Rehabilitation Policy 21-400 | Effective Date: April 9, 2015

Purpose

The purpose of this policy is to:

• Provide an overview of the key elements of rehabilitation;
• Provide direction to staff on planning and managing rehabilitation activities for injured workers; and
• Advise injured workers of what to expect throughout the rehabilitation process.

Scope

This policy applies to injured workers who require rehabilitation.

Statements 

1.0 General 

Rehabilitation is a planned, yet flexible process that requires a cooperative, multidisciplinary approach to support workers injured in an accident arising out of and in the course of employment, in achieving medical recovery and return to work goals. 

Plans for rehabilitation may include a range of benefits and/or services provided under the authority of the Workers’ Compensation Act (WC Act). Depending on the injured worker’s eligibility, the following may be integrated into the rehabilitation plan:

• Medical aid;
• Financial assistance; and
• Return to work activities. 

1.1 Medical Aid 

WorkSafeNB has a legislated responsibility to determine the need for medical aid, as well as the type and extent of medical aid required. In providing rehabilitation, WorkSafeNB is committed to injured workers receiving the right care (based on the right diagnosis), by the right provider, and at the right cost. 

Medical aid may include, but is not limited to, treatment and ongoing care of workplace injuries or diseases. It may include the services of physicians, specialists, and other health care providers, who may provide therapy, medications, and prosthetic and/or assistive devices as required and in accordance with WorkSafeNB’s medical aid policies.

For more information, see Medical Aid policies such as:

• Policy No. 25-001 Medical Aid – Principles;
• Policy No. 25-007 Prostheses, Orthoses and Assistive Devices; and
• Policy No. 25-008 Clothing and Footwear.  

1.2 Financial Assistance 

WorkSafeNB also operates a wage loss compensation system, which means that rehabilitation planning focuses on services, programs, and activities that will help minimize injured workers’ loss of earnings by assisting them to return to suitable employment. Injured workers may receive financial assistance such as loss of earnings benefits and compensation for permanent physical impairment. 

For more information, see policies such as:

• Policy No. 21-210 Determining Average Earnings;
• Policy No. 21-220 Medical Expense Related Travel; and
• Policy No. 21-250 Permanent Physical Impairment. 

1.3 Return to Work Activities 

WorkSafeNB may provide injured workers with appropriate and cost-effective rehabilitation to lessen or remove barriers resulting from the injury, which limit opportunities for injured workers to return to work. 

Return to work activities promote early and safe return to work as part of the therapeutic process of recovery from workplace injury or disease. It is also recognized that, when safe to do so, staying at work during treatment is beneficial physically, psychologically and financially for injured workers. For workers who are unable to stay at work following a workplace injury, rehabilitation focuses on facilitating return to work at a suitable occupation, including gradual or modified return to work programs on a time-limited basis, and/or assisting with workplace modifications needed to accommodate a work-related disability.

For more information, see Policy No. 21-420 Return to Work – Principles.

2.0 Achieving Rehabilitation Goals 

The overall goal of rehabilitation is to help injured workers achieve:

• Pre-accident functional capacity and return to pre-accident employment, if possible; or
• Medical recovery sufficient to enable them to return to safe, productive employment as soon as is medically possible. 

Consistent with Policy No. 21-420 Return to Work – Principles, WorkSafeNB’s rehabilitation goals focus initially on helping injured workers safely continue with their pre-accident employment, or return to the pre-accident employment and/or employer as early as possible. 

However, when this is not possible due to a permanent work restriction, WorkSafeNB’s rehabilitation goals become focused on helping injured workers develop the capacity to re-enter the workforce to obtain employment:

• With an alternate employer;
• That is consistent with their functional capacities and skills; and
• That may help them attain an earning capacity comparable to that which they had before the workplace injury, if possible given their functional capacities. 

In some cases, return to work may be impossible or unlikely. Therefore, throughout the rehabilitation process, WorkSafeNB determines if further treatment or services are appropriate by:

• Obtaining a medical opinion of whether the injured worker’s medical condition has reached a plateau and if further rehabilitation would provide a significant improvement in function;
• Determining whether rehabilitation activities are considered to be medically effective and would significantly improve function;
• Determining whether rehabilitation activities would significantly improve function and reduce the injured worker’s reliance on loss of earnings benefits and/or other WorkSafeNB benefits; and
• Determining whether rehabilitation activities are cost effective when compared to the potential reduction in the injured worker’s reliance on loss of earnings benefits and/or other WorkSafeNB benefits. 

WorkSafeNB is responsible to decide if a specific rehabilitation activity will significantly improve an injured worker’s function. This is achieved by analyzing, on a case-by-case basis, information gathered based on the criteria listed above and all other relevant medical evidence. If WorkSafeNB determines that significant improvement in function is not expected from the activity, WorkSafeNB does not approve the rehabilitation requested. For more information, see Policy No. 21-113 Decision Making. 

However, WorkSafeNB may provide specific services to severely injured workers to promote independent living to the extent possible, given the compensable injury. These services are based on the following policies:

• Policy No. 21-402 Vehicle Modifications;
• Policy No. 21-403 Home Modifications to Assist with Functional Access; and
• Policy No. 25-003 Home Care and Independence 

2.1 Responsibilities in Rehabilitation  

WorkSafeNB develops rehabilitation plans in cooperation with the injured worker, employer, health care providers, physicians, and other parties involved, such as unions, in order to set return to work goals and objectives that are compatible with the medical, functional, and vocational status of the injured worker. 

To be successful, rehabilitation plans require active participation and open communication on a regular basis among all parties involved in the rehabilitation process. For more information, see Policy No. 21-419 Communications in Rehabilitation. 

Injured workers and accident employers have legislated responsibilities under the WC Act to cooperate in the worker’s safe and early return to work. Accident employers, for their part, have an obligation under the WC Act to re-employ injured workers, and a broader duty to accommodate under the Human Rights Act. WorkSafeNB expects:

• Accident employers to take an active role in planning and managing injured workers’ return to work activities; and
• Injured workers to actively engage, participate and cooperate in treatment, rehabilitation, and safe return to work activities. This obligation extends to accepting suitable employment with the accident employer or an alternate employer, once WorkSafeNB has determined the injured worker to be capable of returning to work. 

For more information, see:

• Policy No. 21-214 Determining Continued Eligibility for Loss of Earnings Benefits; and
• Policy No. 21-413 Return to Work – Responsibilities and Re-employment Obligations. 

3.0 Phases of Rehabilitation

Since rehabilitation must be flexible and designed to meet individual workers’ needs, services within the medical, financial, and return to work components of rehabilitation may be provided simultaneously or at various times in the care and management of a worker’s injury.

To facilitate the rehabilitative process, WorkSafeNB has identified three phases of rehabilitation (acute, sub-acute, and chronic), which correspond to the phases of recovery from injury described in Policy No. 25-002 Medical Aid Standards of Care.

Most injured workers do not go through all phases. Also, not all injured workers progress from one phase to the next in a predictable or sequential manner. The actual timing of interventions and rehabilitation activities may vary according to the injured worker’s medical condition and rate of recovery. For example, activities associated with one phase may be more appropriately initiated at an earlier phase.

Though subject to the specifics of each individual case, rehabilitation generally falls into these three phases of activity.

3.1 Phase I – Acute 

In the acute phase of the injury, WorkSafeNB works closely with physicians and health care providers in order to:

• Provide immediate treatment and primary care needed for the injury or illness;
• Confirm a diagnosis as soon as possible;
• Determine the disability duration, in accordance with medically-established guidelines (Disability Duration Guidelines);
• Determine the injured worker’s entitlement to loss of earnings benefits; and
• Communicate early with the accident employer to plan and/or monitor return to work activities.

In many cases, services provided during this initial phase, such as medication and physiotherapy, are sufficient to enable injured workers to continue working, or return to work within the disability duration guidelines for their injury type. WorkSafeNB may also provide assistance for workplace modifications, as determined by WorkSafeNB to be necessary, appropriate, and expedient during this phase.

When injuries are severe or complex, or if the injured worker has not returned to work within the disability duration guidelines, the case moves into the next phase of rehabilitation and case management.

3.2 Phase II – Sub-acute

Generally, this phase of rehabilitation begins when the expected disability duration has elapsed and the injured worker requires additional treatment in order to progress with return to work activities.

WorkSafeNB works with physicians, health care providers, employers, and return to work specialists, as needed, to:

• Provide treatment or specialized therapy, such as work conditioning, to restore function;
• Determine what factors (medical, work-related, psycho-social barriers, etc.) are impeding return to work;
• Provide loss of earnings benefits;
• Determine whether the accident employer will re-employ the injured worker, and if so, in what capacity (return to same job on a full or gradual basis, modified work, or alternate work);
• Communicate the employer’s re-employment obligations and duty to accommodate;
• Provide advice, assistance, and return to work support (assistive devices, workplace modifications, and/or retraining assistance) to the employer in meeting re-employment obligations; and
• Monitor return to work activities, as needed.

The key interventions during this phase are to determine what factors may be impeding the injured worker’s return to work, and to confirm re-employment opportunities for the worker with the accident employer.

Some of the factors influencing whether the injured worker is likely to return to work with the accident employer are:

• Severity of the injury and anticipated work restrictions;
• Progress of medical recovery in relation to disability duration guidelines;
• Level of support for the worker in the workplace;
• The employer’s willingness or ability to accommodate the work restriction;
• The worker’s relationship with the employer;
• The worker’s level of satisfaction with, and control of, the work activities;
• In a unionized environment, the collective agreement provisions and/or union’s level of support for the return to work plan; and
• Social support available for the worker.

3.3 Phase III – Chronic

Generally, the chronic phase begins when healing times for an injury have elapsed. Healing times refer to the point in time when medical healing is usually complete and the medical condition is relatively stable, whereas disability duration in Phase II refers to the point in time when most workers with a particular injury are able to return to work.

WorkSafeNB provides on-going treatment when there is evidence of its medical effectiveness in restoring function and supporting the worker’s return to suitable employment, either with the accident employer or an alternate employer.

Early Chronic

If an injured worker has not returned to work when the healing time has elapsed, WorkSafeNB determines whether the worker has a permanent work restriction. WorkSafeNB determines if a work restriction exists by reviewing medical evidence and/or using a range of objective assessments (for example, functional capacity assessments).

If the preponderance of evidence shows that the worker:

• Does not have an injury-related work restriction preventing a return to pre-accident duties, WorkSafeNB has fulfilled its obligation to the worker, and closes the claim, terminating loss of earnings benefits.
• Suffers from an injury-related work restriction, the worker may be eligible for further assistance, such as vocational rehabilitation (see Policy No. 21-421 Vocational Rehabilitation).

Late Chronic

When further treatment will not improve the worker’s medical condition (i.e., medical condition has reached a plateau), most injured workers who are still unable to return to work will have an identified work restriction.

When an injured worker has a permanent work restriction and the accident employer can accommodate it, WorkSafeNB may provide:

• Assistance such as ergonomic or other modifications to the workplace;
• Job exposure or job shadowing; and/or
• Training on the job.

If the accident employer cannot or is not willing to accommodate the worker’s permanent work restriction, the injured worker is then eligible for vocational rehabilitation. Vocational rehabilitation plans are interdisciplinary, unique to each individual, and take into consideration such factors as the severity of the worker’s injury and any resulting loss of earnings due to the work restriction, functional capacity, transferable skills, educational level, aptitudes, and interests.

For more information, see Policy No. 21-421 Vocational Rehabilitation.

3.4 Conclusion of Rehabilitation

Rehabilitation or rehabilitation plans may be brought to an end or suspended at any time during the phases when:

• Evidence indicates that the injury no longer prevents the injured worker from safely resuming pre-accident work activities;
• The injury has reached a medical plateau and WorkSafeNB determines the injured worker’s estimated capable earnings;
• The vocational plan is completed or discontinued and WorkSafeNB determines the injured worker’s estimated capable earnings; or
• Circumstances are identified under Policy No. 21-214 Determining Continued Eligibility for Loss of Earnings Benefits.

4.0 Documenting the Rehabilitation Plan

The rehabilitation plan is a tool used through all phases of rehabilitation to organize, record, and evaluate the injured worker’s progress. Each plan is unique, time-specific, and clearly outlines responsibilities and expectations in rehabilitation.

At a minimum, an injured worker’s rehabilitation plan should:

• Identify all participants involved in the injured worker’s rehabilitation, including the accident employer, alternate employers (when appropriate), WorkSafeNB staff, health care providers, physicians, and others;
• Set treatment goals, identify healing times, record appropriate treatment interventions, record timeframes for achievement of goals, and document progress;
• Identify, track, and communicate eligibility for, and payment of, benefits such as loss of earnings, allowances, and claim-related travel;
• Document that re-employment obligations and duty to accommodate responsibilities have been communicated to all parties;
• Identify, set, and implement goals, activities, timeframes, and milestones in return to work planning, including vocational rehabilitation activities;
• Identify specific tasks, and who is responsible for accomplishing them;
• Identify what tools are being used to facilitate return to work;
• Identify a schedule for monitoring specific elements of the plan, such as return to work activities with the accident employer; and
• Document all decisions made, as well as recommendations and outcomes of the plan. 

5.0 Monitoring and Adjusting Rehabilitation Plans 

WorkSafeNB expects rehabilitation planning to be a continuous process of planning, monitoring, evaluating, and then adjusting the plan to reflect the injured worker’s progress and any changes to goals and measures. 

WorkSafeNB regularly monitors the medical, financial, and return to work aspects of the rehabilitation plan, including re-employment activities facilitated by accident employers. 

In monitoring rehabilitation plans, WorkSafeNB reviews whether:

• The injured worker is responding to treatment;
• Treatment and return to work activities continue to be mutually supportive;
• The injured worker’s functional capacity appears to have changed;
• The financial situation of the injured worker has changed;
• All parties are cooperating in rehabilitation as defined in Policy No. 21-413 Return to Work – Responsibilities and Re-employment Obligations;
• Tasks and activities are being achieved;
• Return to work goals are being met;
• Return to work goals continue to be realistic;
• Non-work-related factors are impeding progress;
• The injured worker and accident employer are satisfied with the progress of the rehabilitation plan; and
• Issues between the injured worker and employer are impeding the progress of return to work.

As a result of the on-going monitoring and review of the plan, WorkSafeNB may:

• Make adjustments to any component of the plan;
• Work with accident employers to facilitate changes to return to work activities;
• Communicate the results of the review to all parties; and
• Incorporate additional planning, such as vocational rehabilitation, as needed. 

6.0 Injuries During Rehabilitation

Injured workers who suffer an injury or recurrence of injury while participating in a WorkSafeNB-approved rehabilitation program or return to work activity may be entitled to continued benefits, if the tests for entitlement are satisfied. For more information, see Policy No. 21-108 Conditions for Entitlement - Injuries During Rehabilitation.