Serious Injury Program Value-for-Money Audit - Review of the Independent Living policy suite

NOTE: The consultation closed on October 14, 2022. We are reviewing submissions received and will provide additional information on the next steps in the coming months.

Introduction

Under the Workplace Safety and Insurance Act, 1997 (WSIA), the WSIB is required to have an external firm review the cost, efficiency, and effectiveness of one or more WSIB programs through a value-for-money audit (VFMA). The WSIB’s Serious Injury Program (SIP) was the focus of a recent VFMA.

The SIP provides people who experience serious injuries at work with the specialized treatment, equipment, and services they need to enable functional recovery; support return to work where possible; facilitate independent living to the extent possible; and improve quality of life.

The main conclusion of the Serious Injury Program VFMA is that the program demonstrates value for money. To further improve the program’s performance, recommendations were made across nine themes. The following observation (observation three) and recommendation (recommendation one) appear under theme 5.5, Policies, processes, and procedures:

  • Observation summary: Specific policies have not been reviewed to determine if threshold criteria and benefits continue to match the needs of injured workers, and have not been updated to reflect changes in the needs of injured workers and/or workers' needs.
  • Recommendation: Review and refresh benefits related eligibility criteria and services provided for in the suite of benefits policies to ensure they meet the needs of workers across the spectrum of service delivery, including seriously injured workers. As needed, engage key stakeholders as part of the consultation.

As identified in the VFMA, leading practice for eligibility criteria is to base severe impairment criteria on medical (e.g., diagnosis) and functional definitions (e.g., ability to participate in day-to-day activities) and tools, rather than solely or primarily a permanent impairment rating (whether through a single or multiple claims). Most Canadian workplace compensation boards consider the person’s needs and reduced abilities resulting from their work-related injury or illness, rather than an impairment percentage, when determining entitlement to benefits and services similar to those provided for in the independent living policy suite. The boards that do identify an impairment percentage as part of their criteria will still consider providing benefits and services despite the permanent impairment percentage in some circumstances.

The VFMA and its recommendations present the opportunity to assess whether the current entitlement criteria result in people with serious work-related injuries being provided with the personalized benefits and services they need for improved recovery and return to work outcomes, to facilitate independent living, and to improve quality of life.

The VFMA identified the challenges that exist with the independent living policy suite; challenges that SIP staff have validated. The common challenge underlying the suite as a whole is the “severely impaired” threshold that forms part of the entitlement criteria for most of the benefits and services covered in the policy suite. Noting this, the policy review will occur in two phases: 

  • Phase one: The WSIB will seek information from stakeholders to support its analysis of the entitlement criteria for the benefits and services provided for in the independent living policy suite with a focus on the severely impaired threshold.
  • Phase two: The WSIB will share its findings from phase one, and, if applicable, the refreshed entitlement criteria being recommended as a result. Revisions to improve the consistency and equity of benefits and services may also be proposed at this time.

Background

WSIB Serious Injury Program

The SIP is for people who experience a serious work-related injury (including those who are severely impaired as defined in the Operational Policy Manual).1 The serious injury may result from a single incident, or a worsening of a prior impairment, or an accumulation of multiple impairments. Generally, this would be:

  • a new catastrophic work-related injury (e.g., certain spinal cord injuries, major amputations, industrial blindness, extensive burns, moderate and severe brain injuries) with an anticipated non-economic loss (NEL) benefit of 60 per cent or greater,
  • a new significant work-related injury that meets the criteria for acute care (e.g., certain bilateral fractures, bilateral hand burns, certain brain injuries),
  • a 60 per cent NEL under one or more claims,
  • a 60 per cent NEL equivalent after a composite rating which combines NEL and permanent disability (PD) benefits, or
  • an injury prior to January 1, 1990, and a PD benefit of 100 per cent.

Legislation

A person who experiences a work-related injury or illness is entitled to such health care as may be necessary, appropriate and sufficient as a result of the injury or illness and as determined by the WSIB. The WSIA (s.32) provides that health care means:

  • professional services provided by a health care practitioner
  • services provided by or at hospitals and health facilities
  • (prescribed) drugs
  • the services of an attendant
  • modifications to a person’s home and vehicle and other measures to facilitate independent living as in the Board’s opinion are appropriate
  • assistive devices and prostheses
  • extraordinary transportation costs to obtain health care
  • such measures to improve the quality of life of severely impaired workers as, in the Board’s opinion, are appropriate.

Many of the aforementioned forms of health care are oriented toward recovery, to the extent possible, from the injury or illness itself (e.g., prescribed drugs) or minimizing the functional impact of the injury or illness (e.g., assistive devices and prostheses). These forms of health care are broadly available to all people with work-related injuries or illnesses, provided the WSIB finds they are necessary, appropriate and sufficient as a result of the injury or illness.

In addition to these more broadly available forms of health care, the WSIB has discretion to provide coverage for measures its finds are appropriate to: a) facilitate independent living and b) improve the quality of life for those with severe impairments. The WSIA does not define independent living, quality of life, severe impairment, or serious injury.

Policy framework

The OPM includes a suite of policies that provide guidance about the benefits and services the WSIB has determined are appropriate to facilitate independent living and/or quality of life: the independent living policy suite.

These benefits and services are primarily available to injured people within the SIP. Most of these benefits and services require that the severely impaired threshold is met. However, not all injured or ill people in the program meet that threshold, particularly those in the acute care stream, and are therefore not eligible for many of these benefits and services.

Independent living policy suite
Policy Entitlement criteria

17-06-02, Independent Living Allowance

Severely impaired

17-06-03, Independent Living Devices

Severely impaired + benefit/service specific criteria*

17-06-04, Guide and Support Dogs

Severely impaired + benefit/service specific criteria

17-06-05, Personal Care Allowance

Severely impaired + benefit/service specific criteria

17-06-06, Home Care

Benefit/service specific criteria

17-06-07, Vehicle Modifications

Benefit/service specific criteria

17-06-08, Home Modifications

Severely impaired + benefit/service specific criteria

* Details about the benefit/service specific criteria are available in Appendix one: Entitlement criteria for independent living policy suite

Severely impaired entitlement threshold

Most of the benefits and services provided for in the independent living policy suite include the severely impaired threshold as part of the entitlement criteria. An injured person is considered severely impaired if their disabilities/impairments are:

  • permanent and have been rated for either PD benefits totaling at least 100 per cent, or NEL benefits totaling at least 60 per cent, or
  • likely to be permanent in the opinion of a WSIB medical consultant, and are likely to meet one of the criteria above.

The origins of the severely impaired threshold can be traced back to the pre-1989 Act2, which provided for “…such other treatment, services or attendance as may be necessary as a result of the injury for those rendered helpless through permanent total disability”, which was interpreted as being a 100 per cent PD rating. The 100 per cent PD rating was thus established as the threshold for those benefits and services available to people with the most serious injuries.

The pre-1997 Act3 contained a similar provision to that in the pre-1989 Act, but identified people “rendered helpless through permanent total impairment”. The WSIA references neither total disability nor total impairment. Rather, the WSIA provides for health care measures specific to injured people with severe impairments.

The use of the 60 per cent threshold for NEL ratings (versus 100 per cent for PD ratings) arises from the difference between permanent disability and permanent impairment. As outlined in the pre-1997 Act, “disability” means “the loss of earning capacity of the worker that results from an injury”, while “impairment” means any “physical or functional abnormality or loss (including disfigurement) which results from an injury and any psychological damage arising from the abnormality or loss”, and does not take into consideration the impact on ability to earn.

The basis for rating PDs is the Ontario Rating Schedule that estimates the impairment of earnings capacity in an average unskilled worker in more traditional jobs4. The basis for rating permanent impairments is the American Medical Association’s Guides to the Evaluation of Permanent Impairment, Third Edition (Revised) (AMA Guides) that assesses “what is wrong with a body part or organ system and its functioning”as opposed to the impact of the impairment on employability. Of note, neither rating tool specifically measures the impact of the impairment on the person’s ability to carry out their activities of daily living and other activities outside of employment. Very few medical conditions are assessed as 100 per cent under the AMA Guides. Requiring a 100 per cent NEL rating would result in people with injuries the same as or similar to those rated at 100 per cent PD not having access to the same benefits and services. To address this, the WSIB sought to identify a NEL threshold that was equivalent to 100 per cent PD. It was concluded that setting the threshold at 60 per cent NEL would result in similar benefits being available for similar groups of injured people under both the PD and NEL systems.

Opportunity

The severely impaired threshold is a policy requirement for entitlement to certain health care benefits and services. While the threshold has been used as a way to identify which claims should be managed in the SIP, admittance into the program appropriately is not set out in policy. This is because the criteria for entitlement to the health care benefits and services set out in policy and the criteria for having a claim managed in the program are not necessarily the same.

In the past, admittance into the program was limited to those already rated or likely to be rated as meeting the severely impaired threshold. More specifically, catastrophic injuries, cumulative NELs/PDs, and worsening NELs/PDs were managed in SIP. The scope for admittance into the program has since expanded to include those with an injury meeting the criteria for acute care: those with a significant injury that temporarily requires specialized benefits and services similar to those required by an injured person who meets the severe impairment threshold.

People with injuries meeting the criteria for acute care often have immediate and significant needs given the impact of the work-related injury on their basic activities of daily living (ADLs). However, once maximum medical recovery is reached in these cases, the resulting permanent impairment does not usually meet the severely impaired threshold. The SIP temporarily manages these claims, immediately following the injury and up until the injured person reaches independence in their ADLs (typically up to nine months).

The benefits and services provided for in the independent living policy suite were not subject to a corresponding substantive review at that time, to take into consideration this change in scope for admittance into the program. Thus, while the SIP is able to leverage the benefit of the program’s specialized and dedicated case management in these acute care claims, the severely impaired threshold limits the benefits and services available in these claims relative to others in the program. This, despite the fact that an injured person with an acute care claim actually may have similar or greater limitations and needs than others in the program, whether on a temporary or permanent basis. 

As suggested in the VFMA, using the severely impaired threshold may be contributing to a misalignment between people’s needs and the benefits and services to which they are entitled, as demonstrated by the two personas below.

Some injured people in the SIP are not considered for entitlement to benefits and services that could improve functional outcomes, return-to-work outcomes (where applicable), independent living and quality of life.

Evan sustains a traumatic injury at work, requiring a foot amputation. Evan has a spouse and young child, lives in a house on a large property, and is the sole driver and earner for the family. In the acute phase of the injury, Evan is unable to drive or help around the house or with child care. Evan’s spouse is overwhelmed, adjusting to the new reality brought on by the workplace accident, caring for their child, and keeping the household running, all without the ability to make use of their personal vehicle. Because Evan’s anticipated permanent impairment rating is 28 per cent, much lower than the 60 per cent necessary to qualify for severe impairment benefits and services, Evan does not qualify for the independent living allowance (ILA). The ILA could help Even to cover expenses such as taxis, child care, and help around the house during the acute phase of recovery.

Some injured people in the SIP are considered for entitlement to benefits and services they need and to benefits and services they may not necessarily need.

Sam experiences a number of different work-related injuries over the years resulting in two different permanent impairments whose ratings total 65 per cent. Sam is widowed and lives alone in a condo. Sam now has some difficulties with activities of daily living due to the cumulative impact of the injuries. Following discharge from the hospital for the most recent injury, Sam receives a personal care allowance (PCA) and independent living devices (ILDs) to assist with the activities of daily living. While it is not yet clear whether Sam will require assistance additional to the PCA and ILDs to maintain their independent living and quality of life, Sam automatically qualifies for the independent living allowance (ILA) due to the 65 per cent permanent impairment rating. Sam is able to spend the ILA as they see fit to improve their independence and quality of life.

The VFMA and its recommendations present the opportunity to review the scope of benefits and services provided to people in the SIP and the associated entitlement criteria. In particular, to consider whether the current entitlement criteria result in people with serious injuries receiving the personalized benefits and services that:

  • improve recovery and return to work outcomes
  • facilitate independent living and improve quality of life by enabling participation in all aspects of life.

Questions for stakeholders

Below are questions about entitlement criteria, as well as the timing and duration of entitlement. Responses to these questions will support the WSIB’s review and analysis of entitlement to the benefits and services provided for in the independent living policy suite.

  1. Does the severely impaired threshold continue to be a suitable criterion for considering entitlement to the benefits and services in the independent living policy suite?
  2. Is someone’s permanent impairment rating or expected permanent impairment rating a reliable indicator of the scope and duration of the benefits and services they are likely to need as a result of the work-related injury or illness?
  3. Does the severely impaired threshold result in people with serious injuries receiving the benefits and services they need as a result of the work-related injury or illness?
  4. Identifying entitlement criteria for benefits and services supports consistent and predictable decision-making. Aside from the NEL and PD rating, are there other criteria or measures that would better indicate whether someone might need a particular benefit or service? For example, lack of independence with activities of daily living (ADLs), independence with instrumental activities of daily living (I-ADLs), combination of diagnosis and function, standardized tests or assessments.
  5. Many of the benefits and services in the independent living policy suite contemplate long-term, permanent needs. Are there circumstances in which it would be beneficial to provide any of these benefits or services on a short-term or temporary basis?
  6. Immediately following a work-related injury or illness, treatment and recovery are the primary focus.
    1. At what point in a person’s recovery should benefits and services to facilitate independent living be considered? Are there specific factors or indicators that should be considered?
    2. At what point in a person’s recovery should benefits and services to improve quality of life be considered? Are there specific factors or indicators that should be considered?
  7. Are there benefits and services that should be provided immediately and reviewed as the injured person’s needs change?
  8. Are there benefits and services that should be provided only once it is clear what the injured person’s long-term needs are/likely are?
  9. Do universal benefit amounts (e.g., flat rate for the independent living allowance) continue to be appropriate for meeting the needs of people with serious injuries?
  10. Aside from the severely impaired threshold, do the other entitlement criteria in each of the individual policies in the independent living policy suite allow for the provision of benefits and services that align to the needs of those with severe/significant injuries? 
Appendix one: Entitlement criteria for independent living policy suite
Policy Entitlement criteria

17-06-02, Independent Living Allowance

Severely impaired

N/A

17-06-03, Independent Living Devices

Severely impaired

The device,

  • helps restore a worker's ability to
    • communicate
    • be mobile
    • engage in self-care
    • avoid further injury, or
  • prevent future health complications due to the work-related injury
  • is not intended to accomplish any of the objectives of the services covered by the independent living allowance (if the worker is receiving the allowance)
  • meets a permanent or long-term need
  • is appropriate, given the nature of the worker's impairment and functional limitations (e.g., it can be used safely and effectively)
  • is prescribed or recommended by a health care practitioner
  • is reasonable in terms of costs and anticipated benefits
  • is cost-effective considering alternatives on the market
  • meets performance standards generally accepted by medical or clinical rehabilitation specialists, and
  • is certified by Canadian Standards Association International (C.S.A.I.) or meets other applicable safety standards.

17-06-04, Guide and Support Dogs

Severely impaired

The guide or support dog is,

  • necessary to enhance the worker’s independent living and quality of life, or
  • necessary to help in the worker’s return-to-work (RTW) activities, and
  • recommended by the worker’s health professional

17-06-05, Personal Care Allowance

Severely impaired

Worker has difficulty with the activities of daily living

17-06-06, Home Care

N/A

The worker/worker’s

  • is under the clinical supervision of a treating health professional
  • work-related clinical condition is such that the worker can be treated adequately at home with the services available through the home care program
  • needs cannot be met on an out-patient basis
  • is in need (according to the worker’s treating health professional) of at least one of the professional services, such as nursing, physiotherapy, occupational therapy, or speech therapy
  • home is suitable from a health care standpoint to enable the required care to be given
  • family, where applicable, is willing and able to participate in the program where and when required
  • resides in the area designated as being covered by the home care program

17-06-07, Vehicle Modifications

N/A

Modifications will improve or enhance quality of life and facilitate,

  • mobility within the community, and
  • socialization – family, friends, organization

The modification must be essential to the safe operation of, or to the worker’s ability to enter, leave and operate the vehicle

17-06-08, Home Modifications

Severely impaired

  • Severe impairment is permanent
  • Modifications will provide access to an area within the home, and any other areas utilized for ordinary living necessities

 

* Home modifications may also be extended to a worker under their return-to-work (RTW) plan if the worker is clinically capable of engaging or continuing in homebound employment.


1The Occupational Disease and Survivors Benefit Program manages the claims of people with occupational diseases, including those who meet the severely impaired threshold as a result of an occupational disease.

2 Workers’ Compensation Act, R.S.O. 1980, as amended. Applicable to accidents on or before January 1, 1990

3 Workers’ Compensation Act, R.S.O. 1990, as amended. Applicable to accident dates from January 2, 1990 and December 31, 1997 (inclusive)

4 Operational Policy Manual document 18-07-02, The Ontario Rating Schedule. WSIB. October 2004.

5 American Medical Association. Guides to the Evaluation of Permanent Impairment, Third Edition (Revised)