Return to Work in the Pandemic ‐ Considerations beyond Infection

Introduction

We are in the midst of a massive return‐to‐work phenomenon not seen in our lifetime. Thirty million people in the United States have been out of work for months, and with states working toward economic recovery, workers are or will be returning in large numbers over a condensed time period. Industries with high physical demands are opening first, including construction, agriculture, food service, manufacturing, and wholesale and retail trade.

Although our attention is rightly on medical management of coronavirus disease 2019 (COVID‐19) and preventing the spread of infection, there is a silent threat for which we are largely unprepared: post‐COVID work disability. We ignore the risks of work disability at our peril. Health care providers need to understand the health implications of reopening beyond a potential increase in cases and spread of infection. Effectively addressing the threat of work disability will require a wider focus to include consideration of biological, psychological, and socioenvironmental factors.

The Vermont Retaining Employment and Talent after Injury/Illness Network (VT RETAIN) initiative is a federally funded state project that provides assistance to providers, employers, and individuals to support stay at work/return to work (SAW/RTW) and reduce work disability in the state of Vermont. ¹ VT RETAIN leadership comprises a broad spectrum of clinical, academic, employment, wellness, and government experts. With the advent of the COVID‐19 pandemic, the group was charged with finding innovative ways to holistically address the urgent issue of RTW during the pandemic.

In this article, we describe a practical clinical framework for assessing readiness to RTW during the pandemic. This framework uses an occupational medicine approach. Occupational medicine specializes in protecting the health and productivity of workers, controlling workplace hazards, promoting workplace safety, preventing occupational injuries and illnesses, and managing disability. Occupational medicine providers are trained to optimize safe and timely RTW after an injury or illness as well as to manage crisis situations. These occupational medicine roles are particularly important during a pandemic in order to prepare for and minimize widespread health and economic impact. ² , ³ We begin by reviewing the general issue of work disability and the basics of the RTW assessment and process. We then discuss the specific challenges of RTW in the current pandemic. Next, we discuss interventions from a pandemic‐specific standpoint. Finally, we conclude with useful tools for clinicians and employers to use as they navigate through these challenges.

Work Disability

Before the 2020 global pandemic, 8.4 million Americans received Social Security disability benefits as disabled workers. ⁴ Internationally, an estimated 470 million of the worldʼs working‐age people have a disability, ⁵ and the unemployment rate among persons with disabilities is estimated to be 80% to 90% in developing countries and 50% to 70% in industrialized countries. ⁶ When people cannot find work, they are deprived not only of economic resources. Unemployment is an important independent risk factor for adverse physical and mental health outcomes, such as cerebrovascular disease, cardiovascular disease, depression, suicide, and increased health care use, both for the unemployed person and their family. ⁷ , ⁸ On a population level, increased unemployment correlates with decreased overall health. ⁹

Given the importance of work for health, attention to work disability is an obligation for all clinicians, especially for those in rehabilitation fields. Yet clinicians typically receive little to no training in the basic best practices that will help their patients stay at or return to work after an injury, illness, or job loss. ¹⁰ Thus, providers at the front line of RTW decisions may not recognize these risks and may not have the tools to address them.

Work disability can arise from work itself or from non‐work‐related physical or mental health conditions. When work is limited because of any type of health problem, clinicians must recognize the urgency. In addition to the adverse health effects associated with being unemployed, prolonged time out of work can result in other issues that interfere with RTW or put workers at risk during reentry into the workforce. Worsening mental health problems, new or increased domestic abuse, and increasing alcohol or drug consumption may not be apparent and can pose important barriers to RTW and potential workplace safety issues. ¹¹ , ¹² , ¹³ New or worsening medical conditions or physical deconditioning relative to work requirements also may become barriers to work or increase the risk of injury upon return to the workplace.

The first and most important step in promptly preventing work disability is for the clinician is to understand whether there is a risk of work disability. A model advanced by Armstrong et al ¹⁴ and consistent with the World Health Organizationʼs International Classification of Functioning, Disability and Health ¹⁵ involves integrating knowledge of the work, the disease, and the worker, with increasing sophistication needed for more complex situations.

In many cases, work requirements are straightforward and easily understood by the clinician. When conversation with the patient does not elucidate work tasks, obtaining a job description may be helpful, although many job descriptions lack functional information. In this case, calling upon other professionals such as an ergonomist or occupational or physical therapist can better define the work requirements.

Similarly, the clinician often understands the limitations placed on the worker by the disease or injury. Sometimes, though, it may be necessary to consult with a specialist who understands the functional sequelae of a particular disorder (eg, cardiology for heart disease, psychiatry for mental health limitations, or occupational medicine or physiatry for multifactorial impairments, etc.). Consultation with other disciplines such as physical and occupational therapy can provide targeted functional information. If medically safe for the patient and their coworkers, often testing work ability via a trial of modified work (eg, limited hours or modified duty such as lifting limits, position changes, rest breaks, or restricting certain aggravating activities) is useful. When lack of clarity persists, a formal test of work capacity may help assess workers' capabilities relative to the demands of their job. A guiding principle for clinicians and patients is that work releases should be considered medical prescriptions but also dynamic, and they are most effective when updated promptly to respond to changes in the trajectory of the health condition.

The workers themselves are the third component of the model. Motivation, goals, knowledge, personality, training, litigation, finances, alternative job skills, family support, relationship to the employer and coworkers, time on the job, nearness to retirement, and other psychosocial factors are often more important predictors of success than either the job or the illness. ¹⁶ , ¹⁷

With an understanding of the job, the illness or injury, and the individual, the clinician can intervene to prevent work disability. ¹⁸ At the most fundamental level, this involves providing education and reassurance that work is a goal, then planning RTW with the worker, and finally communicating these plans to the employer. In more complex cases, a rehabilitation plan is needed. This may involve a single discipline—a counselor or physical therapist, for example. Increasingly complex cases may involve specialist input or a multidisciplinary team approach.

Work Disability During the COVID‐19 Pandemic

The unemployment rate skyrocketed during the early months of the pandemic from 3.8% to 13.8% by the end of May 2020, with leisure and hospitality industries being most affected. ¹⁹ In addition to the negative consequences of unemployment described previously, the pandemic presents further health challenges for workers. Beyond job loss, pandemic conditions are contributing to an increase in mental health symptoms, substance use, and domestic violence. ²⁰ , ²¹ , ²² , ²³ Moreover, many people have experienced barriers to physical activity and exercise while sheltering at home or social distancing, compounding the issue of deconditioning. ²⁴ Although some may have developed COVID‐19 itself and its potentially complex and poorly defined sequelae, many more workers have risk factors for severe infection or live with people who are at high risk. Anxiety and fear avoidance of COVID exposure at the workplace may affect anyone regardless of occupational duty, and work disability from new and preexisting disorders may be prolonged by superimposed workplace stress and RTW anxiety. These issues also can complicate RTW after work‐related injuries, and in some states, COVID infection from an occupational exposure or anxiety about workplace COVID exposure can be compensable. Furthermore, a diagnosis of COVID‐19 infection is associated with increased incidence of psychiatric diagnosis. ²⁵

All of this has occurred in a setting of reduced access to health care, loss of income, social isolation, and increased responsibilities at home. Meanwhile, jobs have been redesigned during the shutdown, leading to potential new health and safety risks, including workers being less familiar with their job tasks or workflow. Finally, the impact of job loss on health insurance during the pandemic is a huge downstream risk that must be taken into account. ²⁶

Recent evidence that the development of pandemic‐related workplace mental health symptoms is modifiable is encouraging; factors associated with severe psychiatric workplace symptoms include presence of physical symptoms, poor physical health, and viewing RTW as a health hazard, whereas practice of psychoneuroimmunity prevention measures in the workplace such as hand hygiene, wearing face masks, workplace hygiene, and employer concern for health and safety were associated with less severe psychiatric symptoms. ²⁷ Thus, although medical providers may be accustomed to writing a work note for an individual worker at the end of a treatment visit, the population‐level increase in unemployment, pandemic conditions, and associated changes in health status and risk requires a new proactive clinical approach that integrates work disability assessment and intervention into the visit.

Work Disability Interventions During the Pandemic

Employers need to prepare for the challenges of RTW, and workers need to be sure they have rational RTW strategies. Health care providers should think of themselves as partners in the reopening process and be able to proactively support employer and worker RTW planning. This includes screening for a broad range of physical and mental health issues that may arise during the pandemic and could affect ability to work, as well as determining work ability compared to job requirements. We believe that these steps are feasible and will substantially decrease morbidity and mortality associated with unemployment and reduce disability from work.

First, patients' job status should be assessed. Patients should be respected as the experts on what they do for work. Providers should ask about their patients' employment status during the pandemic and if they have any concerns about their job. Next, providers should screen for new medical problems and risk factors that could affect their patients' ability to work. In addition to COVID risk factors, screening should include questions about physical health, physical conditioning, mental health and stress, substance use, abuse, family care responsibilities, any changes to existing conditions, and any other concerns they have identified about their health and work. A simple screening questionnaire like the one in Table 1 can help clinicians identify potential health‐job mismatch.

Table 1.

Types of questions to ask patients to screen for health–job mismatch

1. What do you do for work?
2. What is your work status?	☐ Employed ☐ Furloughed ☐ Unemployed
3. Do you have contact at work with people known to have COVID‐19 or who may have COVID‐19?	☐ YES ☐ NO
4. Do you have concerns about being able to do your job safely?	☐ YES ☐ NO
5. Before the pandemic, were you receiving FMLA, ADA, or workers' compensation benefits or did you have any work restrictions or accommodations?	☐ YES ☐ NO
6. Since the pandemic, are you receiving any FMLA, ADA, workers' compensation, CARES Act, Family First Coronavirus Relief Act, unemployment, or other benefits?	☐ YES ☐ NO
7. Have you had COVID‐19 or have you been exposed to someone with COVID‐19?	☐ YES ☐ NO
8. Are you over 65 years old?	☐ YES ☐ NO
9. Do you have any of these conditions? Diabetes, obesity, or breathing, heart, kidney, liver, or immune problems?	☐ YES ☐ NO
10. Do you live with anyone over 65 years old or who has any of these conditions?	☐ YES ☐ NO
11. Do you feel physically ready to work?	☐ YES ☐ NO
12. Do you feel emotionally ready to work?	☐ YES ☐ NO
13. Do you feel mentally ready to work? (eg, to think and make decisions needed to do your job)	☐ YES ☐ NO
14. Since the pandemic, have you been drinking more alcohol?	☐ YES ☐ NO
15. Since the pandemic, have you been using more drugs?	☐ YES ☐ NO
16. What are your family care responsibilities at home?	☐ YES ☐ NO
17. Do you have safe transportation to and from work?	☐ YES ☐ NO
18. Do you feel safe at home?	☐ YES ☐ NO

ADA = Americans with Disabilities Act; CARES Act = Coronavirus Aid, Relief, and Economic Security Act; COVID‐19 = coronavirus disease 2019; FMLA = Family and Medical Leave Act.

When this screening process identifies a health–job mismatch, clinicians should make a plan to address the problems and provide guidance on work capacity. Specific mismatches and potential interventions are illustrated in Table 2. Clinicians should arrange diagnostic tests and treatment, rehabilitation to improve function, and job accommodations to support employment with a sense of urgency, as delayed return to safe work has substantial negative consequences as described previously. Asking patients about barriers and the support they need can help identify underlying issues and inform steps for RTW. When determining work capacity, consider the physical, emotional, and cognitive requirements; exposure risks; and changes to job tasks to determine if a patient needs new or adjusted job accommodations. When writing job accommodations, focus on what patients can do, not what they cannot do. Starting slowly with reduced hours or limited job tasks and building up to full work can help patients adjust, recondition, and reduce their risk of injury or increases in symptoms.

Table 2.

Interventions to match patient health with their work

What to do when patient says “yes” to…

QUESTION 2: If my patient is furloughed or unemployed Determine work goals Support a return‐to‐work plan based on patient goals Facilitate a physical and mental self‐care plan while out of work Refer to the state department of labor and/or job centers for employment assistance

QUESTION 3: If my patient has contact at work with individuals who have or may have COVID Determine if work can be done remotely or with modifications that increase protection Ensure patient has completed employer‐implemented pandemic training, understands the workplace safety plan, and knows how to follow best infection control practices at work Determine if patient has access to appropriate personal protective equipment that is matched to their job tasks * Provide education and consider removal from work/job change if inadequate safety protection

QUESTION 4: If my patient has concerns about being able to do their job safely Ask what obstacles are preventing them from doing their job safely Ask what support would help them be able to do their job safely Provide work accommodations if needed to increase protection Employees can call their state department of labor for questions or concerns about infection control or other safety practices at work

QUESTIONS 5 or 6: If my patient is receiving benefits or has prior job restrictions or accommodations Ask if job tasks have changed Ask if underlying condition has changed or worsened Update work accommodations to match job tasks to worker capabilities Provide interim accommodations that allow for progressive return to work Update benefits paperwork to protect job and/or wages Prescribe medical rehabilitation, ergonomic assessment, and/or vocational rehabilitation to improve match between job tasks and capability

QUESTION 7: If my patient had COVID‐19 or was exposed to someone with COVID‐19 Follow CDC and state department of health guidelines for duration of isolation for adults with COVID to determine when workers meet criteria for return to work Follow CDC and state department of health guidelines for managing health care provider, community‐related, and travel exposures If required by the employer, provide a letter to the patient when they are medically cleared to return to work and certifying fitness for duty. (Do not include confidential health information.) Provide permanent or temporary work accommodations if needed for sequelae of infection Provide the patient with CDC or state department of health information sheets and resources Know that employers can delay an applicantʼs start date or withdraw a job offer if they have symptoms of COVID or test positive Know that employers can notify coworkers who may have been exposed to a COVID‐positive worker for contact tracing and symptom monitoring; they CANNOT require the affected employee disclose their identity Know that some states allow workers with documented occupational COVID exposure to obtain workers' compensation coverage if they become infected with COVID

QUESTIONS 8, 9, or 10: If my patient or a family member has risk factors for severe COVID infection Follow all recommendations listed in QUESTION 3 and also… Determine whether work tasks are low, medium, high, or very high risk for COVID exposure † Provide work modification letter if needed for additional exposure protection such as remote work, reassignment to a less populated workspace, additional protective barriers or personal protective equipment, designated work clothes, and/or a shift change, etc. Know that employers CANNOT delay an applicantʼs start date or withdraw a job offer if they are at high risk for severe infection Know that employers CANNOT preclude an employee from returning to work solely because they are in the “high‐risk” category unless a medical provider determines through an individualized medical assessment that their condition poses a “direct threat” to their health that cannot be addressed by a “reasonable accommodation.” Provide education and consider removal from work/job change if inadequate safety protection ‡

QUESTION 11: If my patient does not feel physically ready to work Ask what they do for work, how they do it, and which job activities are difficult or easy Address medical diagnosis, treatment, rehabilitation, and reconditioning Provide work modifications such as gradual return to work, lighter tasks, fewer hours, etc. Obtain physical and occupational therapy evaluation or ergonomic assessment if needed to help determine patientʼs safe physical demand level or work modifications Follow up with patient frequently until return to full work or plateau If the patient cannot return to work despite appropriate treatment, rehabilitation, and job modifications, refer promptly to local job centers, state vocational rehabilitation, and social support resources Know that employers CANNOT ask employees directly about a medical condition unless the employee poses a direct threat to themselves or to others or are unable to perform the essential duties of the job because of their condition.

QUESTION 12 or 13: If my patient does not feel mentally or emotionally ready to work Follow the recommendations listed for physical readiness (QUESTION #11) and also… Respect these concerns and assess for mental health diagnoses and needs Refer for appropriate treatment and services (such as medication or counseling) Provide appropriate work modifications such as gradual return to work, time for appointments, rest breaks, access to a quiet work area, noise‐canceling earplugs or headset, extra processing time for more complex cognitive tasks, etc. Encourage use of employee assistance programs if available Provide education and resources such as: General or pandemic‐specific stress or mental health resources from the CDC, state departments of health or mental health, local organizations, etc. Reinforce that self‐care is not selfish and facilitate a self‐care plan (including social connection, giving and accepting support, taking breaks, maintaining physical activity, regular sleep patterns and healthy eating habits, limiting media exposure, practicing stress management such as mindfulness and deep breathing, connecting to a sense of purpose) Make a safety plan for increased symptoms of significant stress, impairing anxiety, or suicide Know that employers CANNOT ask employees directly about mental health conditions unless they pose a direct threat to themselves or to others or are unable to perform the essential duties of the job because of their condition. If anxiety about COVID exposure at work reaches the point that you determine that your patient is unable to work, this may be a compensable work‐related stress claim

QUESTIONS 14 and 15: If my patient has been drinking more alcohol or using drugs Follow same recommendations as for physical, mental, and emotional readiness (QUESTIONS 11‐13) and also… Ask for more details about substance use patterns Provide counseling on decreasing use Refer to treatment program if appropriate Provide information on community and local recovery resources Know that employers CANNOT ask employees directly about substance use unless they pose a direct threat to themselves or to others or are unable to perform the essential duties of the job because of their condition.

QUESTION 16, 17, or 18: If my patient has increased care responsibilities, lack of safe transportation to work, or feels unsafe at home These can be hidden barriers to return to work: Identify them Respond with resources Complete benefits paperwork to help protect job and wage

^* https://www.healthvermont.gov/sites/default/files/documents/pdf/SOV‐Personal‐Protective‐Equipment‐Guidance.pdf.

^† https://www.osha.gov/Publications/OSHA3993.pdf.

^‡ https://www.nejm.org/doi/full/10.1056/NEJMp2013413.

CDC = Centers for Disease Control and Prevention; COVID‐19 = coronavirus disease 2019.

Conclusion

Management of work disability, like management of the many other disabling conditions that clinicians see, requires a team. Colleagues in occupational medicine, physical medicine and rehabilitation, physical therapy, occupational therapy, behavioral health, and other rehabilitation fields can help with treatment and RTW planning. State departments of labor, vocational rehabilitation, health, and mental health and employer assistance programs are good resources for providers and patients. If a provider feels a patient is physically or emotionally unsafe to work despite appropriate treatment, rehabilitation, and job accommodations, the patient should be promptly connected with social support resources.

Learning these critical work disability prevention skills may seem secondary or burdensome at a time when front‐line clinicians are experiencing new levels of stress and disruption to their own work. Yet, as businesses reopen, providers who understand the relationship between health and work will be protecting their patients' health and livelihood. When we return our patients safely to work, we are saving lives too.