Holistic Strategies to Return a Patient to Work

Motivating, educating and facilitating bomb-blast injured service members to return back to combat or to work is a constant challenge in light of their new mental, physical and spiritual state. As members of a multidisciplinary team, we are challenged to help every one of these service members return to combat, cross train them into another military occupational specialty, or return to their own personal vocation utilizing their new prosthetic devices (ranging from fingers, arms, legs and feet).

Outside of the military camaraderie, it is sometimes even more challenging to encourage and assist persons who have sustained a crush injury or amputation—while on the job—to return back to gainful employment. As a nurse case manager for the military for four years and for Hanger Prosthetics for more than two years, I have had the privilege of working closely with workers’ compensation case managers, insurance adjusters and medical directors from around the United States in successfully assisting these injured persons in returning back to passionate and rewarding employment.

A case manager is the key catalyst in implementing a successful plan to get them back to work. Having gained successful case management outcomes, I would like to share with you some of the holistic treatment techniques that have allowed me to see increased results of assisting these service members, patients and claimants return back to gainful employment.

Defining the Case Manager’s Role

It is important to first understand a case manager’s varied roles in caring for a patient. There are three major roles that need to be considered when providing support or caring for these crushing injury and/or amputation patients:

Motivator. This role helps to inspire self-actualization.

Educator. This role is the backbone of the “return to work plan.” It helps the patient and everyone around her to understand the rehabilitation steps, tools and training requirements. 

Facilitator. This role serves as the glue keeping the plan on track and everyone informed. The case manager in this role needs to coordinate referrals and communicate progress (or lack of progress) to all the team members. Realistic individual goals need to be laid out weekly so the patient can easily accomplish them. This will lead to compliance and, if all goes well, a positive outcome of the return to work goal. 

A holistic approach is most successful when motivating, educating and facilitating patients who have sustained these types of injuries to successfully return them to the workplace. The definition of holistic refers to the treatment of a person as a whole and not dissected into parts. It includes focusing on mind, body and soul together and not as separate entities. For example, you would not focus on the body of a firefighter who has sustained an above elbow amputation, fit him into a cable-operated prosthesis, and release him back out into the world. Rather, you would gather what the patient hopes to achieve now that his physical body has changed, what he is physically and mentally capable of doing, and what prosthesis will help him accomplish these goals the best.  Let’s go into closer detail.

Part One: Mind

Some return to work cases and situations become repetitious over time and you will see many motivational, mental and noncompliance barriers. Amputee patients can overcome these barriers if they are identified and dealt with early on. Having access to resources and mentors often helps with new or difficult cases. 

Thinking outside of the box and being unconventional at times enables you to better understand and mentor your patient/claimant. Introduce your patient to others who have had similar or worse occupational injuries and who have been successful at returning to the workforce despite the injury. This can be challenging but it can be accomplished through peer support groups, community sports programs, community reintegration programs and other social activities. Here they will be able to discuss issues they are having and be able to problem solve with others who are going through or who have endured similar injuries.

The probability of success will be very low if you cannot assist your patient with the organization of the return to work plan and assist them in getting the tools needed to implement the plan. It is important to have a response ready for any excuse your patient throws at you. Having a prepared response will assist the patient in the process of returning successfully.

Overcoming Mental Obstacles

Mental barriers can halt a return to work in an instant. Some basic steps in identifying your patient’s internal or mental barriers and helping to conquer them include:

• During your needs assessment, ask the patient what their ideal job was prior to their injury. This should become the treatment team’s core goal. Keep in mind how important it is to keep the family unit on the same page. This dream-job goal is a window to the internal passion of the patient and should be used to ignite the motivation for planning the goal and implementing the rehabilitation process to make it all happen.
• Assist the patient in setting up referrals, evaluations and treatments to work toward the goal they have set forth.
• Introduce the patient to the resources you have available so that they can feel empowered by peer support.
• Follow up as needed, whether daily, weekly or monthly, to ensure that minor goals are being achieved so the dream-job goal can be met.

Muhammed Ali stated, “If my mind can conceive it, and my heart can believe it, then I can achieve it.” With a trainer who worked side by side with him and set clear goals to help him overcome his barriers, Muhammed Ali became a champion.

Part Two: Body

Patients have self perceptions before their occupational injury; and they have even greater perceptions of their physical body after an injury. It is essential that the patient be evaluated and educated on all prosthetic options that can assist them in returning to gainful employment. Not only do they need to be functional, but they also need to feel like their body is whole again. Peer support groups will help them see how others have been successful at returning to the workplace.

Thanks to advancements in prosthetic technology, the “body” segment of holistic rehabilitation has become easier to work with. Newer devices can handle a variety of demands of activities of daily living (ADLs) as well as a variety of vocational tasks assisting patients to get back to work successfully. Recreational attachments also can assist in achieving and maintaining physical fitness by providing the means to participate in personal fitness, community sports, recreational programs or community volunteer programs. Keeping your patient involved in physical events will help them develop new coping skills and gain a new sense of self with the prosthesis in public. In turn, they experience increased self-esteem.

A certified prosthetist can instruct the patient and family on all options of prosthetic devices for different types of vocational duties or functional tasks. Custom designed prosthetic devices based on feedback on job descriptions, input from an occupational therapist and a worksite evaluation can achieve nearly any vocational requirement. By fitting custom prosthetic devices that are functional, environmentally durable and easy to maintain during the duration of the workday, the patient can perform vocational tasks successfully. Additional devices will help with other aspects of the patient’s ADLs. Not only does this prosthetic evaluation help the patient see the options of completing themselves physically again, but it also helps them move from the anger and denial phase into an acceptance phase of their injury.  It is imperative to establish the job goals for the patient and to give them the tools they require to make these goals a reality.

Part Three: Soul

Happiness and contentment are achieved when someone can take care of himself and others around him. Full recovery is when the patient can focus on the needs of others and act in the provider role, i.e., returning to gainful employment. Being able to fulfill themselves by helping others rather than depending on others helps the patient regain confidence and imparts a sense of control, understanding and fulfillment. Encourage the patient to participate in community programs, work-related social functions and volunteer programs. This participation leads to contentment and compliance via hard work and visualizing the outcomes that life still has to offer.

Conclusion

Newton’s first Law of Motion said it best: a body at rest stays at rest; a body in motion stays in motion, unless acted upon by an unbalanced force. But what about the workers’ compensation Law of Motion? Try this: “A body at work stays at work unless acted upon by an unbalanced force.” You, the case manager, must serve as the balanced force and act as the catalyst in the return to work plan.
The distinct roles of the case manager will enable this force. As a motivator the case manager mentors and develops trust and dependability.

As educator, the case manager guides the patient and family to success. And as facilitator, the case manager sets up appointments with the patient, attends appointments and eventually will see the patient become wholly empowered.

A great resource for amputee patients is Amputee Empowerment Partners (www.empoweringamputees.org). This community site is great for finding peer support as well as additional resources. If you would like to set up a direct peer visit through this group, you can also call 866-355-9911.

Dan Blasini, RN, BSN, BC, is a Clinical Case Manager with Hanger Prosthetics & Orthotics, Inc., specializing in upper extremity prosthetics case management. Dan specializes in the rehabilitation of difficult cases of upper limb loss caused by occupational injuries, motor vehicle accidents and medically compromised patients. (dblasini@hanger.com)