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Division of Federal Employees' Compensation (DFEC)

Vocational Rehabilitation Counselor Handbook

Part 4


Part 4 - Medical Rehabilitation Services

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Table of Contents

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1. Overview

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2. Types of Medical Rehabilitation Services

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3. When to Provide Medical Rehabilitation

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4. Examples of Medical Rehabilitation Services

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5. Settings

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6. Period of Services

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7. Nonwork-Related Injuries or Conditions

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8. Referral Process

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9. Monitoring and Documentation

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10. Problems with Non-Compliance

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11. Possible Outcomes of Medical Rehabilitation

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12. Obstacles to Completion

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13. Specified Services

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1. Overview. Medical Rehabilitation refers to those medical and related services necessary to correct, minimize or modify the impairment or limitations caused by a disease or injury so that the Injured Worker (IW) can return to an adequate level of functioning and employment. Thus, it is distinguished from actual medical treatment to cure or relieve the effects of the injury.

Under FECA, medical rehabilitation services may be provided at any stage in the reemployment effort, at the discretion of the Rehabilitation Specialist (RS) and Claims Examiner (CE), when such services are likely to cure, give relief, reduce the period or degree of disability, or aid in lessening the amount of the monthly compensation. See 5 U.S.C. 8103.

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2. Types of Medical Rehabilitation Services. Not exclusively, medical rehabilitation services may include:

a. Intensive services or coordination of care provided in catastrophic injury claims

b. Occupational Rehabilitation Programs (ORP) including Functional Capacity Evaluation (FCE), work hardening, or any physical therapy (PT) or other program aimed at producing work tolerance limitations or physically preparing the IW for return to work

c. Speech therapy, orthotics, prosthetics, assistive technology or other therapies or devices which will enhance the IW's employability or standard of living

d. Psychiatric counseling, substance abuse treatment or pain management

e. Coordination of housing and/or vehicle modifications as described in the FECA Procedure Manual 2-1800

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3. When to Provide Medical Rehabilitation. Medical rehabilitation should be considered early in the rehabilitation effort, if possible, but may be recommended at any time, as deemed appropriate, during the life of the case.

a. As a limited referral. If medical rehabilitation is utilized for coordination of care in catastrophic injuries or for coordinating housing and/or vehicle modifications, then the rehabilitation efforts will be closed once these services have been provided.

b. Prior to vocational rehabilitation referral. Often, newer FECA injury cases will have received medical rehabilitation services facilitated by the contracted DFEC Field Nurse (FN) prior to the referral for vocational rehabilitation. Records related to these services will be available to the Rehabilitation Counselor (RC).

c. Dual track cases. Medical rehabilitation may also be provided for "dual track" cases in which the DFEC FN and RC work together to identify work tolerance limitations in the interest of expediting the IW's return to work (See Part 6, Paragraph 12, of this handbook). In such cases, the FN will focus on the medical aspects of the case while the RC focuses on the vocational aspects which may include scheduling and facilitating FCEs, work hardening or other needed services while beginning the groundwork for the development of a return to work plan with or without the employing agency. Once the IW has stable and well-defined work restrictions, nurse intervention will usually cease while the RC will normally be directed to continue the vocational rehabilitation effort.

d. During the life of a case. In addition, medical rehabilitation services may be identified as needed by the RC, CE or RS at any stage in the life of a case when these services may assist to establish or enhance the IW's ability to function independently and/or return to work.

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4. Examples of Medical Rehabilitation Services.

a. Limited referral or during early vocational rehabilitation. As the sole goal of a limited referral or in the early stages of the vocational rehabilitation effort, the case may be placed in medical rehabilitation status when:

(1) There is an expectation of a work release or lessening of restrictions at the end of the proposed service, e.g. a physician may indicate that the IW should participate in a pain management clinic to reach a higher level of functioning so that he or she can return to work

(2) An FCE is needed so that the physician can have an objective basis for providing work restrictions

(3) A work hardening program will help the IW adjust to the physical demands of a specific job or a general return to work

(4) A short-term course of counseling would be beneficial to address adjustment to disability or return to work

(5) A prosthetic or assistive device is needed to increase the IW's level of independent functioning and/or assist in a return to work; medical rehabilitation status may be used during the time period in which the IW is evaluated and the RC obtains the recommended equipment

(6) A recommendation for evaluation, repair or replacement of a wheelchair or other ambulatory device is needed

(7) Modifications may be needed for a vehicle or home to increase the IW's level of independent functioning and/or enhance return to work efforts

b. Once vocational services are underway. Further into the life of a rehab case, medical rehabilitation may be needed when:

(1) Work restrictions need to be reestablished or altered after return to work services are underway

(2) The IW experiences a recurrence (a change or worsening) of the work-related condition which affects work abilities. This would need to be documented by the attending physician and approved by the CE.

(3) Substance abuse/addiction prevents an IW from participating successfully in a rehabilitation plan and/or returning to work

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5. Settings. There are a very few IWs with catastrophic injuries who receive medical rehabilitation in a hospital setting. When an IW with a severe traumatic brain injury or a spinal injury resulting in quadriplegia is referred to a specialized facility for additional rehabilitation, an RC may be assigned when the IW returns home to facilitate further rehabilitation efforts. However, most injuries are not catastrophic in nature. Most IWs (even in certain catastrophic cases) are appropriately served on an outpatient basis in the local community.

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6. Period of Services. Depending on the type of, and reason for, medical rehabilitation, most services are generally completed within a matter of days to several weeks. Any proposed therapy or treatment should generally not be expected to extend beyond six months.

Specific information regarding FCEs, ORPs and substance abuse are provided in Paragraph 13 below.

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7. Nonwork-related injuries or conditions. DFEC is not responsible for medical costs associated with the diagnosis or treatment of conditions unrelated to the accepted work injury. As such, problems resulting from nonwork-related injuries or disabilities cannot be the focus of DFEC sponsored medical rehabilitation, with very few exceptions (e.g. weight loss programs, substance abuse treatment, or assistive device/technology necessary to facilitate reemployment). The RC can, however, encourage the IW to seek treatment of these conditions on his/her own – particularly if they impact the ability to work – and may also assist in identifying alternate resources for treatment.

If such a nonwork-related condition will impact the return to work efforts, the RC may ask the IW to release medical reports for reference purposes and to assist in the rehabilitation planning process. The RC should discuss the medical impact with the RS and/or CE and proceed as directed.

Note - There are situations where an accepted employment injury may temporarily or permanently aggravate pre-existing medical conditions. An example of that would be where an IW's pre-existing diabetes is aggravated by the accepted condition or by a medication prescribed for an accepted condition. As another example, an IW's accepted ankle condition may cause a consequential back condition because of an antalgic gait.

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8. Referral Process.

a. Referral generated by RS or CE. When a referral for medical rehabilitation is generated by the RS or CE in the beginning of vocational rehabilitation services, the RC will receive the Referral and Award Letter, Form OWCP-35, and the usual supporting documentation (see Part 3 of this handbook). The RS may also send the Rehabilitation Status Report, Form OWCP-3, with any specific or additional instructions.

The RS will direct the RC as to whether there is a need for the submission of a Form OWCP-16, Rehab Plan and Award, and/or a rehabilitation memo identifying the type and length of medical rehabilitation service, provider and cost. A Vendor Rehabilitation Authorization, Form OWCP-24 or equivalent, must be submitted for any treating professional or facility providing medical rehabilitation services. In addition, the RC must include appropriate billing codes as provided by the RS.

b. Referral generated by RC. When/if a need for medical rehabilitation services is identified by the RC, at the time of referral or during the course of vocational rehabilitation, the RC should contact the RS promptly to discuss the issue and, if appropriate, submit the Rehabilitation Action Report, Form OWCP–44. The RS will need to confer with the CE to determine whether the service may be approved.

If approved, the RS will authorize the service on a Rehabilitation Status Report, Form OWCP-3, and forward to the RC and IW. The form will advise the RC of the length of time and number of professional hours authorized for coordination and support of the medical rehabilitation service. The RC and IW may not proceed with services without this authorization. The RC will need to submit the Vendor Authorization, Form OWCP-24.

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9. Monitoring and Documentation.

a. Monitoring. RCs should closely monitor all medical rehabilitation services throughout the course of evaluation and/or treatment. Regular contact with both the IW and treating professionals should occur within the number of professional hours authorized. If additional calendar time or hours are needed to complete or monitor the medical rehabilitation service, the RC should advise the RS via telephone or email and, if appropriate, via the Rehabilitation Action Report, Form OWCP-44, providing justification for the request. The RS should authorize, decline or discuss modification, as necessary. The RC should not proceed until appropriate authorization has been obtained.

b. RC Documentation. The RC should document information regarding the status of the medical rehabilitation service in the monthly rehabilitation progress reports or more often, as appropriate, or as requested by the RS.

c. Facility Documentation. The treating facility or practitioner must provide reports to the RC related to treatment and outcomes. The RC must forward these to the OWCP district office promptly upon receipt for placement into the case file. Reports should include the following elements, as necessary, in relation to the type of services provided:

(1) Evaluation and treatment activities.

(2) Results, including positive or negative changes that have occurred during the course of the medical rehabilitation service.

(3) Information regarding the IW's attendance, efforts, attitude and general condition.

(4) Specific information on the vocational and functional status of the IW and relationship to the targeted job and/or fitness for return to work.

(5) Any issues related to work site safety, accommodations, ergonomics, transportation, etc.

(6) Any additional relevant information, such as recommendations for maintenance of work capacity, improvement in functional status, considerations for alternative occupations, and need for continued monitoring and support.

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10. Problems or Non-Compliance. Any problems or changes in the planned medical rehabilitation services, issues related to IW non-compliance, or medical concerns should be brought to the attention of the RS immediately, via telephone or email communication and, if appropriate, via the Rehabilitation Action Report, Form OWCP-44. The RC should follow the guidance of the RS and CE in addressing these matters.

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11. Possible Outcomes of Medical Rehabilitation. Ideally, medical rehabilitation services will lead to established work restrictions and/or improved employability which may result in subsequent activities toward placement with the previous employer or vocational plan development leading to placement with a new employer.

a. For new or dual track cases. Information obtained during the course of an FCE or other evaluative service is often used by the IW's physician and DFEC staff to determine whether the IW has the ability to return to work and, if so, to clarify work restrictions and the need for any additional medical rehabilitation services. With the guidance of the RS, this information may be used by the RC in the process of evaluation and plan development if it is determined that the return to work effort is to continue.

b. For vocational rehabilitation plans in process. If medical rehabilitation occurred during the course of an ongoing vocational plan, the work restrictions or outcomes should be reviewed to see if they coincide with the current reemployment effort.

(1) Restrictions not significantly different. If any new work restrictions or recommendations are not significantly different and the targeted jobs remain suitable, then the RC will most often be directed to proceed with the previous reemployment effort.

(2) Restrictions have changed. If the work restrictions or recommendations have changed and the reemployment effort that was in place is no longer viable, then a new period of plan development may be approved by the RS in order to identify employment goals consistent with the new work restrictions or recommendations.

(3) No viable work restrictions. If the medical rehabilitation effort does not result in viable work restrictions or recommendations for further services in the return to work effort, the RC, RS and CE must discuss the situation to determine the appropriate course of action. It may be appropriate to temporarily interrupt vocational services for further evaluation or, in some circumstances, closure of the vocational services case may be appropriate. The RC should always follow the direction of the RS in these matters.

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12. Obstacles to Completion. Medical or other issues which could delay or terminate the medical/occupational rehabilitation program, such as the emergence of nonwork-related conditions, recurrences, complaints of high levels of pain, etc. must be reported immediately to the RS and CE. When the service is interrupted, the RC should notify the RS immediately and submit a Form OWCP-44, Rehabilitation Action Report, carefully detailing the reason(s) for the interruption. The RS will communicate this information to the CE in order to discuss and recommend an appropriate course of action based on the circumstances of the case.

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13. Specified Services. Certain medical rehabilitation services including Occupational Rehabilitation Programs, Functional Capacity Evaluations, substance abuse treatments, and home and/or vehicle modifications are subject to program specific provisions. These services may or may not require referral by a qualified physician depending on state or local practices.

Regardless of the type of vendor or professional performing the specified services, all results of these evaluations should be certified by a qualified physician. As such, the RS may direct the RC to obtain a current Form OWCP-5 (Work Capacity Evaluation) from a physician at the conclusion of the service(s) provided.

a. Occupational Rehabilitation Programs (ORP). ORPs are programs which are individualized and focused on return to work. They are designed to assess and/or maximize the work tolerances and capabilities of persons being served. These programs may include work hardening, physical or occupational therapy, functional capacity evaluations (FCEs), pain clinic treatment, mobility, ergonomic or assistive technology evaluations and services. ORPs may be provided in hospital settings, in private or public outpatient settings and, in some circumstances, in the work environment.

Unless otherwise directed, the benefits of ORP therapies are usually achieved in a maximum of 4 – 12 weeks. As such, plans for ORP services should generally not exceed that time frame.

Additional information regarding ORPs may be found in the DFEC Procedure Manual Part 2-0813.12b.

b. Functional Capacity Evaluation (FCE). An FCE is an assessment tool often utilized for those who have experienced an injury that may affect employment. The FCE, normally conducted by a physical therapist, evaluates and gathers information regarding an individual's physical abilities and levels of physical tolerance. Components of an FCE most often include an in-depth interview and/or questionnaire, real and/or simulated work or workstations to mimic the types of physical activities one may perform on the job and to measure physical demands such as lifting, pushing/pulling, squatting, reaching, endurance activities, walking, standing and any other work-specific activities. The information may be used to clarify work tolerances and restrictions and determine whether or not one can return to previous job duties or perform the demands of other occupations.

The information obtained in an FCE may also be used to determine whether there is a need for further medical rehabilitation services and/or whether accommodations may be needed to return to work safely.

FCEs are normally performed in a matter of days to one or two weeks maximum. Any exceptions to this should be discussed with the RS.

c. Substance Abuse Treatment. In some circumstances, DFEC will consider medical services for IWs who are in need of treatment for addiction to alcohol or drugs (legal or illegal), particularly where the addiction is impeding a return to work. In these instances, pain management clinics or drug and alcohol treatment facilities may address these issues and help the IW to become work ready.

(1) Referral process. If the need for such treatment is identified, the RS may forward a referral to the RC requesting facilitation of this service. Or, if the RC believes that an IW involved in plan development or in an approved program is unable to continue due to addiction, the RC should contact the RS immediately and, if appropriate, submit a Rehabilitation Action Report, Form OWCP 44, to discuss the issue and determine appropriate action. The RS will need to confer with the CE to determine whether the service will be approved. If approved, the RC will receive authorization on the Rehabilitation Status Report, Form OWCP-3.

(2) Treatment location and length. Substance abuse treatment is normally provided at a facility in the IW's local community, based on the RC's research and recommendation, and usually for a period not to exceed 28 days.

(3) IW informed consent and/or non-cooperation. The IW must cooperate with authorized substance abuse treatment programs. If the IW does not choose to cooperate, the return to work effort is negatively impacted. In these instances, the RC should contact the RS immediately and submit a Rehabilitation Action Report, Form OWCP 44, to discuss the issue and determine appropriate action.

(4) Monitoring and documentation. The RC should stay in contact with the IW as well as the attending physician and treatment facility staff throughout the course of treatment to monitor progress. This should be reported regularly to the RS on the monthly rehabilitation progress report or on a more frequent basis, as appropriate, or as requested by the RS. Progress and treatment reports from the treating facility should be obtained by the RC and forwarded to the OWCP district office regularly for placement into the case file.

(5) Completion of treatment. Once treatment has been completed, the RC and IW will most often be directed to promptly return to facilitation of plan development or the agreed upon rehabilitation plan. If the treatment program provided follow-up recommendations for the IW, the RC should continue to monitor.

d. Home and/or vehicle modifications. See Part 3 of this handbook and the FECA Procedure Manual 2-1800 for further information.

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