Top 15 Useful Articles and Books on Return–to– Work

The literature on the topic of return–to–work or RTW cuts across multiple disciplines including disability, rehabilitation, occupational medicine, management, economics and law.  The articles and books listed here were culled from a comprehensive review of the RTW literature as of August 2011 and published recently.  Some of the articles are aimed at practicing managers in the field of disability management, others are scholarly empirical articles reporting results of research and one paper reports the evolution and outcomes of a comprehensive disability management program implemented by Shell Oil Company.  This list will be updated periodically as new articles and books are published – stay tuned!

The list is in alphabetical order (by author) and copies of the articles can be obtained from the publisher (go to the journal website) or from libraries that subscribe to the journal in print or electronically (note: you may need to have library privileges).

American College of Occupational and Environmental Medicine (ACOEM) Guideline: Preventing needless work disability by helping people stay employed: Stay-at-work and return-to-work process improvement committee. Journal of Occupational and Environmental Medicine, 2006, 48, 9: 972-987.

The American College of Occupational and Environmental Medicine advocates increased emphasis on “stay at work” programs in addition to “return-to-work” programs.  In this position statement, the ACOEM points out that the fundamental reason for most medically-related lost workdays and lost jobs is not medical necessity but nonmedical decision making related to the stay-at-work/return-to-work process. The ACOEM points out that the current focus of physicians and employers is too often on “managing” or “evaluating” a disability rather than preventing it. The position paper includes a set of recommendations for practice as well as several detailed tables that employers can use as part of their disability prevention strategy.

Amick, B.C., & Gimeno, D. (2007). Measuring work outcomes with a focus on health-related work productivity loss. In Wittink, H. & Carr, D. Editors. Evidence, Outcomes & Quality of Life in Pain Treatment: A Handbook for Pain Treatment Professionals. Pp. 329 – 343. London, UK: Elsevier.

This chapter from a 2008 book directed primarily at physicians provides useful information for employers who need to better understand the full impact of disability on workers, especially the “… productivity consequences of working while ill” (340).  The authors define work role functioning as the continuum from working successfully (ability to meet all work demands for a given state of health) to work absence (inability to meet any work demand for a given health state).Work performance outcomes, a new field of inquiry in public health that integrates health and labor economics, health services research and occupational medicine, falls into the larger field of “health productivity.” A measure of “health related work role performance” would capture productivity losses due to on-the-job decrements in performance; such a measure would complement the  more common measures of labor force status and lost time which focus on absence.   In addition, since the productivity effects of absenteeism and presenteeism differ, different “prevention targets” (331) are needed.  The chapter includes a critique of available measures and offers ideas for collecting relevant data.

Ammendolia, C., Cassidy, D., Steensta, I., Soklaridis, S., Boyle, E., Eng, S., Howard, H., Bhupinder, B., & Cote, P. (2009). Designing a workplace return-to-work program for occupational low back pain: An intervention mapping approach. BMC Musculoskeletal Disorders, 10: 65 – 76.

This article describes a 5-step RTW program designed to reduce the duration of time off work and improve the sustainability of RTW of employees with back pain.  The model is based on “intervention mapping,” a method used to design and implement complex interventions or programs – traditionally used in community health promotion and disease prevention such as AIDS and smoking cessation.  The 5-step plan involves multiple stakeholders and is explained in detail – a useful reference for an employer seeking to start or improve a RTW program.

Dyck, D.E.G. (2009). Disability Management: Theory, Strategy & Industry Practice, 4th Ed. Markham, Ontario, CA: Lexis-Nexis.

This practical text is written by and targeted primarily at Canadian employers and occupational health personnel. Nonetheless, its 26 chapters contain much useful information for US employers and DM personnel. Topics covered in the book range from an overview of DM to “selling a DM program” to top management to discussions of DM theory, best practices, and methods for implementation.

Gardner, S., & Johnson, P.R. (2004). Integrated disability management programs: Good business for good organizations. Journal of Legal, Ethical and Regulatory Issues, 7, 1: 3 – 12.

Published in 2004, this paper’s thorough overview of integrated disability management programs, describes their historical development and also provides a list of characteristics of effective IDM programs.  IDM programs generally merge employer’s voluntary and statutory benefit plans into one program, and thus streamline administrative costs, enhance benefit values and improve employee relations through coordination of benefits. The authors take the position that when employers “treat work as a form of therapy” (6), the focus appropriately is on what the employee can do, thus accelerating the RTW process.

D’Amato, A., & Zijlstra, F. (2010). Toward a climate for work resumption: The nonmedical determinants of return to work. Journal of Occupational and Environmental Medicine, 52, 1, 67-80.

The literature on work rehabilitation and resumption is often restricted to people with physical health problems; yet, the increasing number of employees who have mental health complaints is underrepresented, and RTW programs that target physical conditions are ineffective in responding to needs of workers who experience absence due to stress-related psychological problems. This paper uses the “theory of reasoned action,” which explains how attitudes and beliefs about one’s environment influence decisions, to explain the probability for an employee’s RTW.  After a period of absence, an employee’s likelihood for RTW is influenced by 1) a perception of having recovered from the illness, and 2) a belief they will be able to perform work activities.  In other words, improvement of health is a necessary (but not sufficient) condition for successful RTW.  The authors emphasize that RTW is a process in which factors that are objectively present (environmental and personal char) are interpreted (appraised) by the absentee and thus form their subjective reality. The subjective reality is the basis on which people act as it forms the basis of their estimation of their workability and consequently their decision to RTW or not.

Harte, K., Mahieu, K., Mallett, D., Norville, J., & VanderWerf, S. (2011). Improving workplace productivity – it isn’t just about reducing absence. Benefits Quarterly, 27, 3, 13-26.

This practitioner-oriented article focuses on the need for aggressive data collection and management strategies as essential components of health and wellness programs. The authors provide a readable overview of ways to formulate metrics and establish data management systems as part of corporate absence management and other programs targeting employee health and wellness and workplace productivity.

Loeppke, R., Taitel, M., Haufle, V., Parry, T., Kessler, R.C., & Jinnett, K. (2009). Health and productivity as a business strategy: A multiemployer study. Journal of Occupational and Environmental Medicine, 51, 4, 411-428.

Loeppke and his colleagues report findings from the 2nd phase of a multiemployer study involving 10 employers and 51,648 respondents.  The focus of this paper is on the business implications of a full-cost approach to managing health, one that incorporates productivity measures. Of particular interest is the authors’ claim that cost-shifting of employers (to employees in form of higher premiums, co-pays, deductibles) as a strategy to reduce costs has implications for productivity and possible unintended consequences that lead to delay of care which, in turn, can worsen clinical outcomes and negatively impact productivity.  They advocate a shift in philosophy from a view of employee health as a cost to be reduced to an investment to be managed, especially as the workforce ages and evidence increases that health problems impact performance.  One striking finding is that on average, employers absorb $2.30 in health-related productivity costs for every $1 spent on worker medical or pharmacy costs. When total costs are considered, conditions such as back or neck pain, depression and fatigue are more costly than employers realize; in fact, the list of costly health conditions differs from the list that results when medical and pharmacy costs alone are used. Finally, data demonstrate the need to factor in an industry-specific worker absence multiplier when estimating costs because a simple replacement cost methodology is inadequate.

Mitchell, R.J., & Bates, P. (2011). Measuring health-related productivity loss. Population Health Management, 14, 2, 93-98.

This very recent study relies on data from nearly 1,000,000 OptumHealth HRA participants between 2007 and 2009 to estimate productivity losses for workers who have health conditions and to evaluate the potential costs to firms of health-related productivity losses over a 12-month period.  Their thesis is that firms with successful health and productivity programs have superior business outcomes; however, because methods to measure productivity differ and there is still not a validated method to monetize costs associated with lost work time, especially via presenteeism, the real costs of lost productivity are not captured.  The results of this study show that workers report missing, on average, 1.99 days of work annually due to illness, but they also report that they are limited in performing tasks at work because of health for 9.04 days. When total costs (productivity and medical) are combined, the most costly conditions are cancer, heart disease, back pain and high blood pressure. However, of the 15 most costly conditions, productivity losses are significant for employees with the following health conditions: overweight/obese, depression, high blood pressure, back pain, asthma and migraine. These authors estimate that for every dollar of medical costs, .4 dollars of productivity costs are incurred.

Nicholson, S., Pauly, M.V., Polsky, D., Sharda, C., Szrek, H., & Berger, M. (2006). Measuring the effects of work loss on productivity with team production. Health Economics, 15, 111-123.

This study takes a health economics perspective in measuring effects of work loss on productivity in a team setting where timing and performance of one worker affects others. The authors introduce the concept of the “multiplier” to account for the likelihood that consequences of lost time can be substantially greater than the worker’s wage when the following conditions are present:  Employer must be unable to find replacement worker who is perfect substitute (in terms of productivity); production must occur in team setting; and there must be time-sensitivity to firm-level demand, i.e., price or revenue will fall if output is lost or postponed. Under these conditions, the cost of an absence is the dollar value of the firm’s lost output that results from the absence. Based on an analysis of 57 jobs in 12 industries (843 observations), the wage multiplier ranges from 1.00 (cost of lost time is equal to the hourly wage of the absent worker) for a fast food cook to 11.40 for a construction engineer.

Schultz, A.B., Chen, C., & Edington, D.W. (2009). The cost and impact of health conditions on presenteeism to employers: A review of the literature. Pharmacoeconomics, 27, 365-378.

This article reviews published research on presenteeism, defined as reduced on-the-job productivity due to employee health (vs. other reasons for distraction). Two types of presenteeism are described: 1) due to acute illness – cold, flu – when employees have a choice about attending work; and, 2) chronic ongoing conditions e.g., arthritis when employees may need to work in the face of impairment.  In contrast to absenteeism, presenteeism refers to decreases in productivity by employees whose health problems have not necessarily led to absenteeism as well as for periods before and after absences for those with disabilities.  Presenteeism is often measured as costs associated with reduced work output, errors on the job and failure to meet company production standards. The authors review methodologies to monetize costs of presenteeism but note that there is no agreement on the appropriate method for calculating these indirect costs.  They provide a list of available instruments to assess presenteeism and recommend that EAP programs be used to recognize and treat problems that impact on the job productivity.

Schultz, I.Z., & Rogers, E.S. (Eds.) (2010). Work Accommodation and Retention in Mental Health, NY: Springer Publishing.

This recently published book contains a collection of papers that concern research and practice regarding work among individuals with mental health disorders. The edited collection includes two especially useful chapters: Chapter 23, Disability management approach to job accommodation for mental health disability and Chapter 24, Best practices in accommodating and retaining persons with mental health disabilities at work: Answered and unanswered questions. Chapter 23 presents an argument that supports inclusion of disabilities related to mental health in DM programs because doing so has the potential to significantly reduce costs for employers. Chapter 24 examines interventions at three levels: the societal level, employer level, and employee level; the section on employer-level (mesosystem) interventions describes both prevention and intervention policies that can facilitate positive employment outcomes for persons with mental health disabilities.

Wendt, J.K., Tsai, S.P., Bhojani, F.A., & Cameron, D.L. (2010). The Shell disability management program: A five year evaluation of the impact on absenteeism and return-on-investment. Journal of Occupational and Environmental Medicine, 52, 5: 544-550.

In 2003, Shell implemented a disability management program at eight US petrochemical manufacturing sites. This paper describes that initiative and its results and provides a helpful model for employers considering whether and how to implement a similar program. The Shell program uses a variety of metrics to assess effectiveness including absence episodes, workdays lost, average length of absence, estimated direct costs of absence, calendar days saved and Return on Investment.   Shell’s RTW program resulted in a decrease in average length of absence for nearly every site between 2002 and 2008 and the ROI analysis showed a return in cost savings of $4 for every $1 spent in the first year of the program.  Since initial implementation the ROI has declined; however, it remains positive.  Employers looking for a recent case study of an effective RTW program will find this article useful.

Young, A.E., Roessler, R.T., Wasiak, R., McPherson, K.M., van Poppel, M.N.M., & Anema, J.R. (2005). A developmental conceptualization of return to work. Journal of Occupational Rehabilitation, 15, 4, 557-568.

This paper describes a four-stage developmental model that conceptualizes RTW as an evolving process influenced by different factors at different times. RTW consists of four key phases: off work, work re-en try, maintenance and advancement” (560). This model contrasts with more common ways of viewing RTW as a process focused on helping the absent worker return to work.  Young and her colleagues emphasize that after employees resume work, they continue to transition through the stages of “maintenance” and “advancement” as they work to achieve full vocational potential. As these authors describe it, the developmental model offers “…a dynamic view of RTW in which a work-disabling condition precipitates a cycle that places the worker in an off-work phase during which at least partial physical recovery is needed before work res-entry can be attempted. Once the individual has initiated work re-entry, there is a period of adjustment and determination with regards to the worker’s ability to maintain employment and perform satisfactorily. Once work has been re-established, issues of work retention (or maintenance) and advancement arise.

Young, A.E. (2010). Employment maintenance and the factors that impact it after vocational rehabilitation and return to work. Disability and Rehabilitation, 32, 20: 1621-1632.

This paper specifically examines the two later stages of the developmental model of RTW:  maintenance and advancement.  An explicit focus on these two later stages is needed, according to Young, because continued follow-up after work re-entry is rare despite knowledge that ongoing care can facilitate work maintenance. The author cites these statistics for low back pain:  post-initial episodes of work disability account for 69% of total lost time from work, 71% of assoc indemnity costs and 84% of total medical costs, and she also refers to evidence that suggests that “…there is a systematic trend of increased absence duration with each subsequent recurrence of work disability.”  A key element of Young’s argument is that if a person can make it back to the workplace, physical condition is not highly influential with regards to the maintenance of rehabilitation gains.  Another factor that facilitates RTW maintenance is the worker’s relationship with the supervisor. Finally, Young argues that  “durability” of RTW must not only refer to whether a worker who RTW was still “at work” at some future time period, but should also refer to whether that worker is maintaining and advancing in his/her work performance.