Note: This is not a policy; it is a supplementary document to illustrate how the WSIB will administer the Workplace Safety and Insurance Act, 1997, (WSIA) and Policies 19-02-07 RTW Overview and Key Concepts and 19-02-08, RTW Co-operation Obligations in practice. If there is a conflict between this Administrative Practice Document and the WSIA and/or WSIB policy, the decision-maker will rely on the WSIA and/or WSIB policy, as the case may be.
Key principles
- Workers are entitled to receive benefits for injuries and illnesses that result from accidents that arise out of and in the course of employment.
- Work-relatedness is established when determining initial entitlement. Decision-makers continue to evaluate the work-relatedness of the worker’s ongoing impairment throughout the life of a claim.
- Decision-makers gather relevant information and weigh evidence in order to make adjudicative decisions.
- Decisions are based on the merits and justice of each case.
- Return to work is part of the recovery process. Offering early support and services is the key to achieving full recovery, thereby minimizing the likelihood of a permanent impairment.
- Throughout every stage of the claim and where appropriate, the WSIB will attempt to maintain the employment relationship between the worker and the incident employer.
Introduction
Research has shown that a return to suitable work as soon as a worker is able to do so promotes faster and fuller recovery. The Workplace Safety and Insurance Board (WSIB) has adopted the evidence-based principle of “Better at Work” as the approach for a case management and health recovery model. This approach recognizes the importance of timely access to quality health care, integrated with a return to suitable work, to realize optimal physical and psychological recovery.
After a work-related injury, many workers are able to continue working, performing their pre-injury job (with or without accommodation) or other suitable work. If someone is unable to do their pre-injury job or suitable work and loses time from work due to the work-related injury or illness, the workplace parties (the employer and worker) are required to:
- initiate and maintain contact throughout the worker’s recovery
- begin return-to-work (RTW) planning activities for the worker’s return to suitable work.
The WSIB provides workplace parties with support and services to facilitate RTW when needed and appropriate.
Policy 19-02-07 RTW Overview and Key Concepts and Policy 19-02-08, RTW Co-operation Obligations, align with RTW responsibilities under s.40 of the Workplace Safety and Insurance Act (WSIA). The policies support the “Better at Work” approach, as it encourages active RTW discussions and planning early in the life of a claim. These policies provide guidelines on how the workplace parties and the WSIB can work together throughout the RTW process to establish RTW plans that enable a worker to return to suitable work and promote the worker’s recovery.
The WSIB supports timely RTW integrated with appropriate health care to promote recovery, but recognizes that timely RTW does not always mean immediate RTW. The appropriateness of RTW is based on an assessment of clinical information, the worker’s health and level of function, discussions with the workplace parties regarding the duties and demands of the pre-injury job or other available jobs, and whether accommodations may be necessary to allow the worker to RTW. Where the worker is able to return to their pre-injury job without limitations, or the workplace parties have reached an agreement about the work to be performed, the WSIB does not need to intervene. In most cases, workers RTW soon after the injury or illness without the need for WSIB assistance.
This document focuses on the WSIB’s approach and considerations for determining the appropriateness of a RTW opportunity where the workplace parties do not agree on whether RTW is appropriate, or whether the work available and offered is suitable for the worker.
Impact of musculoskeletal injuries
A significant number of work-related injuries in Ontario are musculoskeletal injuries (injuries to the muscles, tendons, blood vessels, ligaments, nerves, joints, spinal discs and related soft tissue). Following this type of injury, the worker may develop localized inflammation and pain. Initial treatment may consist of rest, ice, compression, elevation and medication. Depending on the area and severity of the injury, the injured area may require a short period of immobilization.
Mobilizing the injured area may be associated with some mild pain. Acute, injury-related musculoskeletal pain typically responds to analgesic and/or anti-inflammatory medications, although these may not be indicated in all cases. Decision-makers should consider the potential impact of pain resulting from the work-related injury on the worker’s functional abilities.
While recognizing the need to heal in the very early stages following an injury, evidence-based best practices do not support “rest” and inactivity for promoting recovery and supporting successful return-to-work. Except where the injured area requires immobilization, maintaining mobility of the injured area is generally encouraged to prevent stiffness and loss of function (e.g., acute post-operative recovery). An injury that requires initial immobilization will need subsequent mobilization of the injured area as soon as it is safely possible and based on input from the treating health care professional.
Workers with musculoskeletal injuries should not ignore the warning signs of overdoing it, nor should they allow a mild increase in discomfort to discourage continued mobility and consideration of returning to suitable and safe work. Decision-makers should re-enforce the concepts that staying active and increasing function often enhances physical recovery and some degree of activity is usually safe and appropriate. Workers with musculoskeletal injuries are encouraged to maximize their function within safe and appropriate limits to support their recovery, rather than avoiding activity, which can lead to deconditioning (weak muscles and stiff joints) and increases the chance of chronic pain.
Functional abilities are sometimes referred to as precautions, limitations or restrictions. Within this document, the term “functional abilities” encompasses abilities, precautions limitations and/or restrictions with respect to physical, social, psychological or cognitive function, depending on the nature of the injury or illness.
Managing health recovery
During the acute phase or early stages of an injury and up until recovery has been achieved, decision-makers collect and assess clinical information to determine the degree or level of the worker’s ongoing work-related impairment and capacity for work. This means monitoring the two aspects of the worker’s recovery – functional and physical. In most cases, functional recovery happens ahead of physical recovery. This means that some degree of movement and activity is generally safe and appropriate even in the early stages of physical recovery.
Decision-makers continuously monitor and assess the clinical information to determine whether the worker has recovered from the work-related injury/disease and/or has achieved sufficient functional recovery to RTW. Where appropriate, decision-makers may refer the worker to health care programs to promote recovery, or initiate RTW services to assist the worker and employer to identify suitable work.
Health care programs such as the Occupational Health Assessment Program (OHAP) are designed to provide expedited access to specialized health care support, and provide a clear and effective continuum of care for workers with workplace injuries or illnesses. Through occupational health hubs across the province, the program provides assessment and case consultation services to help decision-makers with respect to diagnosis, causation, treatment recommendations, and functional abilities.
The focus of an OHAP assessment is to review the worker’s current medical condition, progress and functional recovery, identify any barriers, and develop a goal-oriented treatment and RTW plan. It gives workers fast access to high quality medical assessments, performed by medical experts. The program builds upon existing partnerships with public hospitals across the province with an objective to provide quality care and assist workers with their recovery and RTW.
Functional recovery means regaining the use of the injured body part(s) or cognitive abilities. For example, as a cut on a finger is healing, the hand can gradually resume completing tasks, or as a fractured ankle is healing, the worker can begin to bear weight, then stand, and walk. For illnesses such as occupational asthma, it would mean improved lung capacity. For psychological conditions, it would represent graduated exposure therapy or increasing tolerance to triggering situations.
Physical/psychological recovery is the healing process or repair of the body or cognitive functioning, which may occur naturally or after health care treatment such as surgery, therapy or other treatment modalities.
Determining appropriateness of RTW
The worker’s treating health care professional(s) is required under the WSIA to provide the WSIB with information about the worker’s work-related injury or illness, ongoing impairment, and functional abilities.
Understanding a worker’s functional abilities is the first step in determining their ability to RTW.
WSIB forms available for completion by health care professionals, including the initial Health Professional’s Report (Form 8), contain sections where the health care professional(s) can provide the worker’s functional abilities. When requested, the worker’s treating health care professional(s) completes the Functional Abilities Form to assist the workplace parties with the identification of suitable work and RTW planning. The information also helps WSIB decision-makers determine if RTW is appropriate.
As part of the analysis of a worker’s functional abilities, particularly in the early stages of recovery to determine if RTW is appropriate and whether available work with the employer is suitable, decision-makers may need to review the impact of the following:
Medication – There are a number of medications that may be prescribed to treat work-related injuries or illnesses. Prescribed medications may have adverse effects, which are usually explained to the worker by the prescriber. Fortunately, many of the side effects related to medications for musculoskeletal injuries can be controlled and are not disabling.
Decision-makers should understand the potential side effects of the medication being taken by the worker, and what, if any, side effects the worker is experiencing.
Information from the treating health care professional, the Compendium of Pharmaceutical Specialties (CPS), the WSIB nurse consultant can assist the decision-maker with assessing the potential impact of the worker’s medications with respect to safe RTW. Where necessary, the nurse consultant may contact the treating health care professional to discuss alternative medication or dosage for the worker, to maintain the benefits but reduce the adverse effects to enable RTW.
Travel to and from the worksite – Decision-makers must consider the worker’s functional ability to travel safely to and from the proposed worksite and to their workstation.
With respect to travel to and from the worksite, decision-makers should consider:
- What method of transportation does the worker normally use to travel to work?
- Based on the area and the nature of the injury, can the worker use the same method of transportation, with or without accommodation (e.g. stopping for stretch break along route or traveling during off-peak hours), and not pose a health and safety risk to them or to the general public?
- Are alternative methods of travel available to the worker?
- Do the alternative method(s) of travel unreasonably impact the worker’s commute to work?
- If the worker is able to travel to the worksite, are there any barriers to the worker getting to their workstation once at the worksite (e.g. the distance from the parking lot or bus stop, the terrain)?
Workers should not incur additional travel expenses because the work-related injury/disease temporarily dictates a particular mode of travel. Wherever possible, expense issues relating to travel to work will be resolved jointly with the employer.
When the employer has suitable work available that is within functional abilities, but the worker is unable to get to and from work safely, RTW may not be appropriate
Worker concerns or fears – Some workers may have concerns surrounding the circumstances of the injury or illness and may be anxious or fearful about returning to work. For example, the worker may have a fear of returning to the particular work area or operating the equipment that caused the injury.
These concerns/fears may be barriers to the worker’s RTW, but may not be immediately evident to the decision-maker without thoughtful enquiry and careful listening. In many cases, these concerns/fears will resolve naturally but decision-makers should be sensitive to the worker’s concerns and take them into account when determining ability to RTW. Having a regard for these concerns, case conferencing with the nurse consultant and a return-to-work specialist (RTWS) can assist in the RTW process.
Functional abilities – Workers with psychological conditions or chronic pain disability
A worker may have entitlement for a psychological condition as a result of a physical injury (such as a head injury). A psychological condition can also be related to an extended disablement and associated non-medical socioeconomic factors.
Chronic pain disability (CPD) or a psychological condition may become evident as a secondary condition at some later time after the injury. Decisions on entitlement for these conditions are guided by policies:
Where the worker has a compensable psychological condition, the approach for determining if they have the ability to RTW is the same as that for a worker with a physical injury, including factors such as medication and travel to/from the worksite.
Where the psychological condition becomes evident as a secondary condition, decision-makers must consider the functional abilities relating to the psychological condition in combination with the functional abilities for the physical injury.
For workers with chronic pain, it is important to understand the distinction between chronic pain resulting from a physical injury and the condition known as chronic pain disability as the treatment and functional abilities may be significantly different for each. In cases where CPD has been recognized, the genuineness of the worker’s pain is accepted and it is the pain experience that is the limiting factor and will determine the functional abilities.
Clinical information from the treating health care professional(s), including WSIB specialty and community mental health programs, will be the primary source of information regarding the worker’s functional abilities, but conversations with the worker are an important part of this process. The following factors, as provided in clinical reports and by the worker, can assist decision-makers in evaluating functional abilities and capacity for work:
- Is the worker able to perform activities of daily living, such as self-care, personal hygiene, communication and travel unaided?
- Is the worker able to interact with others including supervisors, peers, and members of the public?
- Is the worker able to perform the cognitive requirements of the job such as regular attendance, making decisions, sustaining focus and attention to complete tasks in a timely manner?
- Are there specific persistent fears or issues associated with the workplace and the accident? (e.g. fear of machinery following amputation of a body part by machinery)
- What is the frequency and prescribed dosage of medication? Are there any potential adverse effects of the medication that may impact functioning?
When attempting to determine the worker’s ability to work and identify suitable work, the workplace parties and decision-makers must be clear about the accepted work-related injury and/or illness, and the associated functional abilities. Where the psychological condition or CPD becomes evident as a secondary condition, the worker’s ability to RTW must be re-evaluated based on the additional or revised functional abilities. It is important to delineate between functional limitations that stem from the accepted physical and psychological injuries and functional limitations that are not work-related, but still must be considered in a RTW context.
Determining ability to RTW
Where it is determined that the worker has achieved sufficient functional recovery that RTW is appropriate, the decision-maker must determine their ability to return to the job or job duties available and offered by the employer. The decision-maker must gather information from both the worker and employer.
When assessing the worker’s ability to RTW, at the time the job or job duties were made available, the decision-maker must consider factors such as:
- What was the worker’s understanding of the health care professional’s directions with respect to returning to work?
- Did the worker understand their rights and responsibilities following a work-related injury?
- What is the worker’s understanding of the job or job duties offered by the employer?
- Was the offer made verbally or in writing?
- Was the worker involved in the process of identifying the job or job duties to enable their RTW?
- What is the worker’s perception of the job offer in terms of physical or psychological demands and their ability to do that work?
- Are there any language barriers that could impact the worker’s understanding of the health care professional’s directions and/or the job offer?
- Did the employer have a clear understanding of the worker’s functional abilities, as well as other relevant factors, when making the job offer?
- Did the employer offer a specific job or job duties, and provide the worker with details of the job and physical demands?
- Did the employer provide the necessary job accommodations to make the job safe and suitable for the worker?
In many cases, decision-makers can determine the appropriateness of RTW and the worker’s ability to return to the work available with the employer based on the factors noted earlier in this document. Decision-makers may also request the assistance of a return-to-work specialist who can review the job or job duties at the worksite.
When determining the worker’s ability to RTW, decision-makers must assess the clinical evidence to first determine if RTW is appropriate. Entitlement to loss-of-earnings (LOE) benefits should only be limited when the decision-maker is satisfied, on a balance of probabilities, that:
a) the job or job duties being offered have been communicated to the worker, and
b) the job or job duties are suitable, which means the job or job duties
- is/are within the worker’s physical and/or psychological and vocational abilities, and
- will not pose a safety risk to the worker, to co-workers or to others, and
- will not impede the worker’s recovery, and
- is/are productive.
Where the decision-maker determines the job is considered consistent with the worker’s functional abilities, the work is available with the employer and it is suitable, there is an expectation that the worker will RTW. Entitlement to LOE benefits is based on the extent to which the earnings for the job offered restore the worker’s pre-injury earnings. LOE benefits are not paid where the pre-injury earnings are fully restored.
External assessment services
When appropriate, decision-makers will arrange for external functional or vocational-related assessment(s) to assist in determining a worker’s ability to RTW to a specific job or to help identify a suitable occupation.
Functional work capacity assessments are carried out at the worksite to assess if the physical, cognitive, behavourial and psychosocial abilities of the worker match the physical, cognitive, behavioural and psychosocial demands of the job. Assessments provide recommendations on job suitability, including accommodations that may be required.
Vocational assessments are used to assess the vocational, functional, social and cultural factors of the worker, as well as their interests, vocational aptitudes, transferable skills, past work experience and academic achievements. Assessments assist in identifying realistic and suitable occupational options for RTW with or without training.
Communication of decisions
All adjudicative decisions should be communicated verbally to the workplace parties, wherever possible, and then confirmed in writing. The decision letter should
- identify the issue decided,
- provide a summary of the facts of the case,
- provide the entitlement rules that apply to the issue (legislative and/or policy criteria, or standards),
- provide the rationale for the decision reached, explaining how the entitlement rules were or were not met,
- reference only evidence that is relevant to the decision, and
- include the timeframe for appealing the decision for all adverse decisions.
Every effort is made to verbally communicate decisions, followed by a decision letter in plain language to ensure the decision and reasons for the decision are fully understood by the worker and employer. The rationale should outline the evidence that was considered relevant to decision-making on each identified issue. Where the decision-maker must weigh conflicting or differing information/medical opinions, the decision letter should include an explanation of the decision-maker’s assessment and how the relevant information/opinions were weighed to arrive at their conclusion.
Decisions relating to a worker’s ability to RTW should identify the level of functional abilities and the specific job or job duties that were considered in reaching their conclusion. The decision letter should clearly explain the basis on which it was determined that a successful RTW can or cannot be achieved, and the resulting impact on the worker’s entitlement to LOE benefits.
Conclusion
The “Better at Work” principle reflects knowledge and best practices relating to recovery from injury or illness. Research has shown that workers recover more quickly and avoid or reduce permanent physical or psychological impairments by integrating health care with return to suitable work.
Although RTW may not be appropriate immediately after the injury or illness in all cases, RTW discussions and planning should begin and continue throughout the recovery process as outlined in Policy 19-02-07 RTW Overview and Key Concepts and Policy 19-02-08, RTW Co-operation Obligations. The WSIB provides workers with expedited access to expert health care and RTW services to promote recovery and facilitate return to suitable work as soon as the worker is able.
Understanding the worker’s functional abilities is a critical factor when determining their ability to RTW. For workers with a psychotraumatic disability or a chronic pain disorder, an understanding of the limitations, restrictions or accommodations in areas such as concentration, cognitive demands, and the work environment is key for determining the worker’s ability to RTW.
In assessing the appropriateness of a RTW opportunity that would enable recovery in the workplace, or return to employment, decision-makers must have regard for the worker’s functional abilities, as well as other relevant issues that may impact their ability to travel to and from the worksite and/or the worker’s ability to perform work in a safe manner. Decision-makers must be satisfied, on a balance of probabilities, that the job or job duties are available and suitable.
Where the worker has the functional ability to RTW and suitable work is available and offered to the worker, there is an expectation that the worker will RTW. Entitlement to LOE benefits is determined based on the extent to which the suitable work restores the worker’s pre-injury earnings.
Document history:
November 2021 – replaces April 2015 document
April 2015 – replaces Best Approaches Guide, Recognizing Time to Heal – Assessing Timely and Safe Return to Work (November 2005) and
– replaces Best Approaches Guide, Return to Work Considerations – Workers with Psychological Entitlement and Chronic Pain Disability (December 2005)
Scheduled review: November 2026