Returning to Work Following a Traumatic Brain Injury: A Challenge or an Opportunity?
Issue: December 2014 | Disability | Download PDF | English By Mary Enslin, Associate Claims Specialist, Cape Town
Ray,* a senior partner in a chartered accountancy firm, was in high spirits as he travelled back to the office from a successful morning meeting with a big client. Suddenly, the mood changed as his car was hit by another vehicle, propelling him off the road and into a ditch. Ray lost consciousness and was rushed to hospital where he was diagnosed with multiple serious injuries – an intracerebral haematoma, a diffuse axonal brain injury, left and right haemothorax, a ruptured spleen, a severe laceration to his right leg, and fractures to his femur and right wrist. Needless to say the road ahead would be a long one…
It is estimated that worldwide every 8 to 18 seconds someone suffers a Traumatic Brain Injury (TBI). The Centers for Disease Control and Prevention (CDC) has reported that approximately 1.5 million individuals suffer from TBIs every year in the United States. Moreover, the rate of TBI-related emergency department visits and hospitalisations has increased steadily over the past 10 years, with TBI incidents more than six times higher than breast cancer, HIV and spinal cord injuries combined. In the USA, 14.3 % of TBIs are caused by motor vehicle accidents.1 However, this figure is not consistent across the globe, with some countries, such as South Africa, reporting as many as 50 % of all new TBI cases being caused by motor vehicle accidents.2
The effects of TBI’s can be devastating, resulting in a wide range of short- or long-term difficulties affecting:
- Cognitive Function (e. g. attention and memory, executive functioning)
- Motor function (e. g. extremity weakness, impaired coordination and balance)
- Sensation (e. g. hearing, vision, impaired perception and touch)
- Behaviour and Emotion (e. g. depression, anxiety, aggression, impulse control, personality changes)
- Other (e. g. substance abuse, family and friends)
Thus, it is no surprise that rehabilitation following a TBI is a complicated field that has received extensive research. But is this research of relevance to the insurance industry? Considering a large proportion of TBI-related deaths and injuries are sustained by individuals of working age in middle income settings, it is fair to assume that many of these individuals will have some form of financial protection in the event that they become disabled. Add to this the fact that for individuals hospitalized following TBI, almost half (43 %) have been found to have a related disability one year after the injury,3 and 50 % of those who were severely injured failed to return to work (RTW) at one-year post injury.4 It is then clear that the management of income protection claims resulting from TBI’s is both a challenge and an opportunity for any claims assessor.
We will follow Ray’s recovery from his TBI, highlighting critical obstacles overcome and lessons learnt within the context of the management of his income protection claim. Special focus will be given to the effects of his cognitive impairments on potential for RTW, as management of higher cognitive functioning impairment presents a unique challenge to claims managers. In fact, one study found that cognitive, behavioral and personality changes were far more likely to result in failure to RTW than any physical deficits.5
We first received an Income Protection claim from Ray’s employer three months after his accident. At the time he was still in hospital and his doctors reported that while his condition had stabilized, he was disorientated and bed-ridden – permanent impairments were expected in relation to his brain, femur and spleen injuries. The definition of disability according to the policy wording was an inability on the part of the claimant to perform his own occupation. Thus, the claim was admitted with a view to review periodically, but it was expected to be a long-term claim as it seemed likely there would be long-lasting impairment.
Over the next 10 months Ray continued to receive medical treatment from a variety of specialists – an orthopaedic surgeon, plastic surgeon, neurologist, occupational therapist, physiotherapist, psychologist and speech therapist – all doing their utmost to ensure the best outcome for Ray. It soon became clear that his physical injuries would heal without any serious permanent damage. However, it appeared likely that his most significant residual deficits would be cognitive impairments as a result of his TBI. Despite these impairments, there could be no denying that Ray’s recovery was remarkable, and better than many had expected. In fact, he progressed so well that a year after the accident, following extensive discussion with Ray and his rehabilitation team, we were in agreement that treatment could begin to focus on preparing Ray to return to work.
Ray described his job as fast-paced and highly stressful, with demands including sustained periods of attention, multitasking, appropriate social interaction and judgment, high accuracy and attention to detail. Due to his position as a senior partner his decisions often had far-reaching implications for the firm and its clients. As such, his employer had a number of concerns regarding Ray’s readiness and capability to practice as a chartered accountant, especially as this would have implications on their professional liability insurance.
An occupational therapist was appointed as a case manager and a meeting was held with one of Ray’s fellow partners at the firm. It was agreed that a graded return-to-work program would commence as follows:
- Work only two to three hours per day
- Work only with existing, familiar clients (no new business)
- Supervision and instruction from another partner
- Continue with weekly occupational and speech therapy
- Income benefit would continue at 100 %, as at this stage of the trial Ray would not be receiving a salary.
Initially, progress was limited – while there was verbal commitment from Ray’s employer, we found that in practice his colleagues were often too busy to provide adequate supervision. There was very little work appropriate for Ray and despite enjoying being back in the office he began reporting frustration at not being able to function as he had before. As the reinsurer, we began to have concerns that perhaps we had implemented a return-to-work program too soon and we worried about the consequences should the program fail. In light of these concerns, an independent neuropsychological evaluation was recommended in order to gain a more detailed picture of Ray’s residual cognitive impairments.
The results indicated that attention, memory, arithmetical skills, reasoning, and visual-spatial/constructional ability were all normal. Borderline impairments were detected in auditory-verbal learning, planning, sequencing, and cognitive flexibility, with multiple confabulation and intrusion errors noted. Despite this, the results were within the average to superior ranges in all areas and it was recommended that the work trial continue with more opportunities for Ray to function independently as a chartered accountant. Unfortunately, the employer was not willing to increase Ray’s independence so the supervised work trial continued as previously agreed.
Three months later we received a progress report from the employer – the feedback was mostly positive, but there were some concerns that Ray’s record-keeping was not detailed enough and the person directly supervising Ray was concerned that his direct style of communication could be offensive to clients. Tension around this point had increased over the past months, finally resulting in Ray’s appointed supervisor withdrawing his support, stating that Ray’s behaviour was inappropriate and unmanageable.
This contrasted markedly with the feedback from the case manager, who found that Ray’s cognitive function, social behaviour and insight had continued to improve. This was a very concerning situation for all involved and it was thus decided that the opinion of an independent occupational therapist, specializing in work functioning, was needed.
This evaluation found that Ray had improved even further since the neuropsychologist’s assessment. There was no evidence of inappropriate behaviour; he showed good emotional control; and attention, memory, cognitive flexibility, and accuracy were all within the average to above average range. The occupational therapist was of the opinion that Ray had recovered to the extent that he was able to perform his own occupation.
What was of interest was the discovery that even prior to his TBI Ray was someone who had always spoken his mind and expressed his opinion honestly as he felt he had a responsibility to do so as a Senior Partner in the firm. Ray expressed a lack of trust in his employer and felt that his direct communication style and personality traits were inappropriately being labelled as symptoms of his TBI, when in fact these were some of the qualities that had made him a successful senior chartered accountant. He also felt that his determination to recover from his TBI was being misconstrued as a lack of insight into the severity of his condition.
Based on all of the objective evidence, and after extensive discussion with the insurer, a decision was made to terminate Ray’s benefit with a six-month grace period as all sources indicated he was fit to return to work in his own occupation. We hoped that this decision would communicate to the employer our belief that any remaining barriers to Ray’s RTW were interpersonal in nature and not related to his cognitive abilities or any other injuries resultant from the TBI.
Lessons in return to work following TBI
Research has found that a number of prognostic factors can be used to predict successful RTW following a TBI. For example, individuals who have more severe injuries, experience fatigue, are dependent on others in their activities of daily living, have transportation issues, and have poor neuropsychological functioning (such as memory, sequencing and judgment), were more likely to have difficulty in returning to work.6 Even factors such as being unmarried, older, and having not completed high school were found to have a negative impact on RTW.7 However, the correlations between these “person-factors” and RTW were always quite modest, suggesting other factors played a more significant role.8
This was confirmed in research by Dr. K. Mitchell (Ph.D., Managing Partner of the WorkRx Group), which found that failure to RTW following illness or injury was not usually a result of the actual medical problem. Rather psychosocial factors were found to be the most significant predictors of successful RTW.9 This is important for us to consider when managing claims – as insurers and reinsurers we have little control over the medical conditions of our claimants, but we may be able to exert considerable influence on the psychosocial environment to improve a claimant’s chances of successfully returning to work.
If we consider Ray’s case it is evident that his injuries were not the most significant challenge when returning to work. Rather, it emerged that pre-existing conflicts in the workplace as a result of personality styles were creating a hostile work environment, which in turn caused the claimant to distrust his employer. See Table 1.
Another aspect to consider is the type of industry in which the claimant works. In Ray’s case, a significant challenge was the perceived risk of liability to which he could expose the firm, should he make an inappropriate decision. A number of strategies were employed to overcome this barrier, including initially limiting Ray’s scope to familiar clients, incorporating supervision from a colleague, and allowing for regular follow-up and feedback from his rehabilitation team. It was only once we were certain that Ray’s judgment, decision-making and attention to detail were adequately recovered, that we felt confident that he did not represent an increased risk of liability to his firm.
A number of elements have been found to assist in RTW following a TBI. Specifically, research recommends
- Early intervention (within six weeks)
- Cooperative decision-making
- A multidisciplinary team (individual, medical personnel, employer and insurer/reinsurer)
in order to create a supportive work environment.
These interventions should include elements such as:
- A supportive employment
- A gradual/graded RTW
- Use of job coaches or case managers
- Work accommodations/compensatory strategies
- Work hardening experiences, on-the-job-training, counselling and guidance
- And ongoing follow-up
Importantly, interventions have been found to be more successful if they are time-contingent, following a pre-defined schedule.10, 11
Despite early interventions being recommended, insurers should be cautious of pressuring a claimant to RTW too early. Failure to fully prepare the individual or the employer contributes to the lack of successful RTW; and early and repeated job failures may cause further emotional and psychological harm.12 Additionally, the consequences of a failed RTW attempt may have far reaching consequences if it causes damage to the relationship between the employer and the insurer. A fine balance is required and as could be seen in this case, sometimes the opinion of external specialists is needed.
The impact of psychosocial issues cannot be underestimated when managing TBI claims. A work environment with a commitment to wellness, a pro-active RTW program, and a people-orientated culture has been found to reduce claims rates and duration.13 But it is the responsibility of the employer alone to facilitate a successful RTW. Insurers and reinsurers need to provide incentives to employers who create opportunities for transitions back to work.
By nature of our position as liaison between the claimant, medical personnel and employer, we are often in the best position to identify the real and potential barriers to RTW and we would do well to remember that claimants and their employers respond positively to recognition and empathy, not threats and demands.14 As could be seen in Ray’s case, sometimes it takes the insurer digging a little deeper to discover that within an individual’s “challenges” lies his/her greatest opportunities.
* Personal information has been changed by the author
For more articles in this publication, view the Table of Contents.