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					Vocational Medical
    Assessors



               Contract



 Operational Guidelines

                        October 2008



  This is a living document and will be updated as required.
                        Vocational Medical Assessors – Operational Guidelines



Contents
Introduction .......................................................................................................... 1
  Role of ACC ....................................................................................................... 1
  Purpose of the guidelines..................................................................................... 1
  Injury and non-injury considerations..................................................................... 1
  Definition of rehabilitation ................................................................................... 2
  Individual rehabilitation plan (IRP)........................................................................ 2
  Discussing recommendations with the client .......................................................... 3


About Vocational Rehabilitation ............................................................................... 3
  Purpose of vocational rehabilitation....................................................................... 3
  Qualifications required for Occupational Assessors .................................................. 4
  Qualifications required for Medical Assessors .......................................................... 4
  Key terms used in vocational rehabilitation ............................................................ 5


The Initial Assessments (IOA and IMA) .................................................................... 7
  Initial Occupational Assessment (IOA) ................................................................... 7
  Initial Medical Assessment (IMA) .......................................................................... 7


Reporting on the Initial Assessments (IOA and IMA) .................................................. 8
  Initial Occupational Assessment (IOA) Report ........................................................ 8
  Initial Medical Assessment (IMA) Report ................................................................ 9


The Vocational Independence Assessments (VIOA and VIMA) .................................... 10
  Vocational Independence Occupational Assessment (VIOA) ................................... 10
  Vocational Independence Medical Assessment (VIMA) ........................................... 10


Reporting on the Vocational Independence Assessments (VIOA and VIMA) ................. 11
  Vocational Independence Occupational Assessment (VIOA) Report ......................... 11
  Vocational Independence Medical Assessment (VIMA) Report ................................. 12
  Medical report quality check by Branch Medical Advisor ......................................... 12


The Steps in the Medical Assessment Process.......................................................... 13
  Step 1 – Background information from ACC ......................................................... 13
  Step 2 – Clinical examination ............................................................................. 14
  Step 3 – The medical report............................................................................... 14
  Step 4 – Recommendations ............................................................................... 14


Appendices ......................................................................................................... 16
  Appendix 1: Relevant Legislation ........................................................................ 16
  Appendix 2: Vocational Services ......................................................................... 22



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                   Vocational Medical Assessors – Operational Guidelines


Appendix 3: Vocational Paths ............................................................................. 27
    Maintain employment ................................................................................... 27
    Obtain employment ...................................................................................... 28
    Regain or acquire vocational independence ..................................................... 29
Appendix 4: Example - Initial Medical Assessment Report ...................................... 31
Appendix 5: Example - Vocational Independence Medical Assessment ..................... 39
Appendix 6: Example - Work Type Detail Sheet .................................................... 46
Appendix 7: US Department of Labor Physical Demand Characteristics of Work ........ 47
Appendix 8: Frequently Asked Questions (FAQs) .................................................. 48
Appendix 9: Flowchart of Client Participation in Vocational Rehabilitation ................. 50




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                  Vocational Medical Assessors – Operational Guidelines



Introduction

Welcome to the Vocational Medical Assessors‘ Operational Guidelines. This document
gives information on carrying out initial and vocational independence medical
assessments for the vocational rehabilitation programme.


It is designed to help ACC-contracted medical assessors:
   Assess a client‘s capacity for vocational rehabilitation, including recommendations for
    further treatment or rehabilitation, or
   Assess whether ACC has completed vocational and medical rehabilitation and the
    client has the capacity to work.


Role of ACC

ACC is responsible for determining clients‘ eligibility and entitlements in a fast effective
way to help them achieve maximum independence. ACC may not take into account the
age limits for weekly compensation when deciding whether vocational rehabilitation will
be cost effective. All applications for vocational rehabilitation beyond three years and
beyond 65 years of age are considered on their merit. Applications for vocational
rehabilitation longer than three years are initially received by client service staff who will
then complete a submission for consideration by the Team Manager/Branch Manager.
The application is then referred to the Customer Service Technical Support Team for
consideration and they will make a recommendation which will be sent back to the client
service staff member.


Purpose of the guidelines

The purpose of the guidelines is to:
   Achieve consistency in the approach to assessments and report writing
   Provide information to assessors about ACC‘s rehabilitation model and legislative
    framework.


Injury and non-injury considerations

In preparing the IMA and VIMA report the medical assessor must take into account any
condition suffered by the client that is not related to their personal injury. This means
that the IRP can be prepared taking into account any non-injury factors. Thus the
question of medical sustainability must reference any non-injury factors present.


However, it may be that the non-injury factors that were taken into account at the IMA,
and considered when developing the IRP, have changed during the course of
rehabilitation. It could also be that new non-injury conditions have developed since the
IMA was completed. In this case the IRP would be amended. Assessors completing the
VIMA need to reference this specifically when commenting on the client‘s capacity to
undertake work.




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                   Vocational Medical Assessors – Operational Guidelines


Definition of rehabilitation

   The focus of this guideline is vocational rehabilitation.
   Other rehabilitation consists of treatment, social rehabilitation, and assorted ancillary
    services such as transport.


Treatment includes:              Social rehabilitation          Ancillary services
                                 includes:                      include:

 Physical rehabilitation         Communication                 Transport to and from
 Cognitive rehabilitation        Home help, child care          rehabilitation
                                   and attendant care             appointments
 An examination for the
  purpose of providing a          Aids and appliances, eg.      Support people
  certificate to ACC (such as      wheelchairs and walking
  a medical certificate for        frames
  time off work).                 Educational participation
 ACC funds the provision of      Training for independence
  treatment through:               programmes
 Reimbursing treatment           Financial management
  providers for their
  treatment consultations         Health care
  and procedures, according       Hygiene care
  to the Accident Insurance       Mobility
  (Insurer‘s Liability to Pay
  Costs of Treatment)             Motivation
  Regulations 1999                Safety management
 Providing bulk funding to       Sexuality
  the Crown for emergency         Cognitive tasks of daily
  department, acute                living
  inpatient and follow-up
  medical outpatient services     Modifications to the home
                                   or personal transport.
 Buying treatment services
  (such as elective surgery)     Social rehabilitation helps
  under contract                 clients regain as much pre-
                                 injury independence as
 Paying for pharmaceuticals     possible in everyday life
  prescribed for ACC covered     skills.
  injuries.


Rehabilitation aims to help restore to the maximum practicable extent a client‘s health,
independence, and participation.


Individual rehabilitation plan (IRP)

All clients are required to have an IRP completed if they are likely to need social or
vocational rehabilitation for 13 weeks or more following an injury. These plans are
negotiated with the client and may include input from employers and the client‘s doctor
and family. Included in these plans are:
   Planned assessments.
   Outcomes for treatment, social, and vocational rehabilitation.



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These plans are signed by both the client and ACC‘s client service staff. Vocational
assessments by either the occupational or medical assessor can be included in the plans
as well as the agreed rehabilitation that will be arranged for the clients. The assessments
are vital to setting goals and planning rehabilitation. IRPs are updated when necessary
and form an important agreement between ACC and clients.


Discussing recommendations with the client

The assessment procedure must follow the principles of natural justice. One of these
principles is the client‘s right to a fair hearing. A client may have a support person
present during their assessment. Clients also occasionally request a tape recording of the
session. Clients should arrange this with the assessor prior to the assessment. In these
cases the medical assessor may also arrange to either retain a copy of the tape or also
record the session.


Client comments
When the assessor has completed the clinical examination component, they should
discuss their findings and the recommendations they are considering with the client and
ask them for their comments. It is important that the client has the opportunity to
discuss any issues they have concerning their injury and the occupations. Client
comments must be included for each work type.


Note:
The AC Act requires a copy of the assessment to be given to the client by their client
service staff member.



About Vocational Rehabilitation

Purpose of vocational rehabilitation

Vocational rehabilitation is designed to help a client:
   Maintain or obtain employment, or
   Regain or acquire vocational independence.
See also Part 4 section 80 of the AC Act for the scope of vocational rehabilitation.


If a client needs vocational rehabilitation ACC will provide the entitlements and
interventions, and support the client in their employment or their ability to become
employed which will help them earn an income and so contribute to an appropriate
quality of life for them. The employment must be:
   Suitable for the client (in terms of their capacity to function)
   Appropriate for the client‘s levels of training, experience, and qualifications.


In practical terms, ACC gives comprehensive vocational rehabilitation services that:
   Focus on the client‘s needs.
   Address any injury-related barriers to the client‘s independence that prevent their
    participation in work environments.



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Additional information for providers is contained on ACC‘s website www.acc.co.nz and
covers information about injury prevention, levies & cover, and claims.


Vocational assessments are required by ACC:
   Whenever a client is deemed to need vocational rehabilitation as described as
    required (Part 4, section 89, AC Act).
   Where new employment or vocational independence is being considered.


Qualifications required for Occupational Assessors

Section 90 of the AC Act states: ―An occupational assessment must be undertaken by an
assessor whom the Corporation considers has the appropriate qualifications and
experience to do the assessment required in the particular case.‖


Each approved assessor must have:
   A tertiary qualification relevant to vocational rehabilitation (eg. occupational therapy,
    rehabilitation, psychology, career counselling, social work, human resource
    management).
   At least two years‘ relevant experience in providing vocational rehabilitation services,
    with demonstrated excellence in service provision and an ability to work effectively
    with ACC.
   Current full membership of a relevant professional association (eg New Zealand
    Association of Occupational Therapists, Career Practitioners Association of New
    Zealand, or New Zealand Society of Physiotherapists).


Qualifications required for Medical Assessors

Sections 93-94 of the AC Act set out the required qualifications of medical assessors:


93. Medical assessor
(1) A medical assessment must be undertaken by a medical practitioner who is
described in subsection (2) or subsection (3).
(2) A medical practitioner who provides general medical services must also—
    (a) have an interest, and proven work experience, in disability management in the
    workplace or in occupational rehabilitation; and
    (b) have at least 5 years' experience in general practice; and
    (c) meet at least 1 of the following criteria:
       (i) be a Fellow of the Royal New Zealand College of General Practitioners or hold
       an equivalent qualification:
       (ii) be undertaking training towards becoming a Fellow of the Royal New Zealand
       College of General Practitioners or holding an equivalent qualification
       (iii) have undertaken relevant advanced training.
(3) A medical practitioner who does not provide general medical services must—
    (a) have an interest, and proven work experience, in disability management in the
    workplace or in occupational rehabilitation; and
    (b) be a member of a recognised college.]



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94. Assessments when medical assessor unavailable
(1) A… medical practitioner who does not qualify under section 93 may undertake a
    medical assessment if the Corporation is satisfied that—
   (a) the circumstances in subsection (2) exist; and
   (b) the… medical practitioner's qualifications and experience are broadly comparable
   with the qualifications and experience specified in section 93.
(2) The circumstances are that—
   (a) a… medical practitioner who does qualify under section 93 is not available to
   undertake a medical assessment without unreasonable delay or unreasonable
   inconvenience to the claimant; and
   (b) the delay or inconvenience would have an adverse effect on providing vocational
   rehabilitation to the claimant.
   (3) Sections 95 and 96 apply to a… medical practitioner who qualifies under this
   section to undertake a medical assessment.


Key terms used in vocational rehabilitation

Independence in employment
The purpose of vocational rehabilitation is to restore the client‘s independence in their
employment situation.


„Medically sustainable‟ ability to work
The concept of ‗medically sustainable‘ is used for the IMA and looks at whether any
identified type of work is medically sustainable, ie there are no medical or treatment
rehabilitation needs. It also asks if any type of work is likely to be medically
sustainable, ie that after appropriate medical or treatment rehabilitation the type of
work will become medically sustainable.


Medical assessors will report on medical evidence regarding a client‘s ability to engage in
work. This allows ACC to make a decision on vocational rehabilitation. Facts on
experience, education, or training are not medical, but occupational and ACC will get this
information from the occupational assessor Medical assessors must ensure they are
giving an opinion that can be medically supported.


   Example:
   A useful test in deciding whether an opinion is in fact a medical one is to put the
   question in a different way. This could be: if this client wanted to work in one of the
   types of work specified and came to you to ask advice as to whether you would
   provide them with medical clearance to do so, would you have a medical reason to
   advise them that they could not, or should not, do so?


Scope of vocational rehabilitation
See Purpose of vocational rehabilitation on pg 3.

Types of work
―Types of work‖ refers to a broad group of jobs and roles that have a common set of
work tasks and functions. For more information see Work type detail sheets in the IOA
report section on page 8, and Appendix 6 on page 46 for an example.



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Vocational assessments
There are two types of assessments in the vocational rehabilitation process: initial
assessments and vocational independence assessments.


    Initial assessments
    The initial assessment process is for all clients who cannot return to their pre-injury
    work and require vocational rehabilitation. It is split into two parts:
       An initial occupational assessment (IOA) to identify the types of work that may be
        appropriate for the client.
       An initial medical assessment (IMA) to determine whether the types of work
        identified in the IOA can be medically sustainable for the client.


    After these assessments the rehabilitation and treatment agreed to is included in the
    IRP. If the client‘s circumstances change (eg their medical status or their employer‘s
    willingness to help with their rehabilitation), the IRP is modified to reflect the change.


    The vocational rehabilitation plan in the IRP will meet the client‘s needs and address
    any injury-related barriers the client has to achieving independence in employment.


    Vocational independence assessments
    The vocational independence assessment process will show whether a client‘s
    rehabilitation has been completed and they are able to obtain/maintain employment
    or have achieved vocational independence. This assessment confirms that the client
    has been given comprehensive vocational rehabilitation assistance that has focused
    on addressing any injury-related barriers to their independence in employment. (See
    Appendix 1 on pg 16 for relevant legislation references.)


    Once the rehabilitation specified in a client‘s IRP has been completed, and if the client
    is receiving weekly compensation, two further assessments may be completed:
       The vocational independence occupational assessment (VIOA).
       The vocational independence medical assessment (VIMA).


    These assessments will ensure that vocational independence has been achieved.


Vocational independence
Vocational independence is achieved when a client has attained their rehabilitation
outcome, ie they can do the work they are trained, experienced, or educated in and they
can work for 35 hours per week or more.


Vocational paths
There are three paths to enable the client to return to work or work readiness (see Part 4
section 80 (1) of the AC Act, and Appendix 3 on pg 27). The paths can be noted in the
IRP, but this is not required. The three paths are:
   Maintain employment
   Obtain employment
   Regain or acquire vocational independence.




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The Initial Assessments (IOA and IMA)

Initial Occupational Assessment (IOA)

The purpose of the IOA is to:
   Assess the client‘s skills, experience and ability to undertake employment
   Identify suitable types of work for the client based on their education, experience,
    pre-incapacity earnings, and training
   Complete a work type detail sheet for each suitable work type.


Initial Medical Assessment (IMA)

Purpose of the IMA
The purpose of the IMA is to produce a report that ACC uses to determine the client‘s
vocational rehabilitation needs and direction. It requires the medical assessor to consider
the types of work that have been identified in the IOA and give an opinion on whether
any of the types of work are, or are likely to be, medically sustainable for the client.


The tasks on the work type detail sheet must be considered against the client‘s post-
injury condition, and the sheets used with the Department of Labor Physical Demand
Characteristics of Work (see Appendix 7 on page 47 for an example) which defines the
terms used by occupational assessors and includes the terms occasional, frequent, and
constant with the percentages of the workday, as well as physical demands such as
sedentary, light, medium, heavy, very heavy, and the typical energy required.


If the type of work is only likely to be sustainable, the report needs to show evidence of
the rehabilitation the client will need in order to carry out the identified type(s) of work.


Assessors to list their qualifications
As experts it is important that medical assessors specify their qualifications. This should
include all qualifications and experience relevant to the type of report they are writing. In
terms of the information considered and the history obtained, the assessor should:
   Identify the documents sent to them by ACC or other sources, eg the client
    Note:
    If the assessor needs more information from ACC, they should request this from the
    client service staff member who referred the client to them.
   Detail who attended the assessment, eg support person or lawyer and what input
    they had, if any
   Identify elements of the history given by, or obtained from, other parties
   Highlight any relevant inconsistencies in the history and information.


For the examination and clinical findings, medical assessors should:
   Document the time taken for the assessment
   Document all the aspects of the examination – it is easy to omit parts of the routine
    clinical examination, eg pertinent normal findings
   Describe all tests performed – detail reduces the potential for later dispute.



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When commenting on the types of work, medical assessors should:
   Comment on the adequacy or otherwise of information provided on the tasks involved
    in the types of work
   Focus on the generic aspects of the tasks
   Give reasons why a type of work is, or is not, medically sustainable – a simple list is
    not sufficient
   Tie the reasoning back to the examination findings, the comments and input of the
    client, and the information provided
   Include comments on the non-injury related conditions, and the impact or otherwise
    on medical sustainability or the client‘s capacity to undertake work
   Provide recommendations for treatment/rehabilitation that could assist the client in
    sustaining a work type, eg pain management, work trial.


The IMA must determine whether the types of work identified by the IOA are, or are
likely to be, medically sustainable. This is required under Part 4 section 89 of the AC Act.


See also Qualifications required for Occupational and Medical Assessors on pg 4.



Reporting on the Initial Assessments (IOA and IMA)

Initial Occupational Assessment (IOA) Report

This assessment report identifies:
   The training skills required for the work types (Unit Group), and the possible
    individual jobs the client could do.
   How the client‘s current skills and abilities match these jobs.
   What further training/skill development may be needed.


Work type detail sheets
A work type detail sheet is completed for each of the work types identified as suitable
(providing job details). A copy of this report is forwarded to the initial medical assessor,
with the specific work type detail sheets. These sheets have been developed by an
occupational assessor for use by assessors and aim to achieve national consistency
regarding descriptions of work environments and work functions. The task requirements
for these jobs may occasionally vary from the specifications and when this occurs the
occupational assessor will detail any variations on the IOA work type detail sheet and the
assessment report.1 See Appendix 6 on pg 46 for a work type detail sheet example.




1 Practitioners without current professional membership of a relevant association must
demonstrate their intent to work towards this within a stated timeframe.



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                   Vocational Medical Assessors – Operational Guidelines


Initial Medical Assessment (IMA) Report

Overview
Before beginning any report, it is wise to review information that has been provided and
assess whether it is adequate or whether there are gaps. If there are gaps or the
information is inadequate, request clarification or further information. Do not be
tempted to fill gaps with assumptions.


The body of the report should list the information considered when preparing the report,
the history and clinical findings gained from the assessment, and the assessor‘s opinion
on the medical sustainability of each identified type of work.


Medical assessors are legally viewed as expert witnesses. The role of an expert witness
encompasses the expectations of honesty, independence, and integrity. Further, the area
of expertise is medical, not legal or occupational. Therefore, the medical assessor must
constrain their opinions to those of medicine.


Report details
The assessor‘s report must specify:
   Relevant details about the client, including details of the client‘s injury
   Relevant details about the clinical examination undertaken by the assessor, including
    the methods used and the findings
   Results of any additional assessments of the client‘s condition
   Information provided to them by ACC
   Medical reports that have been prepared for ACC
   Information regarding any non-injury related conditions that may impact on the
    client‘s ability to work
   Any other relevant medical reports
   The report of the occupational assessor – the IOA (including the work type detail
    sheets)
   The clinical findings from their own examination
   Any other information or comments that the client asks the assessor to consider, that
    the assessor decides are relevant.


Part 4 section 89 of the AC Act requires that the IMA contains a determination of whether
the types of work identified by the IOA are, or are likely to be, medically sustainable.




The Vocational Independence Assessments (VIOA and


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                  Vocational Medical Assessors – Operational Guidelines



VIMA)

Vocational Independence Occupational Assessment (VIOA)

The purpose of the vocational independence occupational assessment is to:
   Review how the client has progressed since their IOA, and how the vocational
    rehabilitation provided to the client has helped. This may include the use of
    professionally recognised, objective assessment methodologies during the
    consultation that achieve defensible and recognised findings.
   Identify suitable types of work for the client based on their education, experience,
    pre-incapacity earnings, and training.


Vocational Independence Medical Assessment (VIMA)

The purpose of this assessment is to ascertain whether the client can do any, or all, of
the work options recommended by the occupational assessor on a full-time basis, ie 35
hours a week or more. See, Part 4, section 108(3) of the AC Act.


The medical assessor also takes into account any comments from the client or their
doctor, and may ask for more information, or a further assessment by a specialist, before
making a recommendation.


This assessment will ensure that comprehensive vocational rehabilitation, as identified in
a client‘s IRP, has been completed and that it has focused on the client‘s needs and
addressed any injury-related barriers to enable the client to either maintain or obtain
employment or regain or acquire vocational independence.


ACC can ask for a determination of a client‘s vocational independence at any reasonable
interval. It is usually completed when the client has finished the vocational rehabilitation
set out in their IRP.


The definition of vocational independence in Part 1 section 6 of the AC Act is:
―vocational independence, in relation to a claimant, means the claimant‘s capacity, as
determined under section 107, to engage in work—
    (a) for which he or she is suited by reason of experience, education, or training, or
    any combination of those things; and
    (b) for 35 hours or more a week‖


See also Qualifications required for Occupational and Medical Assessors on pg 4.




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                   Vocational Medical Assessors – Operational Guidelines



Reporting on the Vocational Independence Assessments
(VIOA and VIMA)

Vocational Independence Occupational Assessment (VIOA) Report

In identifying such jobs and writing the report, the assessor will:
   Consider the client‘s suitability as at the date of the consultation.
   Disregard the effects of the client‘s injury on the client‘s ability to work. The assessor
    will not exclude jobs because they believe the client may not be able to perform them
    due to the client‘s injury (this is the role of the vocational independence medical
    assessor).
   Disregard job availability, geographical location, the client‘s child care requirements,
    transportation availability, and the client‘s pre-injury occupation – except when
    prioritising job options.
   Identify and prioritise job options that most closely align with the client‘s pre-injury
    occupation, while not limiting the jobs for which the client is suited by reason of
    experience, education, pre-incapacity earnings, and training.
   Be realistic about job choices. Jobs must exist within the current New Zealand labour
    market and be full-time occupations, ie 35 hours per week or more.


The client is likely to have received a period of rehabilitation and treatment based on the
initial assessments and so the VIOA will consider and report on work options that the
client is able to perform the ‗next working day‘.


The client will be invited to comment, make submissions, and raise any issues or
concerns about their experience, education, training, pre-incapacity earnings, or potential
job options. However, a client‘s disagreement with some or all of the identified jobs
because they are not the client‘s preference is not a reason for the assessor excluding
them from their recommendations. These concerns will be discussed with the client and
documented.


The VIOA report includes:
   The client‘s previous work experience
   The client‘s education and training attainments
   The client‘s transferable skills
   The identified jobs
   Evidence of having taken into account the client‘s earnings before their incapacity,
    and evidence that the assessor has used their professional expertise to source
    earnings information about other job types.
   A summary
   Comments, submissions, issues and/or concerns raised by the client.


A work type detail sheet is prepared specifying the requirements of each job. See
Appendix 6 on page 46 for a work type detail sheet example.




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Vocational Independence Medical Assessment (VIMA) Report

Assessors to list their qualifications
As experts it is important that medical assessors specify their qualifications specifically
related to the type of report they are writing. See section, Assessors to list their
qualifications on page 7.


The VIMA must determine whether the types of work listed in the VIOA are, or are likely
to be, medically sustainable. This is required under Part 4 Vocational independence,
sections 107-113 of the AC Act.


VIMA report details
The assessor must prepare and provide to ACC a report on the medical assessment that
specifies:
   Relevant details about the client, including details of the client‘s injury
   Relevant details about the clinical examination undertaken by the assessor, including
    the methods used and the findings
   Results of any additional assessments of the client‘s condition
   The assessor‘s opinion of the client‘s vocational independence in relation to the types
    of work identified in the occupational assessor‘s report
   Any comments made by the client to the assessor about the client‘s injury and
    vocational independence related to each of the types of work identified in the
    occupational assessor‘s report
   Recommendations about any medical rehabilitation that will help the client to achieve
    and sustain employment in any of the job options
   Any conditions not related to the injury that prevent the client from having vocational
    independence.


When writing the report medical assessors must take into account:
   Information provided to them by ACC
   Medical reports that have been prepared for ACC prior to preparing the IRP
   Information regarding any non-injury related conditions that may impact on the
    client‘s ability to work
   Any other relevant medical reports
   The report of the occupational assessor – the VIOA (including the work type detail
    sheets)
   The clinical findings from their examination
   Any other information or comments that the client requests the assessor to consider,
    that the assessor decides are relevant.


Medical report quality check by Branch Medical Advisor

A quality check of the medical assessment report is completed by the branch medical
advisor. This quality check ensures that the medical assessor has considered all the
information provided by ACC as well as any additional information or comments provided
by the client. The quality check also ensures that the medical report details:




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                   Vocational Medical Assessors – Operational Guidelines


   The client and their injury
   The clinical examination, the methods used and the clinical findings
   The results of any additional assessments
   The assessor‘s opinion of the client‘s vocational independence for each of the work
    types identified in the occupational assessor‘s report
   Discussion with, and comments made by, the client about each of the types of work
    identified within the occupational assessor‘s report
   Evidence that the medical assessor has identified the types of work that the client is
    able to perform for 35 hours a week or more
   Any non-injury conditions that prevent the client from having vocational
    independence and the rationale for the decision
   Evidence that any conditions or restrictions attached to the recommendations are
    consistent with the requirements on the work type detail sheets provided by the
    occupational assessor
   Any further medical rehabilitation identified during the assessment.


Client service staff or the branch medical advisor may contact the assessor to request
clarification of aspects of the report. This may include further clarification, explanation,
and correction of oversights. Any requests for changes by the client must be referred to
the client service staff member.



Steps in the Medical Assessment Process

Step 1 – Background information from ACC

ACC provides the following information to help the medical assessor with their
assessment:
   A summary of the client‘s injury claim and medical and occupational rehabilitation.
    This will also include any factors that may impact on the assessment, for instance if
    the client has communication difficulties or has been identified as a potential risk to
    the assessor.
   For VIMAs, the IRP completed by the client service staff member and client.
   Previous medical and occupational reports requested by ACC as part of the
    rehabilitation process
   The occupational assessor‘s report detailing the education, training and experience
    the client has in relation to the identified types of work. The report lists all types of
    work reasonably identified as suitable for the client. It also provides in relation to
    each type of work the requirements, including any environmental modifications that
    the assessor identifies as necessary to enable the client to function safely in that type
    of work.


This information is to help the medical assessor become familiar with the client‘s injury
and interventions to date, and the types of work deemed suitable by the occupational
assessor.




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                  Vocational Medical Assessors – Operational Guidelines


Step 2 – Clinical examination

The medical assessor will take a history, clinically examine and document those organ
systems identified as relating to the injury and the impact of the injury in relation to the
individual‘s capacity to work in the identified occupations. This examination will form the
basis of the report. The clinical examination must include recognised testing
methodologies that will give defensible, recognised results. These results form the basis
of the report and recommendations.


If the client service staff member has requested an assessment and the assessor believes
that this should be considered as either a serious injury or complex assessment, the
medical assessor should endeavour to discuss this with the client service staff member
before proceeding with the assessment. However, if the client service staff member or
other decision-maker is unavailable, proceed with the assessment and contact the client
service staff member at the earliest opportunity.


Step 3 – The medical report

ACC requires a medical report from the medical assessor that identifies the facts gained
from the history and the clinical examination and shows how each recommendation
relates to each particular type of work. It is vital that medical assessors are objective and
only report or comment on issues that have been identified in reports already provided,
or revealed in the assessor‘s own history taking and clinical examination of the client.


This report should cover three main areas:
1. The client‘s details, background, and presenting situation.
2. The clinical examination, noting the methods used and the findings.
3. The assessor‘s opinion of the sustainability of work (IMA) and the client‘s vocational
   independence (VIMA) based on the findings that relate to each type of work identified
   by the occupational assessor. The medical assessor must give reasons for their
   decisions, referring to their clinical findings and the specified job tasks, and concisely
   state the outcome, eg is the client able to do the types of work identified or not?


The written reports should follow the formats given in Appendix 4 (IMA) on pg 31, and
Appendix 5 (VIMA) on pg 39.


Step 4 – Recommendations

The occupational assessor will have completed the first section of the medical report. This
section will list the types of work that the client has the skills to perform because of their
education, experience, or training.


The occupational assessor will have also provided a copy of the relevant work type detail
sheets. These sheets provide information on work tasks, work environment, work
function/activity, qualifications, and other relevant comments.




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                   Vocational Medical Assessors – Operational Guidelines


The medical assessor then completes the report and sends three copies to ACC. The
client service staff member provides one copy of the report to the client, and one to the
client‘s GP. One copy remains on the client‘s file. The report is required by ACC within
eight working days of the later of the:
   Date of clinical examination of the client, or
   Date the assessor receives any additional information requested by the client service
    staff member.


When conducting a VIMA the medical assessor will complete the second section of the
recommendation form. The recommendation form represents a summary of both the
occupational and medical assessors‘ evaluation reports.


The branch medical advisor may review with the client service staff member, any issues
arising from the medical assessment reports, specifically:
   Any further medical treatment/examinations and their relevance
   Illness-related issues and how these may affect vocational rehabilitation.


Notes:
   If further information or assessments are required before the medical assessor can
    make a recommendation, the medical assessor should contact the client service staff
    member directly.
   The medical assessor may only make one recommendation, showing their rationale,
    on each other of the occupation recommendations given by the occupational
    assessor.


Further information
If the medical assessor, having reviewed the background information and completed the
clinical examination, requires additional information, they will contact the client service
staff member and request the additional information before making recommendations.




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             Vocational Medical Assessors – Operational Guidelines: Appendices



                                    APPENDICES


Appendix 1: Relevant Legislation

Accident Compensation Act 2001

        Note: Legislation in square brackets is in effect from 1 October 2008.




Part 1 –Interpretation
6. Vocational independence, in relation to a claimant, means the claimant‘s capacity, as
determined under section 107, to engage in work—
   (a) for which he or she is suited by reason of experience, education, or training, or
   any combination of those things; and
   (b) for 35 hours or more a week


Part 4 - Vocational rehabilitation
80. Purpose of vocational rehabilitation
(1) The purpose of vocational rehabilitation is to help a claimant to, as appropriate,—
   (a) maintain employment; or
   (b) obtain employment; or
   (c) regain or acquire vocational independence.
(2) Without limiting subsection (1), the provision of vocational rehabilitation includes the
provision of activities for the purpose of maintaining or obtaining employment that is—
   (a) suitable for the claimant; and
   (b) appropriate for the claimant‘s levels of training and experience.


85. Corporation liable to provide vocational rehabilitation
(1) The Corporation is liable to provide vocational rehabilitation to a claimant who—
   (a) has suffered personal injury for which he or she has cover; and
   (b) is—
       (i) entitled to weekly compensation; or
       (ii) likely, unless he or she has vocational rehabilitation, to be entitled to weekly
       compensation; or
       (iii) on parental leave.
[(2) Despite subsection (1)(b)(i), the Corporation is liable to provide vocational
rehabilitation to a person who was entitled to weekly compensation and who would, but
for clause 52 of Schedule 1 (relationship between weekly compensation and New Zealand
superannuation), continue to be entitled to weekly compensation.]




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86. Matters to be considered in deciding whether to provide vocational rehabilitation
(1) In deciding whether to provide vocational rehabilitation, the Corporation must have
regard to the matters in section 87.
(2) In deciding what vocational rehabilitation is appropriate for the claimant to achieve
the purpose of vocational rehabilitation under section 80,—
   (a) the Corporation must consider whether it is reasonably practicable to return the
   claimant to the same employment in which the claimant was engaged, and with the
   employer who was employing the claimant, when the claimant‘s incapacity
   commenced; and
   (b) if it is not, the Corporation must consider the following matters:
       (i) whether it is reasonably practicable to return the claimant to an employment
       of a different kind with that employer:
       (ii) whether it is reasonably practicable to return the claimant to the employment
       in which the claimant was engaged when the claimant‘s incapacity commenced,
       but with a different employer:
       (iii) whether it is reasonably practicable to return the claimant to a different
       employment with a different employer, in which the claimant is able to use his or
       her experience, education, or training:
       (iv) whether it is reasonably practicable to help the claimant use as many of his
       or her pre-injury skills as possible to obtain employment.


87. Further matters to be considered in deciding whether to provide vocational
rehabilitation
(1) In deciding whether to provide vocational rehabilitation, the Corporation must have
regard to—
   (a) whether the vocational rehabilitation is likely to achieve its purpose under the
   claimant‘s individual rehabilitation plan; and
   (b) whether the vocational rehabilitation is likely to be cost-effective, having regard
   to the likelihood that costs of entitlements under this Act will be reduced as a result of
   the provision of vocational rehabilitation; and
   (c) whether the vocational rehabilitation is appropriate in the circumstances.
(2) The Corporation is liable to provide the vocational rehabilitation for the minimum
period necessary to achieve its purpose, but must not provide any vocational
rehabilitation for longer than 3 years (which need not be consecutive).
[―(2A) Subsection (2) is subject to subsection (2B).
[―(2B) Despite subsection (2), the Corporation may, at its discretion, provide vocational
rehabilitation for longer than 3 years if the Corporation considers that—
   ―(a) the vocational rehabilitation would be likely to achieve its purpose under the
   claimant‘s individual rehabilitation plan; and
   ―(b) the vocational rehabilitation would be likely to be cost effective, having regard to
   the likelihood that costs of entitlements under this Act will be reduced as a result of
   the provision of vocational rehabilitation; and
   ―(c) the vocational rehabilitation would be appropriate in the circumstances.
[―(2C) However, despite subsections (1)(b) and (2B)(b), the Corporation must not take
into account as a factor against providing vocational rehabilitation that the claimant is, or
may become, a person to whom clause 52 of Schedule 1 (relationship between
weekly compensation and New Zealand superannuation) applies.]
(3) This section is subject to any regulations made under section 324.




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88. Vocational rehabilitation may start or resume if circumstances change
(1) The Corporation may, at any time, decide whether or not there has been a change of
circumstances affecting the claimant‘s need for vocational rehabilitation.
(2) If the Corporation decides that there has been such a change, the Corporation and
the claimant may agree to the modification of the claimant‘s individual rehabilitation plan
to reflect the changed circumstances.
(3) The Corporation may resume providing vocational rehabilitation under the claimant‘s
individual rehabilitation plan, with any agreed modifications, to a claimant who—
   (a) had vocational rehabilitation; and
   (b) as a result, obtained employment; but
   (c) is unable to maintain the employment because of his or her incapacity.
(4) This section is subject to section 87(2) and (3).


89. Assessment of claimant‘s vocational rehabilitation needs
An assessment of a claimant‘s vocational rehabilitation needs must consist of—
   (a) an initial occupational assessment to identify the types of work that may be
   appropriate for the claimant; and
   (b) an initial medical assessment to determine whether the types of work identified
   under paragraph (a) are, or are likely to be, medically sustainable for the claimant.


93. Medical assessor
(1) A medical assessment must be undertaken by a medical practitioner who is described
in subsection (2) or subsection (3).
(2) A medical practitioner who provides general medical services must also—
   (a) have an interest, and proven work experience, in disability management in the
   workplace or in occupational rehabilitation; and
   (b) have at least 5 years' experience in general practice; and
   (c) meet at least 1 of the following criteria:
       (i) be a Fellow of the Royal New Zealand College of General Practitioners or hold
       an equivalent qualification:
       (ii) be undertaking training towards becoming a Fellow of the Royal New Zealand
       College of General Practitioners or holding an equivalent qualification
       (iii) have undertaken relevant advanced training.
(3) A medical practitioner who does not provide general medical services must—
   (a) have an interest, and proven work experience, in disability management in the
   workplace or in occupational rehabilitation; and
   (b) be a member of a recognised college.


94. Assessments when medical assessor unavailable
(1) A… medical practitioner who does not qualify under section 93 may undertake a
medical assessment if the Corporation is satisfied that—
   (a) the circumstances in subsection (2) exist; and
   (b) the… medical practitioner's qualifications and experience are broadly comparable
   with the qualifications and experience specified in section 93.




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           Vocational Medical Assessors – Operational Guidelines: Appendices


(2) The circumstances are that—
   (a) a… medical practitioner who does qualify under section 93 is not available to
   undertake a medical assessment without unreasonable delay or unreasonable
   inconvenience to the claimant; and
   (b) the delay or inconvenience would have an adverse effect on providing vocational
   rehabilitation to the claimant.
(3) Sections 95 and 96 apply to a… medical practitioner who qualifies under this section
to undertake a medical assessment.


95. Conduct of initial medical assessment
(1) A medical assessor undertaking an initial medical assessment must take into
account—
   (a) information provided to the assessor by the Corporation; and
   (b) any of the following reports, information, or comments provided to the assessor:
       (i) medical reports requested by the Corporation before the individual
       rehabilitation plan was prepared:
       (ii) any other relevant medical reports; and
   (c) the report of the occupational assessor on the initial occupational assessment;
   and
   (d) the medical assessor's clinical examination of the claimant; and
   (e) any other information or comments that the claimant requests the medical
   assessor to take into account and that the medical assessor decides are relevant.
(2) The medical assessor must also take into account any condition suffered by the
claimant that is not related to the claimant's personal injury.
(3) The Corporation must provide to a medical assessor all information the Corporation
has that is relevant to an initial medical assessment.


96. Report on initial medical assessment
(1) The medical assessor must prepare and provide to the Corporation a report on the
initial medical assessment.
(2) The report must—
   (a) contain the determination required by section 89(b); and
   (b) take into account the matters referred to in section 95.
(3) The Corporation must provide a copy of the report to the claimant.


Part 4 - Vocational independence
107. Corporation to determine vocational independence
(1) The Corporation may determine the vocational independence of—
   (a) a claimant who is receiving weekly compensation:
   (b) a claimant who may have an entitlement to weekly compensation.
(2) The Corporation determines a claimant's vocational independence by requiring the
claimant to participate in an assessment carried out—
   (a) for the purpose in subsection (3); and
   (b) in accordance with sections 108 to 110 and clauses 24 to 29 of Schedule 1; and
   (c) at the Corporation's expense.




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(3) The purpose of the assessment is to ensure that comprehensive vocational
rehabilitation, as identified in a claimant's individual rehabilitation plan, has been
completed and that it has focused on the claimant's needs, and addressed any injury-
related barriers, to enable the claimant—
   (a) to maintain or obtain employment; or
   (b) to regain or acquire vocational independence.


108. Assessment of claimant's vocational independence
(1) An assessment of a claimant's vocational independence must consist of—
   (a )an occupational assessment under clause 25 of Schedule 1; and
   (b) a medical assessment under clause 28 of Schedule 1.
(2) The purpose of an occupational assessment is to—
   (a) consider the progress and outcomes of vocational rehabilitation carried out under
   the claimant's individual rehabilitation plan; and
   (b) consider whether the types of work (whether available or not) identified in the
   claimant's individual rehabilitation plan are still suitable for the claimant because they
   match the skills that the claimant has gained through education, training, or
   experience.
(3) The purpose of a medical assessment is to provide an opinion for the Corporation as
to whether, having regard to the claimant's personal injury, the claimant has the capacity
to undertake any type of work identified in the occupational assessment and reflected in
the claimant's individual rehabilitation plan.


109. When claimant's vocational independence to be assessed
(1) The Corporation may determine the claimant's vocational independence at such
reasonable intervals as the Corporation considers appropriate.
(2) However, the Corporation must determine the claimant's vocational independence
again if—
   (a) the Corporation has previously determined that the claimant had—
       (i) vocational independence under this section; or
       (ii) a capacity for work under section 89 of the Accident Insurance Act 1998; or
       (iii) a capacity for work under section 51 of the Accident Rehabilitation and
       Compensation Insurance Act 1992; and
   (b) the Corporation believes, or has reasonable grounds for believing, that the
   claimant's vocational independence or capacity for work may have deteriorated due to
   the injuries that were assessed in the previous vocational independence or capacity
   for work assessment.
(3) The claimant may give the Corporation information to assist the Corporation to reach
a belief under subsection (2)(b).


Schedule 1 - Vocational rehabilitation
27. Medical assessor
(1) A medical assessment must be undertaken by a medical practitioner who is described
in subclause (2) or subclause (3).
(2) A medical practitioner who provides general medical services must also—
   (a) have an interest, and proven work experience, in disability management in the
   workplace or in occupational rehabilitation; and




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           Vocational Medical Assessors – Operational Guidelines: Appendices


   (b) have at least 5 years' experience in general practice; and
   (c) meet at least 1 of the following criteria:
       (i) be a Fellow of the Royal New Zealand College of General Practitioners or hold
       an equivalent qualification:
       (ii) be undertaking training towards becoming a Fellow of the Royal New Zealand
       College of General Practitioners or holding an equivalent qualification:
       (iii) have undertaken relevant advanced training.
(3) A person who does not provide general medical services must also—
   (a) have an interest, and proven work experience, in disability management in the
   workplace or in occupational rehabilitation; and
   (b) be a member of a recognised college.


28. Conduct of medical assessment
(1) A medical assessor undertaking a medical assessment as part of an assessment of a
claimant's vocational independence under section 108 must take into account—
   (a) information provided to the assessor by the Corporation; and
   (b) any individual rehabilitation plan for the claimant; and
   (c) any of the following medical reports provided to the assessor:
       (i) medical reports requested by the Corporation before the individual
       rehabilitation plan was prepared:
       (ii) medical reports received during the claimant's rehabilitation; and
   (d) the report of the occupational assessor under clause 26; and
   (e) the medical assessor's clinical examination of the claimant; and
   (f) any other information or comments that the claimant requests the medical
   assessor to take into account and that the medical assessor decides are relevant.
(2) The Corporation must provide to a medical assessor all information the Corporation
has that is relevant to a medical assessment.


29. Report on medical assessment
(1) The medical assessor must prepare and provide to the Corporation a report on the
medical assessment specifying—
   (a) relevant details about the claimant, including details of the claimant's injury; and
   (b) relevant details about the clinical examination of the claimant undertaken by the
   assessor, including the methods used and the assessor's findings from the
   examination; and
   (c) the results of any additional assessments of the claimant's condition; and
   (d) the assessor's opinion of the claimant's vocational independence in relation to
   each of the types of work identified in the occupational assessor's report; and
   (e) any comments made by the claimant to the assessor relating to the claimant's
   injury and vocational independence in relation to each of the types of work identified
   in the occupational assessor's report.
(2) The report must also identify any conditions that—
   (a) prevent the claimant from having vocational independence; and
   (b) are not related to the claimant's injury.
(3) The Corporation must provide a copy of the report to the claimant.




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Appendix 2: Vocational Services

ACC has the following vocational rehabilitation programmes/services available for clients. These services are arranged for the client by their
client service staff member.


Service          Service Item      Definition                                                 Client Criteria                Provider
Specification                                                                                                                Criteria

                 Workplace         Evaluation of a client‘s worksite to identify any          Client has employment          Rehabilitation
Graduated
Return to        Assessment        changes necessary to ensure the work environment is        situation or work trial        Professional
Work                               safe. Price includes report and graduated return to        opportunity.
                                   work plan.
                 Worksite Review   Review of the worksite to evaluate effectiveness of        Client has had modifications   Rehabilitation
                                   any modifications or purchased equipment.                  or equipment purchase on       Professional
                                                                                              trial.
                 Graduated         Implementation of supervised increase in hours to          Client has employment or       Rehabilitation
                 Return to Work    fulltime from part-time via a documented GRTW plan.        work trial situation and has   Professional
                 (GRTW)            Trouble shooting where necessary to maintain               had a workplace assessment.
                 Programme
                                   employment situation.

                 Initial           Interview with client to identify any barriers to a        Client has employment          Vocational
Employment       Interview         return to work with same employer, and identification      situation with pre-injury      Practitioner
Maintenance                        of vocational components required for a successful         employer, however employer
Programme                          return to work.                                            does not have alternative
                                                                                              work for the period to full
                                                                                              recovery

                 Worksite Visit    Visit to client‘s current worksite to identify any         As above                       Rehabilitation
                                   physical or vocational barriers to a full return to work                                  Professional
                                   following recovery from injury.

                 Individual        A time-framed individual return to work plan that          As above                       Vocational
                 Programme         outlines individual and group components for client to                                    Practitioner
                 Plan              participate in over the required number of weeks for a
                                   successful return to work.



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Service         Service Item     Definition                                                  Client Criteria                 Provider
Specification                                                                                                                Criteria

                Key Provider     Includes:                                                   As above                        Vocational
Employment      Monitoring       a) weekly meeting or phone call with/to client to                                           Practitioner
Maintenance                      monitor programme progress and ensure on track;
Programme -                      and
continued                        b) report on achievement, or not, of programme
                                 goals, ie. Employment maintenance; and
                                 c) a 3-week follow-up phone call to employer, client
                                 and client service staff member confirming durable
                                 return to work.

                Rehabilitation   Group modules addressing aspects of injury                  As above                        Rehabilitation
                Modules          prevention and injury management.                                                           Professional

                Vocational       Group modules addressing employer and employee              As above                        Vocational
                Modules          responsibilities for return to work.                                                        Practitioner

Functional      Full FCE         Assessment of a client‘s ability to sustain physical        Client has yet to obtain        Rehabilitation
Capacity                         performance in response to a range of physical              employment or work trial        Professional
Evaluation                       demands reliably and safely.                                situation (therefore baseline
(FCE)                                                                                        functioning needs to be
                                                                                             established).

                Task-Specific    Assessment of client‘s ability to sustain specified tasks   Client has employment           Rehabilitation
                Evaluation       reliably and safely.                                        situation or work trial         Professional
                                                                                             opportunity, however GP
                                                                                             needs confirmation via an
                                                                                             FCE that client can attempt
                                                                                             the work.

                Initial          Assessment of client‘s existing education, training         Client has yet to obtain        Occupational
Occupational    Assessment       experience and will take into account a client‘s            employment or work trial        Assessor
Assessment                       earnings before the client‘s incapacity Identification of   situation.
                                 suitable work types on ACC work type detail sheets.




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Service         Service Item      Definition                                                 Client Criteria                 Provider
Specification                                                                                                                Criteria

Occupational    Reassessment     Reassessment as above, in situations where the client      As above                        As above
Assessment -                      service staff member indicates this is required.
continued

                Curriculum        Individualised CV to emphasise marketable qualities        As above                        Vocational
                Vitae (CV)        and skills.                                                                                Practitioner
                Preparation

                Vocational        Assessment of the progress and outcomes of a client‘s      Client is work ready, has yet   Occupational
                Independence      vocational rehabilitation, consideration of whether the    to obtain full employment,      Assessor
                Assessment       types of work identified in the IOA are still suitable     and has completed the
                                  and assessment of whether any new types of work            vocational rehabilitation
                                  are now suitable                                           requirements as per their
                                                                                             IRP

                Initial Medical   Assessment of client‘s medical and injury-related          Client has yet to obtain        Medical
Medical         Assessment        conditions.                                                employment or work trial        Assessor
Assessment                                                                                   situation.

                                  Assessment of whether the client is able to medically
                                  sustain rehabilitation for the jobs identified by the
                                  occupational assessor.


                                  Assessment of any non-injury-related medical
                                  conditions or barriers that may impact on
                                  rehabilitation.

                Vocational        Assessment of the progress and outcomes of client‘s        Client is work ready, has yet   Medical
                Independence      vocational and medical rehabilitation, consideration of    to obtain full employment,      Assessor
                Assessment        whether the types of work identified in the IOA are        and has completed the
                                  still medically sustainable.                               vocational rehabilitation
                                                                                             requirements as per their
                                                                                             IRP.
                                  Assessment of any non-injury-related conditions or
                                  barriers that may impact on the ability of the client to
                                  work.

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                                   Vocational Medical Assessors – Operational Guidelines: Appendices


Service         Service Item   Definition                                                     Client Criteria                Provider
Specification                                                                                                                Criteria

                CV Review      Modification of existing CV to update new skills or            Client has had IOA, CV         Vocational
Work Ready      (optional)     customise for particular work.                                 preparation and FCE if         Practitioner
Programme                                                                                     required, and is ready to
                                                                                              demonstrate their work
                                                                                              readiness, as indicated by
                                                                                              Medical Certificate (ACC18).

                Work Trial     Unpaid work trial of between 3 and 6 weeks duration            As above                       Vocational
                               with close monitoring.                                                                        Practitioner

                Work Ready     Work trial completed with close monitoring. Client has         As above                       As above
                Outcome        demonstrated they have no outstanding barriers to
                              achieve a return to work.

Work            Initial        An initial interview of 30 minutes duration is                 Client no longer has pre-      Occupational
Preparation     Interview      conducted prior to the commencement of the                     injury employment, has had     Assessor
Programme                     programme. The interview is conducted by an                    IOA and requires work
                               occupational assessor and will identify the client‘s           preparation as part of their
                               suitability for the programme; determine appropriate           IRP.
                               individual rehabilitative components; and report any
                               contraindications to the client service staff member.

                Group          A 6 week programme running 9am-1pm each                        As above                       Multidisciplinary
                Programme      weekday, which includes vocational, physical, and                                             including
                               psychological modules. Payment is for a group                                                 Registered
                               programme, which requires a minimum of 6 clients in                                           Psychologist
                               each course. Fee includes providing reports on weekly
                               attendance, progress, and completion, as well as a
                               detailed 6 week group programme plan.

                Individual     A detailed programme running 9am-1pm each                      As above                       As above
                Work           weekday, for up to 6 weeks, which includes
                Preparation    vocational, physical and psychological modules
                Programme      specific to the individual client, identified in the initial
                               interview.


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Service            Service Item     Definition                                                 Client Criteria               Provider
Specification                                                                                                                Criteria

Work               Individual       Provision of a weekly attendance report, progress
Preparation        Work             report and completion report.
Programme -        Preparation
continued          Programme

                   Individual       Includes an individual work preparation plan, which        As above                      As above
                   Work             outlines the rehabilitative vocational and psychological
                   Preparation      components for the client to participate in over the
                   Programme        required weeks, identified in the initial interview.
                   Plan

                   CV Modification Modification of existing CV to update new skills or        Clients assessed under part   Vocational
Transitional
                                    customise for particular work.                             4 section 107 of the AC Act   Practitioner
Job Search
                                                                                               to have vocational
(referral is for                                                                               independence, and require
a maximum of                                                                                   this service during the 3
12 weeks)                                                                                      months weekly
                                                                                               compensation.

                   Job Search       Job seeking advice and assistance. Maximum 12              As above                      As above
                   Services        hours.

                   Job Placement   Placement into paid employment (within the                 As above                      As above
                                    timeframe).




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            Vocational Medical Assessors – Operational Guidelines: Appendices



Appendix 3 - Vocational Paths

Maintain employment

General aim
The focus of this path is to restore the client‘s capacity to continue working with their
current employer in either the same type of work or a different one. Rehabilitation
through this path aims to both:
   Ensure the client maintains their existing job
   Return them to their pre-injury level of work activity, in both the type of tasks and
    the number of hours they work.


If the client is unlikely to return to their pre-injury level of work activity, the next
preference is to consider appropriate alternative types of work with the same employer.
If there are no ‗light duties‘ available, but the job remains open, the client is referred to
an ‗employment maintenance programme‘.


Suitable clients for maintaining employment
Suitable clients for this path have the following features:
   There is a suitable job to which they can return
   The client is physically able, now or potentially, to resume their pre-injury work and
    medical advice must confirm this
   The employer can either keep the pre-injury job open for them or provide alternative
    suitable work
   The client will be able to return to the number of hours they worked before the injury,
    or can build up to that within a specified timeframe.


Suitable interventions for maintaining employment
To help the client achieve the rehabilitation outcome of maintaining employment, the
following vocational assistance may be considered:
   Workplace assessment
   Work ready programme
   Making modifications to the workplace or purchasing vocational equipment
   Modifying their duties
   Employing a provider to monitor and support the client‘s gradual return to work
   Providing an activity-based programme
   Obtaining the provider‘s confirmation of the suitability of any alternative work and
    transport.


Note:
This assistance may be provided concurrently.




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Employer‟s involvement
When working toward maintaining a client‘s previous employment, Part 4 section 71 of
the AC Act requires the employer to help the client with their rehabilitation as per the
IRP. The employer is included as an integral member of the rehabilitation team, as early
as possible in the process.


The more interested and involved the employer is in maintaining the client‘s employment
the sooner the client is likely to achieve the rehabilitation outcome. An employer who is
involved and provides support for a client in the workplace can also save much time and
cost in hiring and training replacement staff.


If this path is selected, the client service staff member must advise both the employer
and the client in writing of the decision to return the client to their pre-injury job.


Obtain employment

The second preferred path is to help a client gain appropriate employment even if that is
with a different employer. Working toward this outcome includes the client making a
reasonable effort to actually obtain work.


General aim
The focus of this path is to restore the client‘s ability to work in either:
   The same type of work for a different employer, or
   A different type of work for a different employer, which uses their pre-injury
    experience, education, or training and is suitable for the status of their injury.


Note:
Remember that a different type of work must be at a similar level to their previous type
of work.


Suitable clients for obtaining employment
Suitable candidates for this path are those clients who have lost their pre-injury job and:
   Are able to work, or can build up to, 35 hours or more a week
   Have sufficient education, training, or experience to reasonably expect to find suitable
    work
   Can gain those skills with some assistance.


Suitable interventions
To help the client achieve employment with a different employer, the following assistance
will be considered by the client service staff member:
   Initial Occupational Assessment (IOA), with CV preparation
   Initial Medical Assessment (IMA).




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Other services that are provided by ACC include:
   Functional capacity evaluation
   Short training course
   Return to work programme
   Work hardening programme.
   Comprehensive pain assessment (if pain is a barrier to returning to work). See Pain
    Management Services - Operational Guidelines, pg 29
   Functional Reactivation Programme (see Pain Management Services - Operational
    Guidelines, pg 14).


Notes:
   Graduated return to work plans must specify a timeframe to return to full-time work
    hours
   Any of the above programmes and interventions may be provided concurrently
   Alternative types of work should be specified if they can achieve the return to work
    outcome within the specified timeframe and the role uses the client‘s existing
    experience, education, or training
   The IMA confirms that the type of work is suitable for the client.


Regain or acquire vocational independence

ACC provides rehabilitation assistance to give the client the support and training they
need to be able to seek and undertake appropriate work. Previously, this option was
called ‗acquire a capacity for work‘, ‗work readiness‘, or combinations of these terms.


General aim
The focus of this path is to:
   Remove any obstacles or barriers that prevent the client from doing any type of work
    for which they have skills, education, or experience
   Help the client use as many of their pre-injury skills as possible in obtaining
    employment.


A different type of work must be at a similar level to the client‘s previous type of work,
and the IMA must confirm that the type of work is suitable for the client.


Suitable clients
Clients who may best follow this path include those:
   Who have suitable education, experience, or training to work in other types of work
   Who are not likely to achieve independence in employment within a reasonable
    period, for any reason
   For whom previous help to try to achieve independence in their employment has been
    unsuccessful
   Who are able to work 35 hours or more per week, or will be able to build up to that,
    in suitable types of work.




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Suitable interventions for regaining or acquiring vocational independence
To help the client regain or acquire vocational independence, consider the following
assistance against the decision-making criteria outlined in Part 4 section 87 of the AC
Act:
   IOA, with or without CV preparation
   IMA.


Other interventions that may be used include:
   Functional capacity evaluation
   Work ready programme
   Work hardening programme
   Short training courses
   Comprehensive pain assessment (if pain is a barrier to returning to work). See Pain
    Management Services - Operational Guidelines, pg 29
   Functional Reactivation Programme (see Pain Management Services - Operational
    Guidelines, pg 14).


Note:
Remember to provide all types of assistance concurrently, wherever possible.




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Appendix 4: Example - Initial Medical Assessment Report

11 July 2003



Assessor details
Dr ABC
123 Main St


Relevant qualifications
MBChB, Dip Occ Med, FRNZCG P


Referred by
Client service staff member Y
New Branch
    Ph
    Fax
    Email
Accident Compensation Corporation


Appointment details
Date of Examination: 5/7/2002
Time: 10am
Duration of Appointment: 75 minutes
Date Requested by ACC: 1/7/2002


Client details
Mrs ―S‖
Date of Birth: dd/mm/1949


Injuries
The injuries as outlined on your referral letter are these:
   Date of Injury
    15/6/97
   Nature of Injury
    ―Occupational Overuse Injury‖ – bilateral medial epicondylitis
   Claim Number
    A1234567/004




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List of medical documentation received including results of diagnostic
procedures


 No.    Date            Document Type                                     Provider

 1      05/07/2002      Referral for Initial Medical Assessment           Client service
                                                                          staff

 2      14/05/2002      Initial Occupational Assessment Report            Career Services

 3      22/05/2002      Work Ready Programme Completion Report            Workbridge

 4      19/04/2002      Return to Work Monitoring                         Ergowise

 5      23/04/2002      Work Trial Completion Report                      Workbridge

 6      15/03/2002      Pain Management Programme                         ADHB

 7      25/05/2001      Occupational Physician Report                     Dr OccPhys1

 8      17/05/2001      MRI Report                                        Mercy MRI

 9      27/02/2001      Occupational Physician Report                     Dr OccPhys2

 10     22/02/2001      Radiology Report                                  ARG

 11     16/06/2001      Orthopaedic Surgeon Report                        Dr Ortho1

 12     12/05/2000      Physiotherapy Feedback                            Pro Rehab

 13     28/07/1998      Occupational Physician Report                     Dr OccPhys2

 14     10/08/1997      Physiotherapy Report                              HMC

 15     14/04/1997      ACC Form: Client Questionnaire                    Client

 16     14/03/1997      ACC Form: Medical Practitioner Questionnaire      Dr GP1


History of the injury
―S‖ was injured when she was working on a six-month contract managing a motel in
Anytown. Her duties involved the full range of motel duties, which included cleaning,
making beds, laundry, office work, and general maintenance.


In December 1996 she developed pain in the right elbow, which was placed in a sling.
This resulted in an extra loading on the left arm. At the same time she was stressed by
the break-up of her marriage in February 1997. She developed bilateral elbow pain. She
employed a cleaner to help.


In July 1997 she went overseas and entered another contract to manage a motel in
another country for 10 months, returning to New Zealand when her mother died. In
October 1998 she bought the rights to sell lollies, until April 2000. This involved sorting
and packing lollies into 5-6kg boxes, taking them from the car boot, opening heavy doors
in the industrial area and making up to 40 calls per day. She had to stop because of the
limitations of elbow function, namely bending, and she required her elderly father to take
care of her. She has had several work trials, the last of which was completed in April
2002, at a motel.




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She has just started a computer course, and this aggravated both her elbows after two
days of typing.


Current state
―S‖ reports pain in both elbows, over the bony prominence of the lateral aspect of the
elbow. This is described as dull and intermittent and is rated as a grade 6 out of 10,
using a Visual Analogue Scale (10 being the worst).


―S‖ reports no other symptoms including numbness or tingling, headaches, bowel
disturbance, or dysmenorrhoea. Mood is unchanged, and there are no signs of
endogenous depression.


She has difficulty getting off to sleep, which may take up to 90 minutes, and she feels
she could do with eight hours‘ sleep rather than the six hours she is getting at present.
The sleep disturbance is not due to her elbows. No daytime sleep is required and daytime
alertness is normal.


Current treatment and medication
In the past ―S‖ has had physiotherapy which loosened the tightness in her arms,
acupuncture which worked for a short period, massage which didn‘t seem to ease the
pain, a rehabilitation programme with work trials which flared up the pain, and a pain
management programme which she states was the best for her and has got her where
she is today. The programme was run by the Regional Pain Service, in January this year
for one month, and she is due for her six-monthly review on 12/7/02.


She has received three steroid injections on the right and two on the left. Past
medications included Vioxx, Tramol, Diclofenac, Paradex, Nurofen and topical agents
Antiflamme and Bee Pollen.


―S‖ is currently taking Betaloc CR, two tablets daily and Amizide one tablet daily for
hypertension. She has been on this medication for six years. She notices that her fingers
go white and cold if she goes outside on a cold winter‘s day.


Vocational history
―S‖ was at school until the age of 15 and started full-time employment as she was
offered a good office job halfway through the fifth form.


―S‖ is right handed and was working as a motel manager up to the accident, and was
successfully able to work until April 2000.


The work is believed by ―S‖ to be related to the current health problems. Her symptoms
are related to activity and the type of work, are activity dependent, and ease with rest.


The past history of occupations include:
   Accounts assistant between 1994 and 1996
   Motel manager between 1997 and 1998
   Self-employed, 1998-2000.




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Psychosocial history
―S‖ lives with her father in his home because of the lack of personal finance. ―S‖
consumes no alcohol per week and is a non-smoker. Stress is present because of her
limited financial resources. She would like to be independent and support herself and live
alone. Activities of daily living that are affected and limited by the accident include all of
the similar activities that were involved at the motel.


Exercise is performed regularly for 30 minutes three times per week. Her gym
membership of three months expired at the end of June; she was attending five to six
times per week.


Leisure activities that are affected and limited by the accident include recreation, eg
walking, playing board games with family, and playing golf since April 2000.


Past medical history
The past medical history includes:
   In 1968 she was involved in a car accident, travelling at a speed of 50 kilometres per
    hour. She sustained a fracture of the right wrist, possibly the left clavicle and rib, with
    puncture of the lungs and a lower back injury.
   Hypertension diagnosed in 1997.


There are no known drug, food, or chemical allergies.


Past surgical history
There is no significant surgical history of note.


Family history
There is no significant family history of note.


Examination findings
―S‖ was a co-operative patient in no obvious distress, and arrived alone at the
assessment. Her blood pressure was 134/86, weight 61.4kg, height 161cm, giving a BMI
of 23. There was no abnormality of the chest or clavicle.


Elbows
   There was no significant deformity or effusion of the elbows.
   There was no obvious wasting noted of the arms and forearms. There was some
    prominence of the lateral epicondyle with an element of fat atrophy, however no
    depigmentation was noted.
   The left elbow lacked 10 degrees of full extension, with pronation and supination
    being normal bilaterally.
   There was discomfort over both lateral epicondyles of the elbow to palpation, the left
    being worse than the right.
   There was no crepitus on movement.
   Strength testing of the muscles around the elbow was 5/5, except wrist extension
    resistance which was slightly weaker on the left and aggravating the elbow pain and
    normal on the right.



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   Reflexes of the biceps were 1/3, the triceps were 1/3, the supinator were 1/3, and
    symmetrical.
   Sensation was normal.


Wrist
   There was no significant deformity or effusion of the right wrist, and it was not
    obvious where there may have been a fracture.
   There was no obvious wasting noted of the forearm or hand muscles.
   There was no significant discomfort of the wrist to palpation.
   There was no crepitus on movement.
   Tinel‘s sign was negative.


Lumbosacral Spin
   Gait was normal and heel and toe walking was normal.
   The Trendelenberg and the Romberg‘s tests were normal.
   Flexion of the lumbar spine was possible to the mid-shins.
   Extension was normal. Lateral flexion was normal and symmetrical.
   Thoraco-lumbar rotation was within normal limits and symmetrical.
   There was tenderness overlying the lumbosacral junction and bilaterally over the
    sacro-iliac joints without significant paravertebral muscle spasm.
   There were tender points over the buttocks and the right medial knee.
   Straight leg raising was 70 degrees on the right and 70 degrees on the left.
   Sciatic stretches were negative. Femoral stretches were negative.
   Reflexes of the knee were 2/3, the ankles were 1/3, and symmetrical, and the
    plantars were down going.
   Sensation was normal. Power was 5/5 and symmetrical.


Investigations
The investigations performed so far included:
    17/05/2001                   MRI Report                  Normal
    22/02/2001                   Radiology Report            Normal


Diagnosis
Based on all of the above, the current diagnosis is:
   Bilateral tennis elbow
   Hypertension.


Medical rehabilitation
As noted above, the main current issue relates to pain from her elbows. Previous
involvement with the pain programme at the Regional Pain Service was very helpful. It
would be important that she attend the planned six-monthly review with this service.

Her hypertension is well controlled on medication. This does not present a barrier to
rehabilitation but it is preferable for vocational rehabilitation to avoid outdoor work with
significant exposure to the cold.



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Discussion and opinion
The diagnosis is bilateral epicondylitis with ongoing pain. This has been successfully
managed through attendance at the pain programme at the Regional Pain Service.
Because of the continuing elbow problem, the physical restrictions would include:
   Lifting, though she coped comfortably with up to 5-6kg of lollies
   Carrying, with the limit of 9kg
   Repetition that involves force, vibration, or lifting.


Because of the hypertension with treatment by a beta blocker (Betaloc CR), outdoor work
is ideally avoided.


Work types
Each of the work types identified by the vocational assessor has been considered below
in conjunction with the medical examination and the suitability of each for ―S‖.


                 It is my opinion that the following types of work are
                        currently medically sustainable for “S”


1. Work type – “Debt Collector” 599311
    In my opinion this work type is suitable because according to the relevant work type
    detail sheet the functional demands of the work type, eg walking, driving, and sitting,
    are all medically sustainable.


    Specifically, there is a good variation in postures needed with the mix of sedentary
    work and moving about. More than very light lifting is unlikely as detailed for this
    work type. Repetitive work is not required.


    The outdoor aspect of this work is not likely to be a problem as there is not significant
    exposure to cold. There is no medical reason to advise that outdoor work must not be
    undertaken. The possible development of white and cold fingers is of nuisance value
    only.

       “S” agrees with this, however she thought she may need to get ear
       phones because of the difficulty of holding the phone, but she is happy
       in this role having had past experience.


2. Work type – “Supply and Distribution Manager” 133611
    In my opinion this work type is suitable because the functional demands of the work
    type, such as sitting, standing, moving, and mental activities are all medically
    sustainable as detailed in the work type detail sheet.


    Specifically there is a good variation in postures needed with the mix of sedentary
    work and moving about. The work is typically in an office environment indoors.
    Stretching, bending, twisting, climbing, and lifting are unlikely to be required.
    Repetitive movements are unlikely to be necessary unless significant keyboarding is
    required.

       “S” agrees with this.



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3. Work type – “Conference and Event Organiser” 149311
   In my opinion this work type is suitable because the functional demands of the work
   type, such as sitting, driving, and mental activities are all medically sustainable and
   are detailed in the work type detail sheet.


   Specifically there is a good variation in postures needed with the mix of sedentary
   work and moving about. The work is typically in an office environment and indoors.
   Stretching, bending, twisting, climbing, and lifting are unlikely to be required.
   Repetitive movements are unlikely to be necessary unless significant keyboarding is
   required.

      “S” agrees with this, however the issue is that she doesn’t have the
      “pizzazz” which she believes is normally part of this role.


4. Work type – “Sales Assistant” 621111
   In my opinion this work type is suitable because the functional demands of the work
   type such as standing, processing, lifting and passing, stretching and twisting, and
   mental activities are all medically sustainable.


   This work type is indoors and the physical demands are in the sedentary to light work
   range. There is frequent standing required but this is not an issue from a medical
   perspective for ―S‖. The position is also sustainable provided that constant repetitive
   hand and finger activities are not associated with this position.


   This work type is classified as sedentary to light physical demand meaning up to 9kg
   may be involved. This is within her physical ability.

      “S” agrees with this, but raises the issue that she was told by her friend
      that she may have to lift heavy objects, and also the fact that she has had
      21 job rejections.


  It is my opinion that the following types of work are likely to be medically
sustainable for “S” after medical rehabilitation as detailed earlier in my report.


5. Work type – “Accounts Clerk” 551111
   In my opinion this work type, particularly the repetitive arm, hand, and finger
   movements, is doubtful in her current situation as exemplified by the aggravation by
   the current computer course, but may be considered once her rehabilitation is
   completed. Participation in the pain management rehabilitation programme review is
   likely to result in her gaining the ability to manage computer use. There is no medical
   reason to advise against the use of a computer.

      “S” agrees with this, however wonders how she would get on with
      computers, because she can be in agony after spending only 15 minutes
      sending e-mail.


6. Work type – “Bookkeeper” 551211
   As in 5 above.




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                  It is my opinion that the following occupation is
                          not medically sustainable for “S”.


7. Work type – “Domestic Housekeeper” 811412
   In my opinion this work type is unsuitable because the functional demands of the
   work type are not medically sustainable.


   This work type is indoors and the physical demands are in the light to medium work
   range. The work type detail sheet confirms that there may be constant walking,
   twisting of the neck and mental activities in this position. There may also be
   occasional carrying or lifting or moving of various items such as furniture, which ―S‖
   will not be able to manage with her injury.

       “S” agrees with this.


Conclusion
Of the seven work types identified to be suitable for ―S‖ by the vocational assessor, it is
my opinion that ―S‖ has currently the physical capacity to perform four of these as
detailed above as being medically sustainable.


Two of the work types are likely to be medically sustainable after further rehabilitation at
the Regional Pain Service. One of the work types, ―Housekeeping‖ is not medically
sustainable.


This conclusion has been discussed by me with ―S‖, who agrees but would like to think
that she could one day return to work as a motel manager. However, she realises that
the housekeeping role that can be involved makes this difficult.



Yours sincerely
Dr ABC



I hereby certify that in giving this assessment, I have undertaken reasonable actions in
the circumstances to give effect to the rights, and comply with the duties, in the current
Code of Health and Disability Consumer Rights. This includes Right 5 [Right to Effective
Communication], Right 6 [Right to be Fully Informed] and Right 7 [Right to Make an
Informed Choice and Give Informed Consent].




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Appendix 5: Example - Vocational Independence Medical
Assessment

                                      Dr Very Good
                      MBChB, MRCGP, Dip Obs, FRNZCGP, Dip Occ Med
THE CLINIC                                                            TEL 00 112-4567
123 MAIN                                                              FAX 00 112-4568
ANYTOWN


Vocational independence medical assessment of:


Name:        Mrs AB
Address:     246 Other Ave
             Anytown


Claim No: Z234567/000


Vocational independence medical assessment issued at the request of Mary Poppins,
Client service staff, Anytown Office.


Date of Assessment:               10/09/2003
Date of Birth:                    23/10/1965
Occupation at Injury:             Bank Teller
Employer:                         Bank
Duration of Employment:           5 years
Date of Accident / Injury:        15/12/1991
Date of Work Cessation:           01/04/1992


Thank you for referring Mrs AB for a vocational independence medical assessment.


I have discussed with her the purpose of the assessment. Mrs AB indicated that she
understood the process as this has also been explained by her client service staff
member.


I have reviewed the following list of referral documents:
   Vocational Independence Occupational Assessment report by AB, 12/4/03
   Vocational Independence Assessment: File Summary, Team Review and Quality
    Check
   Initial Medical Assessment by Dr AB, 20/8/02
   IN4A by Dr AB, 27/4/02
   Medical Certificate
   Vocational Independence Assessment: Client Questionnaire
   Vocational Independence Assessment: General Practitioner Questionnaire



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   Ultrasound R) shoulder, 17/2/2001; X-ray R) shoulder and hand, 14/12/2000; NM R)
    shoulder, 21/6/2002
   Report by Mr Bones, 4/2/2003
   Report by Dr GS, Rheumatologist
   Reports by Dr XV, Occupational Physician
   Reports by Dr YZ, Occupational Physician
   Reports by Dr SS, Rheumatologist
   First Medical Certificate
   Advice of injury form
   Report by HH, Physiotherapist
   GP clinical notes, 11/11/1997 – 6/9/2003
   A CV
   Reports by LJ, Management Consultants
   Work preparation programme
   Individual rehabilitation plan
   Client Consent for Collection and Release of Information
   Initial Occupational Assessment report by CF
   Initial Medical Assessment report by Dr EE.


The following details of interview are those as obtained from Mrs AB.


Background
Adequate information has been received for this vocational independence medical
assessment. It does not conflict with her own history as related to me, which follows.


History of injury, treatment and progress
Mrs AB was working at a bank in 1992. She had two jobs. In the day she worked as a
teller between 11am and 3pm, and at night she worked as a re-check computer operator
between 5pm and 11pm or 12pm. She was using her index and middle fingers a lot in
her work. She was carrying big bundles of cheques, putting them through the computer,
carrying them in trays, and pigeon-holing them to the relevant banks. She developed
soreness of her right shoulder, right arm, right hand, and the right side of her neck.


She attended many different types of physical treatment but found they didn‘t really
help. She seems initially to have been diagnosed with OOS of the right arm. Ultimately
she was put off work in 1994. Despite stopping work she has continued to have some
symptoms. These have been maximal around the right shoulder and have settled
somewhat down in the arm.


Treatment summary
She has attended physiotherapy, acupuncture, massage, and other physical therapies,
which have not really helped much. She has had injections to her right shoulder and to
the elbow and neck but these did not help. She used to take a lot of Paracetamol to
assist but again doesn‘t feel it really helped. She has seen numerous specialists over
time, including Dr SS - Rheumatologist, Dr TW - Occupational Physician, Dr ED -
Occupational Physician, Dr UO - Rheumatologist, and Mr Bones - Orthopaedic Surgeon.
X-rays of the right shoulder and hand dated 19/12/2000 were normal.



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Right shoulder ultrasound of 15/2/2001 demonstrated some mild thickening of the
subacromial bursa but the tendons of the rotator cuff appeared unremarkable. MRI of the
right shoulder on 21/5/2002 suggested tendinosis of the supraspinatus, but in addition
there was slightly unusual fluid signal at the myotendinous junction at the junction of
supra and infraspinatus, suggesting there may be a small interstitial tear.


Most recently she has seen Mr Bones, who indicates that the diagnosis is a right
supraspinatus tendonitis and associated subacromial bursitis impingement. Because of
the time course of matters he did not recommend surgery. He did recommend some
specific shoulder exercises. These were shown to Mrs AB by her physio. She attended the
physio for a total of 10 sessions and now continues to do the exercises at home herself,
having learnt what to do. She has found that her shoulder pain has decreased and she is
more confident in using her shoulder.


She takes Diclofenac only when pain is particularly bad, which is only about once a
month since she started the shoulder exercises recommended by Mr Bones.


Present position
Mrs AB indicates she has lived with symptoms for so long now that she has got used to
them. However, her pain is only about once a month since starting the regular shoulder
exercises, mainly from the right shoulder region, and she tends to point to the superior
aspect of the shoulder in the acromio clavicular area when saying this. She describes the
pain as a muscle pulling pain. She takes Diclofenac for it only when it is particularly bad,
but it helps quite swiftly. Down her arm she feels her symptoms have improved, but
there is still some soreness that she notes if she has been busy doing something.
Activities that can aggravate pain include stretching up for cleaning, hanging washing,
and dusting. Vacuuming, washing dishes and making beds can also make matters worse.
She finds that attempting to massage the shoulder or pushing on it actually hurts and
doesn‘t help. She doesn‘t find that heat or other therapies make a difference. The only
thing that she isolates as assisting is the medication when pain is really bad.


Sleep can be disturbed if she rolls onto her right side, as it then hurts. She can drive.
She feels that using a computer causes an unpleasant sensation of electricity and so she
avoids its use. Often when she performs excessive activity with the right arm she does
not notice problems while doing so, but will notice increased pain when she sits down and
rests afterwards.


Past history of illness
Mrs AB has non-insulin dependent diabetes for which she takes Diamicron and Atacand to
gain control. She had modest hypercholesterolemia, obesity, raised feffitin, liver function
abnormalities, and had an elevated white cell count and associated lymphocytosis when
seen by Prof HA, the physician at the Diabetic Clinic. Once the diagnosis of diabetes was
made the other problems apparently settled. She has lost weight since this time also.
Ultrasound of the liver showed mild fatty changes. A liver biopsy has been taken but was
normal. She has suffered with recurrent headaches of the fronto-temporal region,
particularly of the R) side of her head. She gets these about twice a week. Sometimes
she will use Brufen for them. She does not recall any other major past history.


Occupational history
Mrs AB was born in Australia and moved to New Zealand in 1969. She worked as an
accounts clerk at a printing factory for two years. She was an accounts clerk in a



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government department for a year. She was a bank teller for a bank for two years. She
was an accounts clerk for six months. She worked in another bank as a bank officer for
five years. She left the work there in 1993 because of R) shoulder pain and has not
worked since then.


General health (medical, personal, recreation)
Mrs AB is married. She has two children, aged 16 and 6. She smokes 10 cigarettes per
day. She does not drink alcohol. She indicates she used to be quite sporty, but doesn‘t
do any regular exercise now. She maintains interests in the church. Her husband is a
minister and she is involved in Bible studies etc. She reads a lot and does crosswords.


Pain
Mrs AB describes some muscle pulling pain, which used to be present all of the time
around the right shoulder joint but is now only probably once a month. At times,
however, she can still suffer with soreness affecting the right neck and the right upper
arm, and a strange sensation of the right hand.


Examination
A pleasant woman with normal gait, posture, and handshake. She appeared to sit
through the interview in comfort. Movements of fingers, thumbs, and wrists were fully
normal. There was slight reduction in full left elbow flexion from a childhood fracture,
restricting flexion on the left elbow to 100. Movements of the left shoulder were normal.
Movements of the right shoulder were limited to 150of abduction, 150of flexion, 50of
internal rotation, and normal ranges of adduction, extension, and external rotation.


The circumference of the right upper arm was 0.5cm greater than that of the left upper
arm. The circumference of the right forearm was 0.5cm greater than that of the left
forearm. Reflexes were present and normal (biceps, triceps, and supinator).


Two-point sensation was normal on the digits of both hands. The colour of both hands
and arms was normal. Pulses were present and normal at both wrists. There was no
scarring or evident deformity of the right arm. She was tender to pressure along the joint
line of the right shoulder, but not over the AC joint. There was slight tenderness to
palpation into the muscles of the right upper arm; the elbow was non-tender. There was
slight tenderness to palpation of the right wrist and hand generally.


Movements of the neck were full in all directions, but lateral flexion to the left did cause
soreness on the right-hand side. There are notable scars on the anterior chest including
one with what appears to be keloid formation from a mole removal when she was
younger. Phalens and Tinel‘s tests were negative. She appeared in general to be well.


General
   Weight:             75kg                       BMI: 29
   Height:             160cm
   Vision:             She does wear spectacles
   Mobility:           Appeared fully normal
   Hearing:            Appeared normal through our interview
   Other:              She is right handed.




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Summary of diagnostic investigations
X-rays of the right shoulder and hand dated 19/12/2000 were normal.


15/2/2001 demonstrated some mild thickening of the subacromial bursa, but the tendons
of the rotator cuff appeared unremarkable.


MRI of the right shoulder on 21/6/2002 suggested tendinosis of the supraspinatus, but in
addition there was slightly unusual fluid signal at the myotendinous junction at the
junction of supra and infraspinatus, suggesting there may be a small interstitial tear.


Discussion and opinion
Mrs AB has been diagnosed with right supraspinatus tendonitis and associated
subacromial bursitis and impingement by Mr Bones, having undergone MRI scanning.
This will be the prime diagnosis for the main site in which she gets symptoms now.
Tenderness, although slight of the wrist and hand, would not be explainable by this and
one would therefore think that there has perhaps been more than one diagnosis here. I
would imagine that she perhaps has a resolving pain syndrome of the right upper limb,
and we see the residual sign of this. As stated, the main focus for pain now, however, is
the right shoulder and the MRI has demonstrated pathology here confirmed in Mr Bones‘
report.


The referral to an orthopaedic surgeon that was recommended in the IMA report of Dr EE
has clearly resulted in a considerable improvement in her shoulder pain and condition in
general. She has learnt to do the shoulder exercises and does these on a regular basis at
home as she has found that they have been very helpful.


No further treatment or rehabilitation initiatives are indicated at this time.


The main restriction therefore would be in excessive or heavy shoulder usage and this
would relate to heavy lifting or stretching up or across on the work type detail sheets.
There may well still be, however, some residual restriction of persistent and excessive
repetitive motion of the hands in tasks such as keyboarding.


Work capacity


       Mrs AB has the physical capability to work for 35 hours or more as:


   42213 Receptionist
   Heavy lifting and stretching up or across are not featured in the work type detail
   sheets. Repetitive movements are intermittent and hand tools are commonly used.
   This seems very reasonable. Although computers would be used she would not have
   to do great tomes on them at a time and the job description is well mixed. Walking
   and sitting are featured, as are mental activities. Again, given Mrs AB‘s restrictions,
   she has the physical capability to do this job. She indicates she has never done this
   work and it sounds like it could be a good challenge.

       She finds the prospect of computer keying and typing quite scary.




October 2008                                                                     Page 43 of 50
           Vocational Medical Assessors – Operational Guidelines: Appendices


   42111 Cashier
   Heavy lifting and stretching up or across are not featured on the work type detail
   sheet. Repetitive movements and the use of hand tools are frequent to constant and
   are necessary for operating electronic tills and cash handling.


   The position generally requires contact with the public in such a way that one is not
   actually typing consistently throughout, and in my opinion I feel that she would cope
   in this role.

      She indicated that yes, she supposed there wouldn’t be anything wrong
      with doing this type of work. She thought this might be possible.


   42113 Ticket Issuer
   Heavy lifting and stretching up or across are not featured on the work type detail
   sheet. Although repetitive movements and the use of hand tools are common, the
   position generally requires contact with the public in such a way that one is not
   actually typing consistently throughout, and as such I feel that she would cope in this
   role.

      She indicated that yes, she supposed there wouldn’t be anything wrong
      with doing this type of work.


                 Mrs AB does not have the capacity to work as a:


   552111 Bank Worker
   Sitting is the most common position in this work type detail sheet. Repetitive
   movements are intermittent and hand tools are commonly used. She might end up
   having to do too much in the way of consistent computer input, but in other roles
   would not.

      She indicates that she would like to do this work, but knows that she
      wouldn’t be able to due to her experiences in the early 90s.


   531111 General Clerk
   Heavy lifting is indicated to be uncommon in the work type detail sheet. Sitting is the
   common position. Repetitive arm, hand, and finger movements (keyboarding and
   mouse) are constant for data-entry and data and word processing tasks. The use of
   minor office hand tools such as pens, calculators, and staplers, as well as telephones
   will also be occasional to frequent.

      She thinks she might like to do this, but wonders about how much
      computer use and how she would go answering the phone and whether
      this would be possible for her.


   551111 Accounts Clerk
   The work type detail sheet has common repetitive movements and the use of hand
   tools. Sitting is the common position. It would depend on the particular position, but
   the excess hand and computer usage might become a problem.

      She indicates she used to do this and she liked to do it, but she doesn’t
      think she would manage the computer use now.




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            Vocational Medical Assessors – Operational Guidelines: Appendices


   551112 Cost Clerk
   Common repetitive movements and hand tool usage are features of this work type
   detail sheet. Sitting is the common position. The job description would indicate a
   more consistent computer usage and this might well then be a problem.

        She felt this was similar to the accounting and bookkeeping clerk one and
        the computer use might be a problem.


   551211 Bookkeeper
   Common repetitive movements and hand tool usage. Sitting is the common position.
   The work type detail sheet indicates a more consistent computer usage and this
   might well then be a problem.

        She felt this was similar to the accounting, office clerk, and bookkeeping
        clerk ones and the computer use might be a problem.


   631111 Checkout Operator
   Heavy lifting is indicated to be uncommon in the work type detail sheet, but lifting is
   required albeit perhaps not heavy on a very repetitive basis. The repetitive
   movements and use of hand tools are indicated to be common. Twisting the body or
   neck is indicated to be common. Stretching up or across is not featured although this
   would seem to probably be a feature normally. Overall it is something I would not
   suggest.

        She agreed that packing goods would be a problem for her and did not
        think this would be a good idea.


She was pleasant and co-operative to interview. She presents as a likable, cheerful
person, who would probably be an asset to many workplace settings. I hope that she
finds suitable work in the near future. I wish her all the best in general for the future.




Time
Interview commenced at 9.30am
Finished at 10.50am
cc ACC Client service staff
cc GP




October 2008                                                                   Page 45 of 50
               Vocational Medical Assessors – Operational Guidelines: Appendices



Appendix 6: Example – Work Type Detail Sheet

Fishing Hand - 899212

    Description:

       Catches fish and shellfish using nets, pots, lines and traps in ocean and inland waters.

    Work Tasks (may include any combination of the following):

       Attaches gear and fastens towing cables to nets; casts and lowers nets, pots, lines and
        traps into water; prepares lines, attaches running gear and bait, and sets lines into
        position; hauls in fishing gear and removes fish and other marine life; sorts, cleans,
        preserves, stows and refrigerates catch.

    Work Environment:
       Works on fishing boats or varying sizes carrying out a full range of deck and other on-
        board fishing-related tasks.
       Works in almost all weather and sea conditions.
       Occasionally to frequently works with ropes.
                                2
    Work Function/Activity :
       Medium to heavy physical demand levels.
       Stands and walks about the deck of vessel to move ropes, lower pots and nets, clean-
        up, and complete general on-board tasks.
       Uses upper limbs and body to stretch up and across occasionally when lowering fishing
        equipment, working winches or brining catch on board.
       Bends occasionally to frequently.
       Occasionally to frequently squats or crouches when inspecting catch.
       Occasionally to frequently twists the body or neck.
       Frequently lifts and carries equipment, catch and other on-board supplies and
        materials.
       Repetitive hand and arm movements are required occasionally when processing fish
        and working ropes and winches.
       Driving is not required.
       Uses a range of hand (or power) equipment such as winches, cleats and boat hooks.
       Frequently climbs on and off vessel and may climb on superstructure or rigging for some
        tasks.
       Mental activities necessary include practical technical and organisational skills.
    Further Comments:

       There are limited opportunities for flexibility of movement.

    Entry Requirements:

       Nil.




2
 This document is based on ANZSCO, 2006 (code 899212). Other sources of information that may have been
consulted are industry contacts, employers, newspapers and internet-based sources. For physical demand level
definitions see Matheson, L.N. (1996). Functional Capacity Evaluation.




October 2008                                                                               Page 46 of 50
            Vocational Medical Assessors – Operational Guidelines: Appendices



Appendix 7: US Department of Labor Physical Demand
Characteristics of Work

Overview
The 37.02 US Department of Labor Physical Demand Characteristics of Work chart, lists
the occupational requirements for physical exertion.


Parameters
   Amount of weight moved at work
   Relative frequency that activity occurs during workday (occasional, frequent or
    constant).




Physical         Occasional          Frequent             Constant             Typical
demand level     (0-33% of the       (34-66% of the       (67-100% of the      energy
                 workday)            workday)             workday)             required

Sedentary        10lbs               negligible           negligible           1.5-2.1 METS
                 (4.5 kilos)

Light            20lbs (9 kilos)     10lbs (4.5 kilos)    negligible and/or    2.2-3.5 METS
                                     and/or walk          operate controls
                                     and/or stand with    while seated
                                     operation of
                                     controls

Medium           20-50lbs            10-25lbs             10lbs                3.6-6.3 METS
                 (9-22.7 kilos)      (4.5-11.4 kilos)     (4.5 kilos)

Heavy            50-100lbs           25-50lbs             10-20lbs             6.4-7.5 METS
                 (22.7-45.4 kilos)   (11.4-22.7 kilos)    (4.5-9 kilos)

Very heavy       > 100lbs            > 50lbs              20lbs                > 7.5 METS
                 (45.4 kilos)        (> 22.7 kilos)       (> 9 kilos)




Where
   Operation of controls includes pushing and/or pulling of arm and/or leg controls
   Operating controls while seated includes pushing and/or pulling of arm and/or leg
    controls.


Reference
Matheson LN. Chapter 18: Functional Capacity Evaluation. pages 168-188. In: Demeter
SL, Andersson GBJ, Smith GM. Disability Evaluation. Mosby. American Medical Association.
1996.




October 2008                                                                  Page 47 of 50
            Vocational Medical Assessors – Operational Guidelines: Appendices



Appendix 8: Frequently Asked Questions (FAQs)


How do I take into account non-accident conditions when writing my report?

When completing an IMA report the assessor identifies types of work that are currently
medically sustainable or are likely to be medically sustainable following rehabilitation. In
doing this, the assessor must consider both the ACC covered injury and non-ACC covered
conditions. Types of work that are likely to be sustainable only after treatment or
rehabilitation will need a recommendation for treatment or rehabilitation
recommendation. This will be limited to the needs of the ACC covered injury and the
impact on the client‘s vocational rehabilitation. However, it must also take into account
the non-covered conditions. For example, if a client has ischaemic heart disease and gets
angina on exertion, and had as the covered injury a fractured femur, the rehabilitation
recommended would only be looking at helping with the sequelae of the fracture of the
femur but, due to the heart condition, the recommendation would likely rule out any
work types that were not sedentary or light as given by the work type detail sheet.




What if I consider that the medical diagnosis provided by ACC is wrong?

The basis of good rehabilitation or treatment is a good diagnosis. Assessors will receive
medical reports that ACC has been sent and on which the cover decision will be based. If
as an assessor you conclude that the diagnosis or characterisation of the injuries in these
reports is incorrect, you need to indicate this in the ‗Discussion and Opinion‘ section of
your report. Your recommendations must be based on your own diagnosis.
On receiving such an assessment ACC will need to examine whether the different
diagnosis given by you means that ACC needs to re-examine the issue of cover for the
client. It is not your role as a vocational medical assessor to look at the question of
cover. Your role is to look at the question of vocational rehabilitation and the capacity for
work of the client with the conditions as assessed by you.




What is the definition of heavy lifting?

See Appendix 7 for definitions of ‗heavy‘, ‗very heavy‘, ‗medium‘, ‗light‘ and ‗sedentary‘.




What do I do if the IOA doesn‟t seem correct?

   If this is identified before the medical assessment, please contact the client service
    staff member who sent the referral and advise of your concerns.
   If you identify it at the time of the actual appointment with the client, proceed with
    the assessment as usual and contact the client service staff member before
    completing the report.
   If there is any change, the client can always be contacted for comment after the
    assessment or a follow-up can be arranged if the changes are major.




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            Vocational Medical Assessors – Operational Guidelines: Appendices




What is meant by “Sedentary to light work. Frequently standing at sales counter
for most of the period employed” in the 52111 Sales Assistant Work Type Detail
Sheet from the occupational assessor?

‗Sedentary to light work‘ refers to the requirement to lift negligible to 4.5 kilos and/ or
walk and/or stand with the operation of controls. ‗Frequent‘ refers to 34 – 66% of the
work day. In this case the typical energy required is 1.5 – 3.5 Mets. One Met is the
amount of expended energy equal to 3.5ml (kg – min) oxygen consumption. See also,
‗Appendix 7 - US Department of Labor Physical Demand Characteristics of Work‘.




Why are 35 hours stipulated?

This is the number of hours that are required by the legislation. The AC Act defines
vocational independence as being the capacity to work in a type of employment for 35
hours or more per week.




Who do I contact if I have questions about a vocational medical assessment?

You should in the first instance contact the ACC client service staff member who sent you
the referral. ACC has staff who are knowledgeable about vocational rehabilitation from
both a medical perspective and a rehabilitation perspective and the client service staff
member can put you in contact with the appropriate person if required.




Are there any national guidelines on doing assessments for ACC?

Please see the New Zealand Medical Council‘s statement on ―Non-Treating Doctors
Performing Medical Assessments of Patients for Third Parties‖.


This is held on their website: Medical Council of NZ under Publications and guidance >
Good Medical Practice - Professionalism.




Why can‟t I:
   Add vocational comments to the IMA/VIMA when I have an occupational
    qualification?
   Add new jobs to the IMA/VIMA?
   Add tasks if I know the job and disagree with the occupational assessor?

Medical assessors are the experts in the medical area and need to limit their comments
to this field. This is required by the AC Act and relevant case law.




October 2008                                                                   Page 49 of 50
                              Vocational Medical Assessors – Operational Guidelines: Appendices


               Appendix 9: Flowchart of Client Participation in Vocational Rehabilitation




October 2008                                                                                      Page 50 of 50

				
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