’s current functional capacity, limitations, and medical restrictions.
      • The functional demands of the tasks or job must be known
        • Knowledge, skills, and abilities – physical, cognitive, and social
      • Specific medical qualification standards, legal requirements, company policies, or concerns about the safety of coworkers, the public, or the business may also apply
  4. Actions necessary to resolve the situation and return the worker to work are identified.
    1. If worker can be safe and comfortable doing their usual job or can independently make any necessary modifications, they should be able to return to work.

This process does not take long if the job is not demanding of the impaired body part or function, the medical condition is minor, and the worker wants to go to work.

However, oftentimes the situation is more complicated and the SAW/RTW process turns into a negotiation between the employee and the employer on whether the employee can return to work. Sometimes steps 2-4 of the SAW/RTW process have to be repeated multiple times.

No matter how complicated the situation gets or how many times the steps need to be repeated, the three basic questions requiring answers always remain the same:

  1. What are the worker’s current work capacity, medical restrictions, and functional limitations?
  2. What are the functional demands of the intended job?
  3. If the worker’s functional capacity matches the functional demands, what is required to affect an actual return to work?

The outcomes of the SAW/RTW process greatly impact the overall health and well-being of workers, their families, and employers by determining whether people stay engaged in or withdraw from work and the subsequent consequences that follow.

There are four general recommendations in which SAW/RTW processes can be improved:

  1. Adopt a disability prevention model
    1. Increase awareness of how rarely disability is medically required
      • Stop assuming that absence from work is medically required and that only correct medical diagnosis and treatment can reduce disability
      • Pay attention to the non-medical causes that underlie discretionary and unnecessary disability.
      • Reduce discretionary disability by increasing the likelihood that employers will provide on-the-job recovery.
      • Reduce unnecessary disability by removing administrative delays and bureaucratic obstacles, strengthening flabby management, and by following other recommendations in this report.
      • Instruct all participants about the nature and extent of preventable disability.
      • Educate employers about their powerful role in determining SAW/RTW results.
    2. Urgency is required because prolonged time away from work is harmful
      • Shift the focus from “managing” disability to “preventing” it and shorten the response time.
      • Revamp disability benefits systems to reflect the reality that resolving disability episodes is an urgent matter given the short window of opportunity to renormalize life.
      • Emphasize preventing or immediately ending unnecessary time away from work, this preventing development of the disabled mindset, and disseminate an educational campaign supporting this position.
  2. Address behavioral and circumstantial realties that create and prolong work disability
    1. Acknowledging and dealing with normal human reactions
      • Encourage all participants to expand their SAW/RTW model to include appropriate handling of the normal human emotional reactions that accompany temporary disability to prevent it becoming permanent.
      • Encourage payers to devise methods to provide these services or pay for them.
    2. Investigate and address social and workplace realities
      • The SAW/RTW process should routinely involve inquiry into and articulation of workplace and social realities.
      • Establish better communication with SAW/RTW parties
      • Develop and disseminate screening instruments that flag workplace and social issues for investigation.
      • Conduct pilot programs to discover the effectiveness of various interventions.
    3. Find a way to effectively address psychiatric conditions
      • Adopt effective means to acknowledge and treat psychiatric co-morbidities
      • Teach SAW/RTW participants about the interaction of psychiatric assessments of people with slower than expected recoveries
      • Routine
      • Make payment for psychiatric treatment dependent on evidence-based
      • Cost effective treatments of demonstrated effectiveness
    4. Reduce distortion of the medical treatment process by hidden financial agendas
      • Develop effective ways and best practices for dealing with these situations.
      • Instruct clinicians on how to respond when they sense hidden agendas
      • Educate providers about financial aspects that could distort the process.
      • Procedures meant to ensure independence of medical caregivers should not keep the physician “above it all” and in the dark about the actual factors at work.
      • Limited, non-adversarial participation by impartial physicians may be helpful.
      • When possible, reduce the differences between benefit programs that create incentives to distort
  3. Acknowledge the contribution of motivation on outcomes and make changes to improve incentive alignment
    1. Pay physicians for disability prevention work to increase their professional commitment
      • Develop ways to compensate physicians for the cognitive work and time spent evaluating patients and providing needed information to employer and insurers as well as resolving SAW/RTW issues.
    2. Support appropriate patient advocacy by getting treating physicians out of a loyalties bind
      • SAW/RTW process should recognize the treating physician’s allegiance
      • Reinforce the primary commitment to the patient/employee’s health and safety, and avoid putting the treating physician in a conflict of interest situation
      • Focus on reducing split loyalties and avoid breaches of confidentiality
      • Use simpler, less adversarial means to obtain corroborative information
      • Develop creative ways for treating physicians to participate in SAW/RTW without compromising their loyalty to their patients
    3. Increase “real-time” availability of on-the-job recovery, transitional work programs, and permanent job modifications
      • Encourage of require employers to use transitional work programs
      • Adopt clearly written policies and procedures that instruct and direct people in carrying out their responsibilities
      • Hold supervisors accountable for the cost of benefits if temporary transitional work is not available to their injured/ill employees; consult with unions to design on-the-job recovery programs
      • Require worker participation with ombudsman services available to guard against abuse
      • Make ongoing expert resources available to employers to help them implement and manage these programs
    4. Be rigorous yet fair to reduce minor abuses and cynicism
      • Encourage programs that allow employees take time off without requiring a medical excuse
      • Learn more about the negative effect of ignoring inappropriate use of disability benefit programs
      • Discourage petty corruption by consistent, rigorous program administration
      • Develop and use methods to reduce management and worker cynicism for disability benefit programs
      • Train all parties to face situations without becoming adversaries
      • Be fair and kind to workers in the SAW/RTW process
    5. Devise better strategies to deal with bad faith behavior
      • Devote more effort to identifying and dealing with employers or insurers that use SAW/RTW efforts unfairly and show no respect for the legitimate needs of employees with a medical condition
      • Make a complaint investigation and resolution service available to employees who feel they received poor services or unfair treatment
  4. Invest in system and infrastructure improvements
    1. Educate physicians on “why” and “how” to play a role in preventing disability
      • Educate all treating physicians in basic disability prevention/management and their role in the SAW/RTW process
      • Provide advanced training using the most effective methods
      • Make appropriate privileges and reimbursements available to trained physicians
      • Focus attention on treatment guidelines where adequate supporting medical evidence exists
      • Make the knowledge and skills to be taught consistent with current recommendations that medicine shift to a provocative health-oriented paradigm from a reactive, disease-oriented paradigm
    2. Disseminate Medical Evidence regarding recovery benefits of staying at work and being active
      • Undertake large scale educational efforts to that actively recommendations become a routine part of medical treatment plans an treating clinicians prescribe inactivity only when medically required
      • Specify that medical care must be consistent with current medical best practices
      • Adopt an evidence-based guideline as the standard of care
    3. Simplify/standardize information exchange methods between employers/payers and medical offices
      • Encourage employers, insurers, and benefits administrators to use communication methods that respect physician’s time
      • Spending time digesting excerpting, and highlighting key information so physicians can quickly spot the most important issues and meet the need for prompt, pertinent information
      • Encourage all parties to learn to discuss the issues in functional terms and mutually seek ways to eliminate obstacles
    4. Improve/standardize methods and tools that provide data for SAW/RTW decision-making
      • Help physicians participate more effectively in SAW/RTW process by standardizing key information and processes
      • Persuade employers to prepare accurate, up-to-date functional job descriptions (focused on job’s maximum demands) in advance and keep them at the benefits administrator’s facility
      • Send them to physicians at the onset of disability
      • Teach physicians practical methods to determine and document functional capacity
      • Require purveyors of functional capacity evaluation methods and machines to provide published evidence in high-quality, peer reviewed trials comparing their adequacy to other methods
    5. Increase the study of and knowledge about SAW/RTW
      • Complete and distribute a description of the SAW/RTW process with recommendations on how best to achieve desired results in disability outcomes
      • Establish and find industry-specific, broad-based research programs
      • Collect, analyze, and publish existing research
      • Formulate research to better understand current practices and outcomes, determine best practices and test alternative solutions to problems
      • Develop a way to effectively communicate the findings of completed research to all decision-makers
      • Solicit needs for future research

Overall recommendations to improve the SAW/RTW process will require:

  • A sense of urgency
  • Attention and priority
  • Research
  • Experimentation with new methods and interventions
  • Infrastructure development
  • Policy revision
  • Methodological improvement and dissemination
  • Education and training
  • Incentive alignment
  • Funding

 unav, & Stay-at-Work Return-to-Work Process Improvement Committee. (2006). Preventing Needless Work Disability by Helping People Stay Employed. Journal of Occupational and Environmental Medicine, 48(9), 972–987.