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A vocational rehabilitation approach to occupational health: the OT-way

By Jo Vallom-Smith

Published 12 September 2023

Vocational,Rehabilitation,Written,On,A,Paper,And,A,Book.

Introduction

The occupational therapy (OT) and occupational health (OH) professions emerged in the same periods for similar, work-focussed reasons. Over the centuries, we went in different directions and have remained relatively separate for far too long. Happily, however, we are now coming together to benefit employees and employers alike.

The following quotes are taken from Occupational Health: The Value Proposition (2022, Dr Paul J Nicholson OBE):

“Occupational health disability case management interventions that include early contact with workers on sick leave and specific agreements around work modifications result in faster returns to work and are cost saving”

“It is suggested that active occupational health care aimed at prevention and rehabilitation is more profitable than a focus on treatment”

A large meta-analysis of what works in occupational health found that interventions that were proactive and followed a rehabilitation model were effective and provide a good return on investment.

In Mark Howard’s wonderful 2023 article, he explains the potential downsides of traditional OH services, which, in my experience, make up the majority of OH provision in the UK. He quotes Peckham, et al., (2017) who says “researchers and practitioners entering the field are largely being trained to assess and control exposures using approaches developed under old models of work and risks.” and goes on to argue that “we need to better align with the current realities of work and health and to prepare practitioners for the changing array of workplace health challenges.”

What is VR?

The Vocational Rehabilitation Association defines vocational rehabilitation as “a multidisciplinary intervention offered to those with physical, psychological and/or social difficulties enabling a return to work or preventing loss of work”. Vocational rehabilitation interventions use a rehabilitation approach, which usually means working with the same person over a period of time to support them to work towards certain work-focussed goals. This kind of intervention has a strong evidence base for return on investment, especially for chronic and fluctuating conditions such as ME/CFS and fibromyalgia.

Following a referral, VR practitioners undertake an initial assessment, which is usually much more in-depth than a standard management referral. The VR practitioner may then make some initial recommendations, and the service may be complete at this stage. More often, however, the practitioner will book a follow-up appointment to review the interventions and make further recommendations accordingly. In this model, the interventions continue as long as there is a need and cease when this has been resolved. This creates the possibility for a more person-centred and targeted approach.

Whenever appropriate, VR practitioners will liaise with other stakeholders, such as HR representatives or the line manager, to gain a fuller perspective on the workplace situation to plan interventions appropriately.

Another element that often forms a part of VR interventions by OTs is “functional restoration” or “work hardening” programmes (the former being the preferred term). These can be delivered as an outpatient or in-house service. Functional restoration programmes (FRPs) may include time in the gym or the workplace, specifically working on factors that are preventing a return to work. These are widely used in the US, Canada and Australia and have a good evidence base for efficacy.

In this article, I often refer to the “OT” as this is my field of experience (and bias!). However, in many cases, these services are expertly delivered by a “VR practitioner” who may come from a vast range of backgrounds, including but not limited to nurses, psychologists, social workers and “non-qualified” workers.

How does VR fit into OH?

VR provision within OH is not standard, and there is a wide diversity in how VR is delivered. In some OH companies, OTs are providing a hybrid VR-OH approach which has been received incredibly well with employers, who come back time and again for this service. Using this hybrid approach, all management referrals are undertaken by OTs, who will make a clinical judgement for each case as to whether they will follow up with this person to deliver VR interventions or if the one-off management referral was sufficient.

In other OH companies, OHAs or OHNs screen employees, who will then signpost, as needed, to an OT for VR interventions. In my experience, many employers want VR for their employees but cannot access vocational rehabilitation through their existing OH provider. Therefore, a growing number of employers, particularly SMEs, are seeking these interventions through external specialist VR companies, most often from the insurance and medicolegal sector, where VR interventions are more commonplace.

Who is best placed to deliver VR?

I want to caveat this section by acknowledging my obvious bias towards OTs! However, I will try to back up my bias with evidence. OTs were created in response to a huge societal need for VR in the moral treatment movement and post-WW1. Our degree focuses on understanding the person, the task they’re required to do, and the environment in which they do it. We are rehabilitation experts and work in many rehabilitation fields. Our training covers not only mental health and physical health but also cognitive, neurodivergent, neurological, ME/CFS, chronic pain conditions and most other types of conditions that humans experience.

OTs consistently focus on function over pathology. Whilst we understand and consider diagnoses, medication and treatment, these are rarely our focus. We are hyper-focused on how any condition (or conditions) impact the functional ability of any individual worker. From day one of our degree, we learn to break down any task into the minutiae of its physical, social, cognitive and myriad other components using “activity analysis”. Throughout our degree, we are taught about the biopsychosocial model and how to incorporate this into all areas of our practice.

OTs can and do work as occupational health advisors (OHAs), delivering traditional one-off management referral services and achieving the same quantity and quality of work as their nurse colleagues. However, they also work as “specialist OTs”, delivering a vast range of assessments and interventions. This may include cognitive assessments, functional capacity evaluations (FCEs), ergonomics and specialist mental health assessments.

A recent work-related development in the OT world is that we now work widely in GP surgeries, offering VR interventions and writing fit notes. OTs are well placed to offer this service due to their understanding of VR, breadth of training and focus on function.

Case study example:

One of the cases that, I feel, best demonstrates the unique contribution of OTs delivering a VR approach to OH, is that of Mr X, who had worked as an operations manager for a public service organisation for many years. He sustained a road traffic injury which resulted in an amputation of his non-dominant upper limb below the elbow. Before returning to work, HR referred him to an occupational therapist. It was felt that their in-house OH team might not have the skills required for this complex and high-profile case. In the referral, practical concerns were raised regarding Mr X’s ability to use DSE and operate a vehicle, but HR also identified some significant anxiety and low mood symptoms, which they felt may present an additional barrier to returning to work.

The occupational therapist met with the employee, completed an initial assessment and wrote an initial report. The occupational therapist then met with Mr X on several occasions over the following months and supported the implementation of various recommendations:

Voice recognition software to reduce the typing demand of his job

Arrangement of vehicle control adaptation

Engagement with the employer’s EAP (employee assistance programme) for cognitive behavioural therapy

Signposting to peer support groups for amputees

A phased return to work. Not only the hours of work but gradually increasing the particular demands of Mr X’s job that he found most challenging.

The occupational therapist liaised with the employee, HR, H&S and line manager throughout this process to ensure a smooth and sustained return to work.

In other settings, this gentleman may have been seen by an OHA or OHN, a physiotherapist and perhaps a physician. Mr X may have needed to repeatedly share his traumatic story and disclose the needs that made him feel incredibly vulnerable to people he may only see once. In this case, however, Mr X was seen by one health professional throughout, who was able to build a therapeutic relationship and coordinate all relevant services to meet all of his occupational needs. As well as seeing one professional, the VR approach was key in reviewing recommendations to ensure they met the identified needs.

I honestly believe that, without a VR approach, this case may have ended very differently. With a VR approach, everyone is a winner. The employee feels valued and listened to, the business retains important talent, and the occupational therapist has the satisfaction of going on a journey with a person and following a case to its conclusion.

 

Conclusion

In this article, I hope to have convinced you that occupational therapists have a key role in occupational health provision. Whether through specialist assessments, working as OHAs or delivering vocational rehabilitation interventions. There is a river of untapped potential here, and employees and employers will be the beneficiaries if we can make this shift together.

I’d like to leave you musing with a question.

What would a working population look like if all employers used a VR approach to OH instead of the traditional OH provision?

Jo Vallom-Smith | OT for OH : Linkedin : Facebook

Jo Vallom-Smith is an occupational therapist who has specialised in the field of occupational health. Jo is the director of OTforOH, a specialist recruitment agency placing OTs in OH roles. Jo runs an informal networking group for OTs who work in occupational health. Jo is also on the national executive committee for the Royal College of Occupational Therapists, Specialist Section Work and is the Occupational Health co-lead. 

 

OH Today Spring 2023
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