DRAFT Standard 34: Return to work - early intervention

1. Introduction

1.1. About the Standard of Practice

SIRA’s Standards of practice: expectations for insurer claims administration and conduct (Standards) were published in December 2018 and apply to all claims from 1 January 2019.

Changes to the Standards were made to support the commencement of reforms to pre-injury average weekly earnings (PIAWE), which apply to workers injured on or after 21 October 2019. Changes were also made to clarify expectations in relation to claims management during the COVID-19 pandemic.

All insurers are expected to comply with these Standards, except for Coal Mines Insurance Pty Ltd and the Workers Compensation (Dust Diseases) Authority (Dust Diseases Care). However, SIRA encourages all insurers operating in the NSW workers compensation system to adopt the overarching claims management principles and any relevant Standard.

Directions to comply with these Standards, including the expectations and benchmarks, may be issued to insurers under Division 4 of Part 7 of the Workers Compensation Act 1987 (the 1987 Act), which will make contravention (breach) of a requirement of the Standards an offence under section 209 of the 1987 Act. Section 194(2) makes compliance with a direction to insurers a condition of an insurer's licence issued under the Act.

SIRA may issue a Direction to an insurer to comply with individual Standards or all of the Standards.

1.2. Purpose and scope

SIRA developed the Standards to support and encourage insurers to have effective claims management practices to help deliver positive experiences and outcomes for workers, employers and the people of NSW.

The Standards contain overarching claims management principles that apply generally across all aspects of claims management and provide direction for the handling and administration of claims under the workers compensation system. These are:

Principle 1: Fairness and empathy

Principle 2: Transparency and participation

Principle 3: Timeliness and efficiency

These principles support the workers compensation system objectives outlined in section 3 of The Workplace Injury Management and Workers Compensation Act 1998 (1998 Act).

Individual Standards apply to particular aspects of claims management and are presented in a way to make clear the following elements:

Principle: the broad principle to be adopted by insurers when dealing with a particular aspect of a claim

Expectations: SIRA expectations for processes, procedures or methods to be applied in the handling and administration of claims relevant to that Standard topic

Benchmarks: an indication of what claims activities or actions SIRA may use to measure insurer performance against expectations.

The Standards should be read in conjunction with the requirements of the workers compensation legislation, regulation and guidelines.

1.3. New Standard for Return to work – early intervention

A new Standard of practice has been developed to support and set expectations for insurers in their early management of claims. Specifically, it is designed to:

• Promote the management of claims in accordance with legislative requirements, while tailoring services to workers’ needs, providing transparent communication about the process, establishing trust with the worker and focusing on early treatment and return to work.
• Support the insurer to adopt practices to assess for the risk of delayed recovery across four key domains including:
  • Personal
  • Workplace
  • Healthcare
  • Insurance and legislative
• Support the insurer to match interventions to address risks identified.

1.4. Have your say

SIRA is seeking your feedback in relation to the new Standard of practice by no later 5pm on Monday, 28 February 2022. Written feedback may be provided via email to: Policy&[email protected]

SIRA will be working to finalise any changes to enable the new Standard to come into effect by the end of the first quarter of 2022.

2. Standard 34: Return to work – early intervention

Early and tailored contact with relevant stakeholders provides invaluable information to inform the early identification of potential risk factors for delayed recovery. A subsequent analysis and prioritisation of risk factors and matched intervention strategies will strengthen stakeholder commitment, prevent work loss and optimise recovery and work outcomes.

3. Context

3.1. Overview

This Standard of practice has been developed to support and set expectations for insurers about early intervention and the importance of identifying risks for delayed recovery and designing and implementing actions to address these risks.

3.2. Factors influencing Return to work outcomes

Factors with moderate to strong evidence of influencing return to work outcomes are summarised under four key domains. The evidence[1] supports the four domains as:

Personal – includes biological, psychological, behavioural and social factors relating to the worker

Workplace – considers the working environment, relationships, design, support systems and how a workplace accommodates return to work

Healthcare – includes the provision of treatment and rehabilitation

Insurance and legislative – includes claims agents, insurers, regulatory authorities and other government and non-government agencies.

A focus on an optimal outcome means a focus on early intervention. Early intervention involves actively coordinating all stakeholders from the first conversation to the point of developing an injury management plan, including:

• early and supportive contact
• assessing risk for delayed recovery
• matching interventions to identified risks (injury management planning)
• equipping the worker to drive their own recovery
• supporting the employer to provide suitable work
• a coordinated multi-domain approach to ensure work focused outcomes.

A consistent and high quality early intervention approach enhances stakeholder experience and outcomes.

Implementing the overarching claims management principles when communicating with all stakeholders is critical in optimising return to work outcomes. These principles support the workers compensation system objectives outlined in section 3 of the 1998 Act.

3.3. Capabilities and personal attributes of case managers

The evidence^2and 3 supports it is essential for case managers to have a range of capabilities and personal attributes to be successful in delivering high quality case management. These include:

• commitment to ongoing professional development
• strong communication and problem-solving skills
• ability to collaborate with diverse stakeholders
• empathy
• resilience
• emotional intelligence.

For complex claims formal qualification and/or recognition of prior experience is required.

^{1. Collie, A., Lane, T., Di Donato, M. and Iles, R. August 2018. Barriers and enablers to RTW: literature review. Insurance Work and Health Group, Monash University, Melbourne, Australia.}

^{2. Safe Work Australia. 2017. Taking action: A best practice framework for the management of psychological claims in the Australian workers’ compensation sector.}

^{3. Moo, A., Bywood, Dr P., Clark, B., McMillan, Dr J. July 2021. Best Practice for Person-Centred Case Management: A Literature Review. Institute for Safety, Compensation and Recovery Research, Melbourne Victoria.}