WSIB, The Service Delivery Model Return to Work A Presentation … · 2016. 9. 20. · A...
Transcript of WSIB, The Service Delivery Model Return to Work A Presentation … · 2016. 9. 20. · A...
WSIB,
The Service Delivery Model
&
Return to Work
A Presentation to the OSACH
Toronto Safety Group
September 16, 2010
1
About the WSIB
• The Workplace Safety and Insurance Board (WSIB) has over
4,500 staff in Toronto and in 13 Regional offices.
• The WSIB is the fourth largest group insurance company in
North America.
• Since its creation of the Workman’s Compensation Board in
1915 (now the WSIB), the WSIB provides coverage to injured
workers and no-fault insurance to Ontario workplaces that
protects employers from litigation.
• The WSIB is entirely financed by employer premiums. We
receive no money from the Ontario provincial government.
V2
Some Quick Facts
• Approximately 4 million workers are covered by the WSIB
(about 70 per cent of Ontario’s employment).
• The WSIB provides benefits and services to over 550,000
injured and ill workers, surviving spouses, and children - almost
five percent of Ontario’s total population.
• The WSIB manages over 350,000 claims a year, makes over a
million decisions a year and pays out over $3.4 billion in claim
payments.
• The WSIB provides a range of services to approximately
225,000 employers.
V2
Prevention
• The WSIB's vision is the elimination of all workplace fatalities,
injuries, and illnesses.
• There are a number of ways we are creating healthier and safer
workplaces in Ontario.
• WSIB Prevention roles include:
• Disability Prevention Specialist
• Workwell Evaluator
• Prevention System Collaboration Specialist
V2
Prevention
• Safety Groups
• Safe Communities Incentive Program (SCIP)
• Experience Rating Programs (NEER, CAD-7, MAP)
• JHSC Certification & First Aid
• Prevention Contact Centre
V2
The Life of a Claim
Registration ,Determining Eligibility And
Payment
How is a Claim Established?
A claim can be initiated by :
• Employer’s Report of Injury/Disease (Form 7)
• A medical report (e.g. Form 8)
• Contact by the worker
– Form 6 or letter
– Phone Call
Initial documents are scanned to the imaging
system and the claim is assigned a claim
number
Employer Obligations - Reporting
Employers must report a work-related accident
to the WSIB if they learn that a worker requires
health care and/or:
• is absent from regular work
• earns less than regular pay for regular work (e.g., part-
time hours)
• requires modified work at less than regular pay
• requires modified work at regular pay for more than
seven calendar days following the date of accident
Loss of Earnings (LOE) Benefits
If a claim is allowed
• WSIB pays loss-of-earnings (LOE) benefits when an
injured worker (IW) is disabled from work
• Bill 99 (Jan.1, 1998) – LOE benefits are paid at 85% of
weekly net average earnings
• Maximum gross earnings covered (2009)
$74,600
Paying LOE Benefits
LOE benefits are paid until:
– impairment ceases
– earnings are restored
– suitable and sustainable work is offered that
restores earnings
– worker is deceased
– worker reaches the age of 65
If the worker is 63 years of age or older at the
date of injury, benefits can be paid for up to 2
years
The New Service Delivery Model
In support of the Road to Zero, the NSDM provides increased prevention
support, strengthened service excellence, financial sustainability, improved
return to work (RTW) and recovery outcomes.
NSDM has:
– new and redesigned jobs
– evidence based case management approaches
– improved coordination and alignment of the delivery of services to injured
workers and employers to achieve the aggressive improvement targets
set out in the Road to Zero
Account AnalystsShort Term Case
Managers
Service Delivery
Manager
Nurse Consultant
Eligibility
Adjudicators
Eligibility Manager Revenue ManagerPrevention
Manager
Claims Services
Account Specialists
Revenue Manager
Account Specialists
Long Term Case Management
Short Term Case Management
Initial
EntitlementCCP /
Primary
D
O
I
30
days
180
days
Eligibility Area
Supporting Roles:
Investigator RTW Specialist Medical Consultant
Account ServicesWorkplace Program
Services
Service Delivery
Manager
Long Term Case
Managers
Nurse Consultant
How Are Services Being Delivered?
Case Management Framework
Primary Adjudication
•Claims that are straightforward
in accident history are directed
to Primary Adjudication
Eligibility Adjudication
• Claims where entitlement is not obvious and further enquiries are necessary are assigned to an Eligibility Adjudicator
• Primary and Eligibility Adjudicators determine entitlement using the Five-Point Check System
• When a claim is allowed, if full recovery and a RTW to pre-injury work is not evident in the first 30 days, the case is transferred to a Case Manager whose primary focus is RTW and recovery.
Case Transfers
Cases are transferred from Eligibility to the Short
Term Case Manager (STCM) for case
management when there is:
• lost time and the worker has not RTW
• lost time and the worker has RTW that is different
than the pre-injury/illness work, or
• no lost time but the work is not consistent with the
pre-injury/illness job and a permanent impairment
is anticipated
The Short Term Case Manager (STCM)
Role
The role of the STCM was created to improve RTW outcomes for workers and employers.
Case managers use a case management approach that is proactive, efficient and outcome focused. Their primary focus is to establish supportive and influential relationships in the workplace, working together to set safe and sustainable RTW goals and creating plans that support RTW and recovery.
The Long Term Case Manager (LTCM) Role
• LTCM’s key focus is to leverage their expertise in managing complex and chronic cases, enabling best possible RTW and recovery outcomes and mitigating the long term effects of injuries/illnesses for the worker.
• Cases are transferred to LTCM from STCM when:
– RTW options with the employer have been exhausted and Permanent Impairment (PI) anticipated and worker not expected to be fit for pre-injury duties within 26 weeks from date of injury
– RTW with the employer remains viable and a PI is anticipated but worker has no capacity to RTW within 26 weeks from date of injury
The Return To Work Specialist’s (RTWS) Role
In cases when the worker and employer are experiencing
difficulty in setting up a RTW plan or the plan is not
progressing as initially laid out, the RTWS is an expert
resource available to the workplace parties (WPP’s)
through the case manager.
The primary objective of the RTWS is to lead the return to
work process in those cases that will benefit from a
worksite intervention, helping the parties to minimize
obstacles and concentrating on achieving a positive RTW
outcome.
RTWS Responsibilities
To ensure that the RTW obstacles are understood and there is an
opportunity for the worker and employer to be heard and participate
in the RTW direction, the RTWS will:
- invite all necessary parties, including the union if
appropriate, to discuss and negotiate RTW options
- explain their role
- lead collaborative conversations by asking probing
questions
- involve the in workplace parties in assessing RTW
obstacles and opportunities and facilitate
discussion to ensure agreement
Return to Work
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Why Have a Return to Work (RTW) Program ?
1. Social and moral obligations
2. Financial Impacts
3. Legal obligations
– Section 40 - duty to communicate and co-operate
– Section 41 - re-employment obligations
– Human Rights Code and its policy on Duty to
Accommodate
The Workplace Parties (WPP)
• The worker and employer are best positioned to
develop their own return to work solutions.
• In most cases, the WSIB is not involved in the RTW
process, except to communicate to the WPP’s their
statutory obligations, monitor activities, determine
compliance with the obligations to co-operate and re-
employ, and provide dispute resolution.
• Many of the new or redefined roles in WSIB’s New
Service Delivery Model can assist the WPP’s achieve
their return to work goals.
The RTW Goal
The RTW goal in case management is to return the worker to safe and sustainable work with the injury employer based on the following hierarchy:
1. Return to pre-injury job (starting point and overall goal) with incident employer
2. Return to pre-injury job accommodated with incident employer
3. Return to work comparable in nature and earnings to the pre-injury job (with accommodation if required) with incident or other employer
4. Return to alternate work (with accommodation if required) with incident or other employer
Questions?
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