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Evaluation of Permanent Psychological Impairment

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					                             CONSULTATION PAPER

1.      TITLE

Evaluation of Permanent Psychological Impairment


2.      ISSUE

The adoption of a schedule and decision-making model for the assessment of
psychological impairment under section 23(1) of the Workers Compensation Act
(the "Act").


3.      BACKGROUND AND HOW THE ISSUE AROSE

This issue arose from concerns raised in the early 1990’s by the Office of the
Workers’ Advisers that the schedule used by the Workers’ Compensation Board
(the “Board”) for assessing psychological impairment under section 23(1) was not
publicly available; was not authorized by policy; and was out of date.


4.      LAW AND POLICY

Section 23(1) of the Act provides:

       Where permanent partial disability results from the injury, the
       impairment of earning capacity must be estimated from the nature and
       degree of the injury, and the compensation must be a periodic
       payment to the injured worker of a sum equal to 75% of the estimated
       loss of average earnings resulting from the impairment, and must be
       payable during the lifetime of the worker or in another manner the
       board determines.

Section 23(2) provides:

       The board may compile a rating schedule of percentages of
       impairment of earning capacity for specified injuries or mutilations
       which may be used as a guide in determining the compensation
       payable in permanent disability cases.

Pension awards for permanent partial disability under section 23(1) may be
scheduled or non-scheduled. Scheduled awards are made using the Permanent
Disability Evaluation Schedule (the "PDES") adopted by the Board under section
23(2) and set out in Appendix 4 of the Rehabilitation Services & Claims Manual




May 30, 2001                                                                  Page 1
(the "RS&CM"). If a disability or affected part of the body is not listed in the
PDES, the pension award is considered to be non-scheduled.


Policy item #39.50 of the RS&CM provides that as the PDES does not include
psychological disabilities, they are “non-scheduled” awards. Policy item #22.33
provides that reference may be made to the American Medical Association’s
Guides to the Evaluation of Permanent Impairment (the “AMA Guides”) to
determine the appropriate percentage of disability for psychological impairment.

Sometime prior to 1998, the Compensation Services Division (the “Division”)
developed and applied a Psychological Impairment Schedule (the “Modified
Schedule”) for the assessment of psychological impairment. The Modified
Schedule was based on the AMA Guides, 1st edition and the Diagnostic and
Statistical Manual of Mental Disorders, 3rd edition (the “DSM-III”).

In 1998, the Panel of Administrators (the "Panel") adopted, on an interim basis, a
new table of percentages of disability for psychological impairment (the
“Schedule”). It forms part of the PDES and supercedes the Modified Schedule.

This new Schedule, based on the 4th edition of the AMA Guides and the DSM-IV,
is found in Appendix A of this paper. 1 The Schedule sets out three categories
of impairment:
• Aphasia and Communication Disturbances;
• Disturbances of Mental Status and Integrative Functioning; and
• Emotional (Mental) and Behavioural Disturbances.

Under each category, the Schedule sets out four levels of severity. For each of
these levels, the Schedule then sets out the range of percentage of disability.
These percentages are the Board's estimate of the approximate impairment of
earning capacity of an average worker.

A comparison of the Modified Schedule and the new Schedule is found in
Appendix B. The differences between the two systems are further elaborated in
Appendix C.




1                                                                  nd
  At the time that the concerns were raised in 1992, there was a 2 edition of the AMA Guides
                                                rd  th      th
and a DSM-IIIR had been issued. Since then, 3 , 4 , and 5 editions of the AMA Guides were
issued as well as a DSM-IV, and a DSM-IV-TR all of which differ in certain respects from prior
                 th                                                                th
editions. The 5 edition of the AMA Guides is not significantly different from the 4 edition in the
context of this issue.


May 30, 2001                                                                                 Page 2
5.      INTERIM POLICY

A. Rationale

The new Schedule was adopted as an interim policy to provide an opportunity for
refinements to be made to the categories and the percentage ranges assigned to
them.

B. Psychological Disability Committee

In May of 1998, a Psychological Disability Committee was appointed by the Vice-
President of the Compensation Services Division. The Committee consists of the
Director, Psychology, a senior representative from Vocational Rehabilitation
Services, the Senior Disability Awards Medical Advisor, and a senior
representative from the Long Term Disability Department.

Pursuant to the 1998 Panel resolution, the Committee is authorized to make
decisions on the percentage of disability to be awarded to workers for permanent
psychological disability under section 23(1).

The 1998 resolution also authorized the Committee to collect and analyze data
on psychological disability claims. It directed the Committee to obtain
appropriate information and advice in order to make recommendations on certain
aspects of the new Schedule including:
(a)   the appropriateness of the categories of psychological disability
      recognized under the interim policy and whether those categories should
      be revised;
(b)   the guidelines to be used in applying the categories for psychological
      disability;
(c)   the appropriateness of the percentages or ranges of percentages of
      disability assigned to the categories of psychological disability under the
      interim policy and whether those percentages or ranges should be
      revised;
(d)   changes in the amount of compensation costs resulting from the interim
      policy and the likely costs resulting from any of the Committee's
      recommendations; and
(e)   such other incidental matters that the Committee considers appropriate.




May 30, 2001                                                                Page 3
6.      DISCUSSION

A.      The appropriateness of the categories of psychological disability
        recognized under the interim policy and whether those categories
        should be revised.

As already indicated, the new Schedule sets out three categories of impairment:
• Aphasia and Communication Disturbances;
• Disturbances of Mental Status and Integrative Functioning; and
• Emotional (Mental) and Behavioural Disturbances.

Under the old system, the categories of impairment in the Modified Schedule are
based on the 1st edition of the AMA Guides. The categories in the new Schedule
are based on the 4th edition of the AMA Guides. Under the new system, the
definitions of adaptability to stress and change/executive dysfunction, as well as
other clinical impairment definitions, are also based on the 4th edition.

Under the old system, the Modified Schedule distinguishes between organic and
non-organic mental disorders.2 Under organic mental disorders, the same three
categories of impairment are listed as are found in the new Schedule (i.e.
communication disturbances, integrative function disturbances, and emotional
disturbances). A separate percentage rating system is set out for non-organic
mental disorders under the categories of affective disorders (depression) and
anxiety disorders. Under the new Schedule, no distinction is made on whether
the cause of the impairment/disability is organic or non-organic. Rather, the
categories apply regardless of etiology.

Under the old system, the Modified Schedule has four levels of severity of
impairment for organic mental disorders and three for non-organic mental
disorders. Under the new Schedule, there are four levels of disability. These are
(a) mild, (b) moderate, (c) marked, and (d) extreme. In both schedules, the
levels relate to activities of daily living, social functioning, concentrating, and
adapting.

Support for use of the 4th edition of the Guides is found in the AMA Guides
themselves. The American Medical Association strongly discourages the use of
any but the most recent edition of the Guides because the information would not
be based on the most recent and up-to-date material.3 (It should be noted that
there is a more recent 5th edition. However, it provides no significant changes
from the 4th in the context of this issue.) Further, Board psychologists have a
professional obligation to apply the highest of professional standards including
the most current AMA Guides and diagnostic system (DSM-IV).

2
  Organic refers to conditions that arise from brain trauma and cause neuropsychological
problems (e.g. memory problems and executive function impairment). Non-organic conditions
are those reactive to trauma or injury (e.g. post traumatic stress disorder and depression).
3
  Page 1/5.


May 30, 2001                                                                              Page 4
B.      The appropriateness of the percentages or ranges of percentages of
        disability assigned to the categories of psychological disability
        under the interim policy and whether those percentages or ranges
        should be revised.

(i) Disability versus Impairment

In order to address the appropriateness of the percentages of disability, it is
important to understand the distinction between disability and impairment.

Section 23(1) directs that the "impairment of earning capacity must be estimated
from the nature and degree of the injury". Section 23(2) states that the Board
may compile a rating schedule of percentages of impairment of earning capacity
for specified injuries which may be used as a guide in determining the
compensation payable for permanent disability.

An award under section 23(1) is intended to represent a measure of loss in terms
of disability expected on average to result from a particular impairment.4 The
term disability relates to the effect of the impairment on earning capacity and
recognizes vocational impact.

The AMA Guides deal with impairment not disability. Impairment is defined in the
AMA Guides as, "the loss of, loss of use of, or derangement of any body part,
system or function. Permanent impairment ... is not likely to remit despite
medical treatment.”5 Impairment is assessed by medical means and is a medical
issue.

The 4th edition of the AMA Guides emphasizes that impairment percentages
derived according to the Guides criteria should not be used to make direct
estimates of disabilities.6 To address this concern, the new Schedule sets out
estimates of percentage of disability for given impairments. As a result, the new
Schedule is not merely a restatement of the percentages found in the AMA
Guides. Rather, an effort has been made to recognize vocational impact or
capacity.

Under the old system, the Modified Schedule listed percentages of impairment.
A psychologist would assess a worker's impairment and assign a percentage
rating using the Modified Schedule. A Disability Awards officer would then
assess the disability resulting from the impairment and assign a disability rating.


4
  This is to be distinguished from a section 23(3) award. Section 23(3) directs that where the
Board considers it more equitable, it may award compensation for permanent disability having
regard to the difference between what the worker was earning before the injury or is able to earn
in some suitable occupation after the injury. The award is intended to reflect the individual's loss
over the long term.
5
   Glossary.
6
   Page 1/4.


May 30, 2001                                                                                   Page 5
However, often the officer would merely adopt the psychologist's impairment
rating as the disability rating.

This past practice of adopting the impairment rating as the disability rating likely
resulted in low ratings. Indeed, some commentators have noted that the
impairment ratings in the AMA Guides may themselves be too low.7 For
instance, the 4th edition of the AMA Guides defines 95% to 100% impairment as
a state approaching death. A significant psychological impairment resulting in a
need for directed care and continued supervision is given an impairment rating of
30% to 49%. As a result, it has been observed that benefit systems relying
heavily on the impairment ratings in the AMA Guides “value some impairments at
inappropriately low levels”.8

The new Schedule uses the impairment ratings in the AMA Guides as a starting
point. However, it also factors in the vocational impact and the effect of the
impairment on earning capacity. Consequently, the ratings under the new
Schedule tend to be higher than those under the Modified Schedule, which did
not take such factors into consideration. Thus, while the Modified Schedule lists
levels of impairments from 0% to 95%, the new Schedule lists levels of disability
from 0% to 100%.

A rating of 100% disability under the new system is assigned to workers who are
totally unemployable. Under the old system, these workers would have been
rated between 60% and 85%, as the ceiling was set at 95% and 100% was a
comatose state. Thus, workers who were between 60% and 85% under the old
system are now usually or often 100%.

Under the new system, the role of the Claims Adjudicator Disability Awards has
changed. The Committee assigns the percentage of disability. The adjudicator
then determines whether to award either a functional or a loss of earnings
pension.9

The Committee considers that the new Schedule is consistent with a worldwide
trend to recognize psychological disability at par with physical disability; a shift
away from the traditional biomedical model solely used in the past by
compensation systems.




7
  E.A. Spieler et. al., “Recommendations to Guide Revision of the Guides to the Evaluation of
Permanent Impairment” (Jan. 26, 2000) 283 JAMA 519.
8
  Ibid at p. 521.
9
   A loss of earnings award is paid whenever the assessment produces a higher figure than a
functional award.


May 30, 2001                                                                               Page 6
(ii) Development of the Schedule

Historically, disability schedules have been criticized as having no scientific or
empirical validity. To address this, one approach would be to do a historical
study of all psychological impairments and their impact on earning capacity.10
Average disability percentages could then be established for each level of
impairment.

Such an approach was not considered feasible for the purposes of developing a
schedule on psychological impairment at the BC Board. Rather, the Board set
the new Schedule by allocating 100% disability that would clearly warrant such
an award in every case. The 100% disability cases under the new system are
those where a worker is considered to be totally unemployable. The percentages
up to 100% were then spread among the remaining levels. During the course of
the interim policy, the Committee used data from actual cases to refine the
Schedule and make recommendations on an empirical basis.

To this end, the Committee developed a database. Board psychologists were
trained in the application of the database to ensure standardization of
assessment procedures. Consistency of decisions was evaluated and
quantitative analysis was done. Ratings under the old system and the new
Schedule were compared.11

C.      The guidelines to be used in applying the categories for
        psychological disability.

Under the new system, the Committee follows psychological disability guidelines.
A decision-making model is one of the key components of the disability
guidelines, which are used along with the new Schedule to translate impairment
descriptions into disability ratings.

In developing its guidelines for assessing occupational disability, the Committee
first standardized a method of assessing permanent psychological impairment to
enhance inter-rater reliability in making the impairment determination. Inter-rater
reliability refers to consistency among Committee members rating the percentage
of disability and addresses the repeatability of results. Inter-rater reliability of the
Committee members was found to be high - the highest levels of agreement
having been found for 100% disability cases and 0% to 50% disability cases.

The Committee did a qualitative analysis of implicit decision-making criteria of the
Committee members. Implicit decision-making criteria are criteria actually used
by the decision-makers with or without full articulation of them. They analyzed
100% disability cases to identify patterns of psychological dysfunction and their

10
   Data was not readily available and the time required to do such a study made such an
approach impractical.
11
   The Committee’s findings in this regard are found below under paragraph E, “Other”.


May 30, 2001                                                                              Page 7
impact on work disability. They reviewed existing, pertinent decision-making
models with respect to their possible application to the development of guidelines
for the evaluation of psychological disability. This led to the identification of the
Ethnographic Decision-Making Model as a viable option for validation.
The Committee consulted with numerous international experts, scanned relevant
literature and then consulted with Dr. Kirk A. Beck, Ph.D., a specialist in the field,
to develop an interdisciplinary team decision-making model. His report
"Translating Psychological Impairment into Occupational Disability Ratings: A
Decision Making Model" is available upon request.

The model allows for the identification of implicit and explicit decision-making
criteria as part of a decision-making tree that can be objectively validated. This
replaces decisions that were formerly based on judgment alone.

Under the old system, a single psychologist assessed impairment and a single
Board officer assigned the disability rating. Under the new system, a committee
approach is used to assess disability. The Committee, composed of a clinical
psychology expert, a medical expert, a vocational expert, and a disability
awards/compensation specialist, use the disability guidelines, the decision-
making model, and the Schedule to arrive at an assessment of disability. The
process followed is found in Appendix D.


D.      Changes in the amount of compensation costs resulting from the
        interim policy and the likely costs resulting from any of the
        Committee's recommendations.

While some preliminary costing has been done, several limitations have been
identified including difficulties in obtaining historical pension costs for individual
workers. For example, due to the design of the Board’s pension system, it has
been difficult to capture the majority of claims where a permanent psychological
impairment award under the old system has been granted since most claims are
coded by injury or disease type and not by any consequent psychological
impairment. Thus, further analysis is currently being undertaken using the
Psychology Department’s database. This will include comparisons with the
overall population of claims.


E.      Other

Committee Findings and Recommendations

Over the course of the application of the new Schedule for the evaluation of
psychological impairment, the Committee made the following findings and
recommendations:




May 30, 2001                                                                      Page 8
The Committee found that the four levels of severity of impairment of earning
capacity (mild, moderate, severe, and extreme), lend themselves to relatively
easy discrimination and identification by Committee members. Consistency of
Committee member ratings within levels of impairment is high.

The Committee reports that the interdisciplinary team decision-making model is
optimal for psychological disability determinations for the following reasons:
• Its makeup provides a wide knowledge base in clinical psychology, medicine,
   vocational rehabilitation, and compensation.
• The model eliminates potential biases and provides improved fairness and
   objectivity in the process.
• The model characterizes a high level of consistency and inter-rater reliability.

Notwithstanding, the Committee found that the guidelines should not constrain
the judgment of the Committee where an atypical or unusual case is presented.
In all cases, discretion should be allowed in the decision-making process, given
the complex and dynamic nature of psychological disability evaluation.

The Committee supports the use of a schedule that has one integrated rating
system for all psychological conditions including those of organic and non-
organic origin. Though traditionally, these types of impairment were assessed
separately by clinicians and outlined in different sections of the AMA Guides, the
Committee feels that there is no scientific, clinical, or administrative reason to
maintain separate disability determination paths for them. The Committee
reports that functionally, the effects of these impairments are inseparable and
one functionally based system for their determination is most appropriate. For
example, the functional effects of depression arising from brain trauma and
depression arising from the trauma of amputation and limb loss are measured
the same way. The etiology or origin of the conditions becomes of secondary
importance for disability determination purposes.

With respect to the actual percentages of disability, based on its empirical
research of the data collected over the course of the interim policy, the
Committee is recommending alterations under each of the categories of
impairment found in the new Schedule as follows:

(a)   mild disability: 0-25%
(b)   moderate disability: 30-70%
(c)   marked disability: 75-95%
(d)   extreme disability: 100%

The Committee considers that these changes to the new Schedule are minor and
consistent with the application of the new Schedule. They will keep the
categories consistent with the highest number of cases in specific categories.




May 30, 2001                                                                   Page 9
The Committee is also recommending that disability ratings be made in 5%
increments due to the unreliability of more refined discriminations.


7.      OTHER CANADIAN JURISDICTIONS

Comparisons with other boards and commissions must be approached with
caution as most jurisdictions have adopted a different pension scheme from that
in BC. Many jurisdictions award a lump sum amount based upon the degree of
impairment, rather than disability. These lump sum payments may be combined
with a further award to compensate for economic loss.

Most jurisdictions compensate for a permanent psychological impairment.
However, a majority of boards and commissions distinguish between organic and
non-organic psychological impairments in calculating benefits.12 A maximum
award of 100% is possible for a permanent psychological impairment in many
jurisdictions. But some boards and commissions, such as the Yukon board, will
award 100% only in cases “approaching death”.

Several jurisdictions rely upon early editions of the AMA Guides in assessing a
psychological impairment. These may be used in combination with rating
schedules developed by individual boards or commissions. For example, Nova
Scotia uses chapter 14 of the AMA Guides 4th edition to determine the existence
and degree of a worker’s permanent impairment due to compensable mental or
behavioural disorders. However, as a rating schedule is not contained in chapter
14, the board relies on a rating scale based on the 2nd edition of the AMA Guides.


8.      ROYAL COMMISSION

The most recent Royal Commission did not specifically address issues around
the Schedule but did say:

        A comprehensive review of policies, procedures and practices in
        compensation services as they relate to psychological impairment and
        treatment would greatly assist to alleviate inconsistencies, improve service
        levels in both psychiatry and compensation services, and make practices
        understandable to the stakeholders and clients alike.13




12
   The following jurisdictions distinguish between organic and non-organic psychological
disorders: Alberta, Saskatchewan, Nova Scotia, Prince Edward Island, Newfoundland, the Yukon
and the Northwest Territories and Nunavut.
13
   Royal Commission on Workers’ Compensation in British Columbia, For the Common Good,
January 20, 1999, Volume I , Chapter 6, at p. 72.


May 30, 2001                                                                          Page 10
Overall, the commission recommended a new pension system. Such a system
would replace sections 23(1) and 23(2) of the Act.14 Instead, an award for non-
economic loss would be provided. Economic loss would be considered
separately.


9.       OPTIONS

Option 1 - Status Quo

Revert back to the old system of using a Modified Schedule based on a dated
version (the 1st edition) of the AMA Guides in assessing permanent psychological
impairment. Disability for psychological impairment would again be a non-
scheduled award.

The Committee would cease to be authorized to make decisions on the
percentage of disability to be awarded for permanent psychological disability
under section 23(1). Concerns around impairment ratings being used as
disability ratings would go unresolved, as would concerns about the use of the
Modified Schedule.

Option 2 - Adopt the interim policy as final policy

Adopt the table found in the interim resolution as part of the PDES. Decisions on
the percentage of disability to be awarded for permanent psychological disability
under section 23(1) would be made by a Committee using the Board’s disability
guidelines and the new Schedule without modification. Inter-rater reliability and
consistency in decision-making would be underscored.

Option 3 - Adopt a modified version of the interim policy

Adopt the table found in the interim resolution as part of the PDES, modified as
follows:

(a)   Mild disability: 0-25%
(b)   Moderate disability: 30-70%
(c)   Marked disability: 75-95%
(d)   Extreme disability: 100%

Decisions on the percentage of disability to be awarded for permanent
psychological disability under section 23(1) would be made by a Committee
using the modified new Schedule and the Board’s disability guidelines. Inter-
rater reliability and consistency would be underscored.



14
     Dissent by Commissioner Stoney.


May 30, 2001                                                                Page 11
10.     CONSULTATION

The Policy and Regulation Development Bureau would like your comments on
the issues discussed in this paper including comments on the options presented.

Please direct your response to Susan Nickerson-Graham by June 29, 2001,
including your name, organization, and address via:
www.worksafebc.com;
fax #604-279-7599;
e-mail address snickers@wcb.bc.ca; or
mail it to:   Susan Nickerson-Graham
              Policy Director
              Policy and Regulation Development Bureau
              Workers’ Compensation Board
              PO Box 5350 Station Terminal
              Vancouver BC V6B 5L5




May 30, 2001                                                              Page 12
                                     APPENDIX A


Psychological Disability

The categories and descriptions are based on the American Medical Association
Guides to the Evaluation of Permanent Impairment (4th Edition). The Board
follows the principles of assessment set forth in that publication in assessing
permanent psychological impairment.

113      Aphasia and Communication Disturbances                                %
(a)      Minimal disturbance in comprehension and production of              0-10%
         language symbols of daily living
(b)      Moderate disturbance in comprehension and production of             11-50%
         language symbols of daily living
(c)      Inability to comprehend language symbols. Production of             51-100%
         unintelligible or inappropriate language for daily activities
(d)      Complete inability to communicate or comprehend language             100%
         symbols

114      Disturbances of Mental Status and Integrative Functioning
(a)      Some impairment but ability remains to satisfactorily perform       0-25%
         most activities of daily living
(b)      Impairment necessitates direction and supervision of daily          26-100%
         living activities
(c)      Impairment necessitates directed care under continued                100%
         supervision and confinement in home or other facility
(d)      Individual is unable without supervision to care for                 100%
         self and be safe in any situation

115      Emotional (Mental) and Behavioural Disturbances
         The impairment levels below relate to activities of daily living,
         social functioning, concentration, and adaptation
(a)      Mild - impairment levels are compatible with most useful            0-25%
         functioning
(b)      Moderate - impairment levels are compatible with some, but          26-75%
         not all useful functioning
(c)      Marked - impairment levels significantly impede useful              76-100%
         functioning
(d)      Extreme - impairment levels preclude most useful functioning         100%




May 30, 2001                                                                   Page 13
                                          APPENDIX B

        Old System “Modified Schedule”                             New System “Schedule”
     Category            Description   Percentage      Category           Description       Percentage

                     Class 1           0-15%                           Minimal              0-10%
                                                                       disturbance
Communication                                       Aphasia and
Disturbances         Class 2           20-45%       Communication      Moderate             11-50%
                                                    Disturbances
                     Class 3           50-85%                          Marked inability     51-100%
                     Class 4           95%                             Complete inability   100%
                     Class 1           5-15%                           Mild impairment      0-25%
                                                    Disturbances of
Complex Integrated   Class 2           20-45%                          Moderate             26-100%
                                                    Mental Status
Cerebral Function
                     Class 3           50-85%       And Integrative    Marked               100%
Disturbances
                                                    Functioning
                     Class 4           95%                             Extreme              100%
                     Class 1           5-15%        Emotional          Mild                 0-25%
                                                    (Mental) and
Emotional
                                                    Behavioural
Disturbances
                                                    Disturbances
                     Class 2           20-45%                          Moderate             26-75%
                     Class 3           50-85%                          Marked               76-100%
                     Class 4           95%                             Extreme              100%
                     Affective
                     Disorders
Non-Organic
Mental Disorders     •     Class 1     0-5%
                     •     Class 2     10-45%
                     •     Class 3     50-95%
                     Anxiety
                     Disorders
                     •     Class 1     0-5%
                     •     Class 2     10-45%
                     •     Class 3     50-95%




May 30, 2001                                                                                   Page 14
                                 APPENDIX C

               Old System                              New System
1. Based on first edition of the AMA      1. Modelled after the 4th edition of the
   Guides                                    AMA Guides, with different
                                             impairment categories
2. Ceiling of 85% for workers who are     2. Ceiling of 100% for workers who
   totally unemployable (with a 100%         are totally unemployable (therefore
   award for workers in a comatose           easier to get 100% and high level
   state)                                    awards given this downward shift)
3. The impairment rating assigned by      3. Impairment rating assigned by the
   the psychologists was accepted by         psychologists are reviewed to
   Disability Awards as the actual           identify the impact psychological
   disability rating                         impairment has on work capacity
4. Rating by a single person              4. Rating by an interdisciplinary
   (psychologist)                            committee
5. Did not require psychologists to       5. Requires psychologists to focus on
   focus on vocational aspects of            vocational aspects of impairment
   impairment
6. Likely underestimation of the actual   6. Vocational impact of psychological
   impact of psychological injuries on       impairment is better recognized.
   work capacity (traditional                This is consistent with the world-
   biomedical model solely used in the       wide trend to recognize
   past by compensation systems)             psychological disability at par with
                                             physical disability
                                          7. The growing numbers of permanent
                                             psychological disabilities may
                                             indicate systemic change in
                                             acceptability of psychological
                                             disabilities at WCB (with improved
                                             recognition of severity of impairment
                                             among compensation services’
                                             staff)




May 30, 2001                                                                  Page 15
                                         APPENDIX D

Permanent Psychological Disability Assessment

Overview of the Process:
i.      A complete psychological and neuropsychological assessment is
        completed by either the Board’s Psychology Department or an external
        consultant. This assessment determines the scope and severity of the
        psychological impairment according to the Board’s current Clinical
        Guidelines for the Evaluation of Psychological Impairment. The
        Guidelines are based on the most recent edition of the American Medical
        Association’s Guides for the Evaluation of Permanent Medical Impairment
        and any updates and revisions thereof.

ii.     The worker’s entire claim file, with the up-to-date psychological and
        neuropsychological assessment and a determination of permanent
        psychological impairment, are submitted to the Committee for review and
        consideration.

iii.    The Committee meets once a month to review submissions and
        determines the percentage of permanent psychological disability arising
        from a work injury or occupational disease.

iv.     The Committee forwards its decision, to the Disability Awards Claims
        Adjudicator responsible for the claim for further determination, if any, of
        either a functional impairment award or a loss of earnings award.

Decision-Making Criteria Used by the Committee

The following are considered by the Committee in the determination of
permanent psychological disability:
i.      Are there symptoms of a diagnosable psychological impairment?
ii.     Is there a pre-existing psychological impairment?
iii.    Is there a portion of the psychological impairment arising from a work
        injury?
iv.     Does the psychological impairment affect current work/vocational
        capacity?15
v.      Is the worker capable of returning to pre-injury employment?


15
   Vocational capacity is understood as the worker’s ability to perform the tasks associated with
those occupations that match his or her educational and occupational background and
transferable skills, in the absence of work-related neuropsychological or psychological
impairments.


May 30, 2001                                                                                Page 16
vi.     Is there a significant risk of deterioration and/or of residual symptoms after
        return to work?
vii.    Can a job change attenuate or eliminate the psychological impairment?
viii.   Does the person have the capacity to perform a job in a competitive
        environment?
ix.     Is the person able or expected to adapt adequately, with or without job
        accommodation, despite the psychological impairment?
x.      Does the psychological impairment significantly interfere with the person’s
        ability to perform most activities of daily functioning?
xi.     Is there a significant lack of adaptability to change and stress and/or
        significant executive dysfunction?16
xii.    Is the person totally dependent on others for daily living?

Application of the Decision-Making Model

The following process of the Committee is based on the decision-making criteria
and the associated disability percentages.

i.      A determination is made that there is no disability unless there are
        symptoms of psychological impairment along with a DSM-IV diagnosis.

ii.     A determination is made whether the presenting symptoms are the direct
        result of a work-related injury or whether there is a pre-existing
        psychological impairment.

iii.    A determination is made on the portion of the psychological impairment
        that is compensable where pre-existing psychological impairment is
        demonstrated. If the psychological impairment is attributed entirely to a
        pre-existing psychological impairment, there is no disability rating (0%).

Iv.     A determination is made on the extent that the psychological impairment
        affects current vocational capacity. The Committee considers the portion
        of the impairment attributed to a work-related injury. If the psychological
        impairment does not affect current vocational capacity, no award is
        granted (0%).

v.      A determination is made of whether the worker is able to return to his/her
        pre-injury employment when the psychological impairment impacts current
        work capacity. If the worker is able to return to their pre-existing
        employment, an award in the 5% range (mild disability) is offered.

16
  The definitions of adaptability to stress and change/executive dysfunction, as with other clinical
impairment definitions, are based on the American Medical Association’s Guides for the
Evaluation of Permanent Impairment.


May 30, 2001                                                                                 Page 17
vi.     If it is highly likely that the worker’s impairment may worsen or he/she
        presents with residual symptoms of mental disorder, then a higher award
        may be offered.

vii.    If the worker is unable to return to his/her pre-injury employment, then a
        vocational change is considered. A worker is awarded a rating in the 5%
        range (mild) for psychological disability, if a vocational change can
        eliminate or attenuate the psychological impairment.

viii.   If a vocational change does not eliminate or ease the psychological
        impairment, a determination is made of whether the person has residual
        vocational capacity in a competitive employment environment. A worker
        who has residual vocational capacity and is expected to/currently be able
        to work (with or without job accommodation) is awarded a rating in the
        25% range (higher end of mild range).

ix.     If the worker’s residual vocational capacity is seriously compromised, a
        determination must be made of whether the psychological impairment
        significantly interferes with the person’s ability to perform most activities of
        daily living.

x.      If the worker, who otherwise has no capacity to work in a competitive
        environment, has residual ability to adapt to change and his/her executive
        functions are not significantly compromised, then a rating in the 50%
        range (moderate) is recommended.

xi.     If the worker is not totally, but partly dependent on others for daily living
        activities, the recommended rating is considered marked (75%-80%
        range, or more).

xii.    If the worker is unable to perform most activities of daily functioning and is
        totally dependent on others or requires constant/regular supervision for
        daily living, then there is an award of 100% for occupational disability
        (extreme disability).

xiii.   Significant impairment in executive functioning and/or lack of adaptability
        to change and stress combined with dependency on others results in
        100% (extreme) disability.

Note:
Pain Disorder, with or without psychological factors, is not considered to be a
mental disorder and as such is rated according to the Board's existing policies on
chronic pain (Policy item #39.01 of the RS&CM, "Subjective Complaints").


May 30, 2001                                                                      Page 18

				
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