Category Archives: Testing

Predictive Psychosocial Triggers For Workers’ Compensation Claims

There are a number of factors, which, if present, provide accurate prediction of who will benefit from early psychological evaluation. Current research is conclusive that the two most predictive psychological factors regarding who will file a non-traumatic occupational injury claim are:

  • Job task dissatisfaction; and,
  • Distress as reported on Scale 3 of the Minnesota Multiphasic Personality Inventory (MMPI). The MMPI Scale 3 was created using patients who exhibited some physical complaint for which no general medical explanation could be established.

However, employers rarely sense job dissatisfaction in one of their workers and claims adjusters don’t administer the MMPI to claimants before or even after they file claims.

So, when we attend claims association meetings in New Jersey, we are often asked what psychosocial factors, if present in a claim, should prompt a speedy referral for an Initial Psychological Evaluation. With that in mind, and drawing on the best evidence-based scientific research available, we’ve put together a list of specific Predictive Triggers for workers’ comp claims, Triggers which, if three or more are present, indicate early referral for an Initial Psychological Evaluation  is important. Keep in mind that our Initial Psychological Evaluation, although not technically an IME, is done at the IME level.

In no particular order, here are the Triggers:

  • History of abuse, sexual and/or physical
  • Excessive alcohol consumption
  • History of narcotics abuse
  • Depression, or a history of it
  • Coping inadequacy
  • Two or more prescriptions for narcotics
  • Perception of poor health in general
  • Passive attitude
  • Widowed or divorced
  • Tendency to catastrophize and make a referral
  • Blue collar, physically demanding job
  • Complaints of headaches, with no head injury
  • PTSD complaint, without traumatic experience
  • Age over 40
  • Low non-work activity levels
  • History of Somatization (Somatization is the conversion of anxiety to physical symptoms)
  • Driving distance from home to work greater than  30 miles
  • History of filing workers’ comp claims, or other legal claims
  • Poor performance in high school

If you’re a claims adjuster, a nurse case manager or an attorney handling workers’ comp claims, you’ve seen many claims where a number of these Predictive Triggers are present. And you’ve probably been frustrated because the claims have not closed when they should have; they drag on; MMI seems elusive. Work Comp Psych Net can help. Give us a chance. Create an account and login at www.workcomppsych.net to Make a ReferralSooner – Faster – Smarter.

There Is A Need For Better Psychosocial Intervention In Workers’ Compensation

This morning, Workers Comp Insider, the Grand Daddy of workers’ compensation blogs, published an illuminating post focusing on why workers’ comp claims professionals wait far too long to engage qualified psychologists.  This, from the opening of Are We Only Paying Lip Service To Psychosocial Issues In Workers’ Compensation?:

It is a cliché in the workers’ comp industry that claims adjusters never want “to buy a psych claim.” Perhaps that’s why they rarely resort to psychologists until the horse is out of the barn and grazing four pastures over. By then it’s a last resort kind of thing.

The Insider goes on to say that claims payers and psychologists just don’t understand each other. It chides those claims adjusters who settle for asking only the basic questions suggesting that “digging deep” and

peeling the injured person’s personality onion to discover what really matters will allow for early detection of those relatively rare cases where speedy referral to a qualified psychologist might make all the difference.

We couldn’t agree more, yet lest we with the PH. D.s after our names begin to feel too comfortable, we come in for some sharp criticism, too. Most of us “know not even the first thing about workers’ compensation and give every indication of being proud of it.” Ouch.

The blog post suggests that we and the payers need to come together to build a system that works for everyone and that if claims adjusters are attuned to the subtle nuance inherent in a good conversation with an injured person, then perhaps certain signs will become apparent that indicate early psychological intervention is warranted.

Part of that coming together requires trust on both sides. The Insider suggests that a sign of trust on the side of the payers would be to adopt a  policy that “entrance into a payer network should not be determined solely by a license to practice and the forced acceptance of a ridiculously low fee. Quality and results matter.”

Finally, the post tells payers that they have a whole lot of educating to do, education that should start today. Why?

Because identifying early and resolving quickly the factors that have the potential to turn physical injuries into mental health problems will save employers, the folks who pay the bills, a significant amount of money and adjusters, whose goal it is to put the toothpaste back in the tube, considerable otherwise wasted time.

That, in a nutshell, is why we created Work Comp Psych Net. To partner with payers for the betterment of injured workers to build a better system – Sooner, Faster, Smarter.

A Good History: The Devil Is in the Details

It has been my experience that taking an extensive history from an injured client about a head injury has to be more than just “what happened, where did you hit your head and what do you remember?”

One has to determine whether loss of consciousness occurred and, if so, for how long. If loss of consciousness was prolonged, has the injured worker experienced Post Traumatic Amnesia? Post Traumatic Amnesia refers to the time the head injury happened until when the patient is laying down consistent, recoverable memories. While head-injured workers may have islands of memory during this period, they often do not retain their memories consistently. Understanding and evaluating this is vital to providing the injured worker the appropriate services and treatment.

A real-life example will help to understand what I mean.

A patient recently was referred to me secondary to depression from a work­related accident. The history provided to me was that the worker had  slipped and fallen at work. When she was delayed in returning to work, a neurological evaluation concluded that her overall presentation was more impaired than would be expected for the type of injury she had suffered – a simple slip and fall. The suggestion then was that her problem was more psychological than neuropsychological or phsyical.

In our initial session, I took a very extensive and detailed history of the actual events . The accident report said she slipped on water and fell in the hallway and had been out of work since then. The history was woefully incomplete. It did not tell me anything about what kind of fall, what was going on surrounding the event and what happened after the event. From talking with her, this is what I learned and what should have been in the history I’d been given: She was a kindergarten teacher. She was walking 20+ kindergarteners in a line down a hallway. This was the first week of school and the children did not know what to do, so she had to help them stay together in a line in order to follow her . This was when she slipped on a puddle of water from a nearby water fountain, fell on the floor, hit her head and lost consciousness. I asked her what she remembered when she awakened into consciousness. She told me there was someone standing over her asking her something.

She was cloudy about the event.   I asked if there was anyone in the hall? “No.”  Any children? “No.” Any other teachers? “No.” Any nurse? “No.”

So, I learned that when she regained consciousness, the hallway was cleared of everyone with the exception of the person who was standing over her trying to talk to her.

If you extrapolate from that to try to determine the duration of her loss of consciousness, you would conclude that from the time she slipped, fell and lost consciousness, the following would most likely have occurred : The kindergarteners would have been upset, anxious and crying. Another teacher would have had to notice that, gather the children and take them into another room. This would have taken at least a few minutes. Meanwhile, a colleague would presumably try to get the nurse. And, finally, while all of this was going on, someone would stay with her. This would be the person who was standing over her trying to talk to her when she awakened from her loss of consciousness.

This history now suggested that at the very least, she had  lost consciousness for around 10-15 minutes and awakened to a vague sense of someone asking if she were all right. She told me she does not remember what she replied. She thinks she said she was okay. She was confused, dazed and disoriented.

There was no ambulance called, and she was sent home.  She slept the rest of the weekend. While she had ‘islands of memory” over the next couple of weeks, she was not laying down consistent memories , suggesting a protracted Post Traumatic Amnesia.

Clinically, all of this presented a very different picture from the one I had been given initially. From a simple slip and fall with a neuropsychological testing that looked too impaired for someone who just had a slip and fall, this woman clearly had a head injury.  She had a positive loss of consciousness of 10-15 minutes, islands of memory and Post Traumatic Amnesia for a couple of weeks.

My report to the case manager was that this was a  woman who had suffered a very serious injury. By the time she got to me, she had been struggling for weeks with no services for the head injury. Her deficits included neurocognitive dysfunction, post-traumatic vestibular dysfunction and post-traumatic visual dysfunction.       Much of the delay in treatment had to do with an initial assessment in which the history was incomplete and the conclusions less than accurate. If a complete history had been taken at the beginning, she could have been helped with these issues and would have improved more rapidly. The accident analysis and narrative failed this woman and she paid the price.

The bottom line to this is that we at WCPN know the importance of taking a very detailed history. Of course, this is important for any accident, but even more so for accidents involving head injuries, which by their very nature are psychologically problematic. For us, getting the history right is the first essential step in treating our patients sooner, faster,smarter.

Neuropsychological Testing reports – What they should be saying about injured workers!

As a neuropsychologist with over 37 years of neuropsychological testing experience I have a keen appreciation for the time and cost of neuropsychological testing. A key question to me is what value does this expensive assessment have to the injured worker or to his payor of medical services?

In answering this question I am reminded of a case several years ago as Clinical Director of Cambridge Rehabilitation Services. Called on to consult by a private disability insurance carrier, this man had been a top salesman in New Jersey for a national company for many years. Unfortunately he suffered a brain injury from which he physically recovered but left him with mild cognitive impairments. The referral included his medical reports and a Neuropsychological Test report. This report was not from a local neuropsychologist but by a leading expert from New York. The expert, well published and a professor, made many correct observations and conclusions about my patient.   However, it was my belief that the report missed the mark on informing his disability insurance carrier about his rehabilitation potential in terms of return to work.

I went over the test data and concluded that the expert, retained by claimant’s attorney on behalf in his disability claim, presented a very static view of his capabilities.   As with many Neuropsychological Test reports I have reviewed over the years, several critical work related questions went unaddressed. The expert simply opined the claimant had suffered cognitive impairments and that returning to his job “as is” was not possible. With the simple “yes he is disabled” conclusion, a disability “payout” was inevitable with this report in hand.

After an interview with the claimant, I imagined a very different outcome for him, one that he was eventually very pleased with in the long term.

My report to his insurance carrier pointed out several missing factors left unaddressed in the prior report.

  • Job related cognitive limitations – The specific cognitive changes causing his loss of work functions
  • Potential benefits of rehabilitation efforts– the specific interventions and their projected benefits to improving his work product
  • Emotional and motivational factors– the personality factors which could be tapped into and leveraged to assist him in perservering with a rehabilitation program that would assist him in accepting personal changes
  • A specific time line for return to work and projected costs– a detailed outline of the time and cost of the rehabilitative efforts.

His insurance carrier offered him our cognitive rehabilitation program in lieu of a full and permanent disability payout, with the option of the payout if the program failed. He chose the rehab offer.

Our team of a neuropsychologist, speech pathologist and cognitive therapist went to work on an intensive basis with interventions in his work environment itself. Remediation efforts attacked his critical cognitive weaknesses that blocked him from success and within 3 months he returned to work. While his work output was still diminished (after all he had been national top salesman for several years, allowing quite a bit of leeway), he was happy he could see himself successful earning a living, competing in the workplace as he always had.

The full cost of our cognitive rehab program was less than 4 months of the disability payments that would have been paid to him had our interventions not been successful! A net win-win for all.