With 24/7 operations and diverse staffs, hospitals need to be as fully staffed as possible at any given time. So when it comes to handling employee absences—especially those of nurses—due to disability, a transitional return-to-work program is essential. Kristin Tugman, senior director of health and productivity development for disability insurer Unum, discusses best practices for developing a program that succeeds.

Health systems and hospitals are facing unprecedented challenges—including uncertainty surrounding health care reform, shortages in skilled staff, and increases in operating costs against declining revenues—while still working to fulfill their mission of delivering quality patient care.

Hospitals also face unique operational challenges, as they are 24/7 operations with a diverse workforce comprising a wide range of occupations and skills.

A key focus for hospital administrators is ensuring they are fully staffed around the clock with the right employees. Employee absences can translate into lost productivity and higher costs, and they also impact the quality of patient care. As a result, the ability to effectively manage lost time due to disability and other absences is a critical need.

As hospitals look for ways to maximize productivity while managing employee absences due to disability, a transitional return-to-work program can be a key element in their overall disability and absence management strategy.

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For a typical large hospital, the price tag for disability and lost time is staggering. Based on Unum's experience with more than 1,500 hospitals in the United States, a hospital with 5,000 employees could have as many as 62 employees out of work every day, including 22 nurses. Assuming a typical patient load of four patients per nurse, this level of absenteeism could impact the health care of 90 patients. Over the course of a year, this level of disability can cost up to $4.5 million in lost productivity and wage replacement.

Absent employees create some hard choices for hospitals. Do they overstaff to make up for absent workers? Do they draw on a nurse pool and incur overtime expenses? Do they increase nurse-patient ratios, potentially affecting patient care? Do they limit the number of beds that can be filled, reducing revenue?

This potential cost illustrates why disability and absence management is so important to hospitals, why hospitals are focused on absence management strategies, and why their choice of a disability and absence management partner is so important.

Unum's data in 2010 shows that the incidence of disability in the health care industry is consistently higher than other industries. In hospitals, the incidence of family and medical leave under the Family and Medical Leave Act is 40% higher than other industries for two key reasons. First, virtually every disability, by definition, qualifies for job-protection under FMLA; so if disability is higher, then the FMLA incidence is automatically higher as a result. Second, employee demographics, specifically the female population, play a key role because we tend to see more women taking time off to care for family members.

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Age also is a key driver of disability. The average age of employees trends higher in hospitals than in other industries. The average age of employees in other industries is 42, compared with 44 for all hospital employees and 48 for nurses. In addition, the nature of hospital work—being physically challenging, requiring long hours and including exposure to illness—also increases the incidence of disability for hospital workers.

On average, hospitals also typically see longer claim durations, driven by hospital workforce demographics and the nature of the work. As the average age of working nurses continues to increase, hospitals are likely to see a related increase in the complexity and severity of the disabilities they face. One factor that comes into play is chronic conditions, such as heart problems, low back problems and diabetes. These conditions increase with age and, when they are not addressed, drive longer leave durations.

According to Unum's internal data, musculoskeletal problems are the leading cause of long-term disability for nurses, accounting for 32% of long-term disability leaves, compared with 26% in the company's overall block of business.

When it comes time to return to work, transitional return to work, or RTW, programs should be structured and predictable.

An effective transitional return-to-work program recognizes that disabled employees do not regain 100% of their original work capacity instantly. Recovery is incremental. So it is essential to understand the point at which a disabled employee has recovered enough to begin transitioning back into a productive role at work, as well as reasonably understand when the person will be able to return to full capacity.

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It is a common misconception among employers that “return to work” means simply coming back to the workplace on light duty—and therefore being unproductive—for an extended period of time. An effective return-to-work program is much more than simply bringing an employee back to the workplace. Instead, it requires close cooperation between hospital management and the disability insurance carrier to understand what kinds of job modifications can be used to facilitate a return to work well in advance of anyone becoming disabled. Manager buy-in is a key component to any effective and successful RTW program.

The cornerstone of an effective RTW program is the creation of a series of transitional RTW pathways before any individual becomes disabled. These early intervention pathways are a planning tool and a structured method of reducing lost time using a series of agreed-upon options. RTW pathways also serve as a communication guide between the employer, the disability insurer and the employee's physician. All diagnoses, with the exception of maternity, would be considered candidates for an early intervention program.

When an employee actually goes out on disability, the insurer's vocational consultants use these pathways as guidelines to talk with the employee's physician about any physical restrictions and limitations the employee may have. It is also helpful to begin talking with the employee about ideas for how they can return to work as soon as is physically possible after the onset of disability. As the person recovers enough to begin the pre-designed program, the vocational consultant will use the transitional pathways to draft a personal recovery plan.

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Typically, a return-to-work plan covers no more than 30 days. It is important to make sure the employee is incrementally improving so he or she can return to their original position. An end date helps to avoid a prolonged transition. The transition period may be extended if necessary, but usually lasts for a maximum of approximately 45 days. In rare instances, if we see the person is not performing the tasks as expected beyond the specified maximum timeframe, then the manager should be able to access either a return to work resource within the employer organization or the disability vendor who can determine the next best step. It's important to note that if the transition period extends beyond the specified maximum timeframe frequently in an organization, then it's recommended that the return-to-work program structure be re-examined to determine if it is capturing the right candidates at the right time.

Patient safety and quality of patient care also play an important part of an effective RTW program. It's important for any organization, especially hospitals, to have an employee back to work only after they are up to the job. And in the case of hospitals, patient safety is top of mind when developing transitional RTW programs. Targeted and safe return to work practices can effectively reduce the duration of short-term disability leave by helping employees through their recovery.

It's important to remember that no matter how well designed the RTW pathways are, there are some people who should not be at work because they are still sick or haven't recovered enough. A return-to-work program should never force employees to come back before they are ready.

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Coupled with typical RTW restrictions—such as reduced lifting, reduced sitting/standing and reduced work hours—a hospital-tailored transitional return-to-work program might include accommodations such as reduced patient load, partnering with a co-worker, taking on a special project, taking a temporary assignment in the same area (like conducting chart audits rather than patient care) or working in an alternate location.

Alternative work locations are frequently the foundation of a successful return-to-work plan because most times nurses need to be close to 100% physically to work back on the floor.

A typical transitional RTW plan for a nurse might begin with a week or two of less strenuous work in another department, perhaps making ambulatory surgery pre-procedure phone calls. The work is more sedentary than floor nursing but allows the employee to begin using his or her clinical skills. Then the individual might spend another week in ambulatory surgery admissions, doing work that requires more movement and clinical tasks but is still less strenuous than regular duties.

Finally, with the employee back to 90%-95% of pre-disability capacity, he or she would return to their original floor with two or three days of reduced workload before resuming original duties. Unum's experience shows that this process helps an individual feel more prepared for a full return if they can transition for a couple of days back into full duty on their original floor.

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By planning transitional-work pathways before employees become disabled and intervening as early as possible to create customized plans for employees, a transitional return-to-work program helps managers and employees understand what to expect and it can create a sense of accountability.

Having a structured plan takes the guesswork out of absence management and helps hospitals maximize productivity in a challenging environment.

Kristin Tugman is senior director of health and productivity development for Unum, where she works with large employers, including hospitals, on transitional return-to-work programs. She can be reached via email at ktugman@unum.com.