1. Date - View Header and Footer to edit
WSIB, The Service Delivery Model & Return to Work A Presentation to the PSHSA Safety Group September, 2010 1

2. About the WSIB
The Workplace Safety and Insurance Board (WSIB) has over 4,500 staff in Toronto and in 13 Regional offices.
The WSIB is the fourth largest group insurance company in North America.
Since its creation of the Workman’s Compensation Board in (now the WSIB), the WSIB provides coverage to injured workers and no-fault insurance to Ontario workplaces that protects employers from litigation.
The WSIB is entirely financed by employer premiums. We receive no money from the Ontario provincial government. V2 V2

3. Some Quick Facts
Approximately 4 million workers are covered by the WSIB (about 70 per cent of Ontario’s employment).
The WSIB provides benefits and services to over 550,000 injured and ill workers, surviving spouses, and children - almost five percent of Ontario’s total population.
The WSIB manages over 350,000 claims a year, makes over a million decisions a year and pays out over $3.4 billion in claim payments.
The WSIB provides a range of services to approximately 225,000 employers. - V2 V2

4. Prevention
The WSIB's vision is the elimination of all workplace fatalities, injuries, and illnesses.
There are a number of ways we are creating healthier and safer workplaces in Ontario.
WSIB Prevention roles include:
Disability Prevention Specialist
Workwell Evaluator
Prevention System Collaboration Specialist V2 V2

5. Prevention V2 Safety Groups Safe Communities Incentive Program (SCIP)
Experience Rating Programs (NEER, CAD-7, MAP)
JHSC Certification & First Aid
Prevention Contact Centre V2 V2

6. Registration ,Determining Eligibility And Payment
The Life of a Claim
Registration ,Determining Eligibility And Payment

7. How is a Claim Established?
A claim can be initiated by :
Employer’s Report of Injury/Disease (Form 7)
A medical report (e.g. Form 8)
Contact by the worker
Form 6 or letter
Phone Call
Initial documents are scanned to the imaging system and the claim is assigned a claim number
All forms can be accessed on our WSIB website at
Describe the process of establishing a claim including:
Imaging of the initial and subsequent forms/reports
Assignment of a claim number by Claim Registration
Triaging of a claim to ensure it is routed to the appropriate adjudication area for
further handling

8. Employer Obligations - Reporting
Employers must report a work-related accident to the WSIB if they learn that a worker requires health care and/or:
is absent from regular work
earns less than regular pay for regular work (e.g., part-time hours)
requires modified work at less than regular pay
requires modified work at regular pay for more than seven calendar days following the date of accident
When a work-related accident occurs, all workplace parties have other obligations under WSIA,
in addition to reporting the accident to the WSIB

9. Loss of Earnings (LOE) Benefits
If a claim is allowed
WSIB pays loss-of-earnings (LOE) benefits when an injured worker (IW) is disabled from work
Bill 99 (Jan.1, 1998) – LOE benefits are paid at 85% of weekly net average earnings
Maximum gross earnings covered (2010) $77,600
Explain when a worker is entitled to LOE benefits (total and partial disability)
State the change in benefit levels from 90% to 85% of NAE as a result of Bill 99

10. Paying LOE Benefits LOE benefits are paid until:
impairment ceases
earnings are restored
suitable and sustainable work is offered that restores earnings
worker is deceased
worker reaches the age of 65
If the worker is 63 years of age or older at the date of injury, benefits can be paid for up to 2 years
LOE benefits are paid until:
impairment ceases
earnings are restored
suitable modified work is offered that restores earnings
the worker dies
the worker reaches the age of 65
If the worker is 63 years of age or older at the date of injury, benefits can be paid for up to 2 years
Permanent impairment (PI) means certain health care benefits can continue to be paid
At 72 months post-accident:
LOE benefits are locked in to age 65
A worker can be eligible for a NEL re-determination to age 65

11. How Are Services Being Delivered?
Claims Services
Workplace Program Services
Account Services
Service Delivery Manager
Service Delivery Manager
Eligibility Manager
Revenue Manager
Revenue Manager
Prevention
Manager
Eligibility Adjudicators
Short Term Case Managers
Long Term Case Managers
Account Specialists
Account Specialists
Account Analysts
Nurse Consultant
Nurse Consultant
Supporting Roles:
Investigator RTW Specialist Medical Consultant 30
days
180
days
CCP / Primary
Initial Entitlement
DOI
It’s important to understand that all of the case management staff, from Eligibility to Long term Case management, are using the Case Management model.
Let’s take a few moments to review the various roles within the NSDM.
Eligibility Area
In the Eligibility Area, the focus is on making timely and quality eligibility decisions, and in identifying and assessing cases early to determine the scope of proactive case management required.
Wherever possible, information will be gathered person to person (avoiding forms and letters).
For example, in our Central Claims Processing area, registration clerks will now call employers on claims registered on a Health Professionals Report of Injury (Form 8) to provide you with a claim number; enquire regarding the submission of your Employers Report of Injury (Form 7); and check on the RTW status.
This is the new level of service you can expect.
Our Primary Adjudicators will continue to focus on expediting initial eligibility decisions in new claims. Where they are unable to do so because of issues such as case complexities or outstanding information, they will quickly move it along to the Eligibility Adjudicator who is specialized in making eligibility decisions.
Eligibility Adjudicators will be able to request the assistance of Case Managers in files where entitlement has not yet been determined and there are issues related to return work (such as job suitability). Ownership of the case remains with the Eligibility Adjudicator until the initial entitlement decision is made.
Eligibility Adjudicators can also request the assistance of an Investigator, who will help gather information that: cannot be easily obtained, is missing, or where there are issues of compatibility (this means compatibility of diagnosis to accident or disablement history).
Claims will be transferred from the Eligibility Adjudicator to a Case Manager where entitlement is allowed with ongoing benefits and the worker has not returned to regular work, full pay. The principle in this model is that “cases move forward, not backwards” with a clear focus on return to work and recovery.
Case Management
Depending on where a claim is in its lifecycle, and the specific type of services required, there will be collaboration between various roles within the NSDM. However, at any given time, a case will only have one Case Manager assigned.
Case Managers are experts in return to work, and manage a claim from the perspective that every worker will be returning to work with the accident employer…. or with a new employer, where the accident employer is ruled out. We have created two unique Case Manager roles to reflect the different journeys workers may have in returning to work.
First, we have the Short Term Case Manager whose exclusive focus is on early and safe return to work with the accident employer. Their primary focus will be to establish supportive and influential relationships with the workplace, working together to set safe and sustainable return to work goals, and creating plans that support return to work and recovery.
Secondly, we have Long Term Case Managers available to assist workers whose cases may be more complex – this is in terms of the length of their medical recovery (generally longer than 26 weeks from date of injury/illness), who need services outside of the WSIB….. such as vocational services, to assist with a return to the accident employer, or preparation for a return to work with a new employer. Examples of this include: non-dominant hand training, skills training programs, and English as a Second Language programs.
These Case Managers request assistance from various internal speciality resources when needed, to help in this return to work process. These resources include the following roles:
The Return to Work Specialist brings a specific specialization to a case and assists in managing return to work issues when the STCM identifies an obstacle that they can’t overcome on their own, and that needs to be overcome in order to achieve the best possible RTW outcome. It is anticipated that the majority of the RTW Specialist’s interventions will occur right in the workplace.
These RTW specialists can also call upon an Ergonomist, who has an expertise in determining whether or not a specified job is appropriate to the worker’s functional abilities. These folks identify ergonomic barriers and generate accommodation solutions based on their observations and with input from the worker and employer.
Nurse Consultants on our teams are there for support in making and communicating health care entitlement decisions, and provide clinical advice, guidance, and interventions to mitigate recovery obstacles delaying recovery and return to work.
Our Medical Consultant supports Case Managers and Nurse Consultants. He also contacts attending physicians to help progress the case forward. These discussions including issues such as high risk opioid use, conflicting prognosis, and misaligned messaging to our workers.
The NSDM also has three new roles relating to account and disability management. Some employers will have already begun to feel a difference in how their account inquiries and issues are being handled.
Through the centralizing of revenue related functions within the WSIB’s Employer Service Centre employers are now served by:
Account Analyst – who’s focus is on transactional work (e.g. balance enquires, address changes, etc )
Account Specialist – who handles more complex account issues (e.g. registrations and classifications)
The Disability Prevention Specialist (DPS) – who provides an essential link between Service Delivery and the important work of the Prevention Division in actualizing our commitment to support the elimination of all workplace injuries, illness and fatalities.
Short Term Case Management
Long Term Case Management
Eligibility Area
CONFIDENTIAL

12. Case Management Framework
We mentioned a more standardized, personalized and collaborative approach to case management that is being used as a tool in our road to zero.
I would like to show you the model that our staff are now using in the NSDM.
Case management is an approach to facilitating, coordinating and linking services that work together to achieve planned outcomes, with a focus on the worker. The case owner is accountable for orchestrating case management, including relationships and communication while they are working this framework.
You will note that the two key success factors for the model are, in fact , communication and relationship. Greater interpersonal engagement with all workplace parties is fundamental to this approach, as is proactive and timely decision making.
The model works on behalf of worker and employer rights, obligations, and pursues positive outcomes regarding prevention, RTW , recovery , and compensation.
It encompasses a set of activities which may be done individually or simultaneously. Since case management is an iterative process, these activities may be repeated several times during the life of a case.
They are:
collect essential information at the most opportune time to develop intelligence for achieving the outcomes of the case;
think critically and analyze the info collected to assess and understand the obstacles and opportunities as well as to differentiate and
position for goal setting and decision making
to set a collaborative and appropriate goal for the worker in order to develop the best plan, and make decisions that are accurate, fair, timely, transparent and well-communicated
collaboratively develop a roadmap for success, and identify steps, milestones and tasks together with the WPP to achieve the goals
timely execution of the planned activities
interactively manage and drive the plan with all appropriate parties to ensure it all happens!
complete the plan with the desired outcomes achieved: communicate the closure
ensure sustainability is achieved to ensure quality of life is maintained and to develop self-adjusting process to achieve desired outcomes in the future
This case management approach came about through the effort and dedication of more than 70 people within our program development division.
We are committed to using this standardized approach to bring consistent and formalized planning, facilitating, coordinating and linking of services that will improve RTW and recovery outcomes. Our staff will always use this model to keep a case moving forward towards the established goals.

13. Primary Adjudication
Claims that are straightforward in accident history are directed to Primary Adjudication
Explain how straightforward Form 7’s are triaged to Primary Adjudication for allowance
and processing

14. Eligibility Adjudication
Claims where entitlement is not obvious and further enquiries are necessary are assigned to an Eligibility Adjudicator
Primary and Eligibility Adjudicators determine entitlement using the Five-Point Check System
When a claim is allowed, if full recovery and a RTW to pre-injury work is not evident in the first 30 days, the case is transferred to a Case Manager whose primary focus is RTW and recovery.
Explain how claims where further enquiries are required are triaged to Eligibility to conduct timely
enquiries by phone with the injured worker and employer
Reference 5 Point Check as a systematic approach to determining entitlement which will be covered
in more detail shortly
Reference case transfer process to Case Management
STCM can provide RTW assistance to the Eligibility Adjudicator

15. Case Transfers
Cases are transferred from Eligibility to the Short Term Case Manager (STCM) for case management when there is:
lost time and the worker has not RTW
lost time and the worker has RTW that is different than the pre-injury/illness work, or
no lost time but the work is not consistent with the pre-injury/illness job and a permanent impairment is anticipated
Explain when cases are transferred from Eligibility to Case Management

16. The Short Term Case Manager (STCM) Role
The role of the STCM was created to improve RTW outcomes for workers and employers.
Case managers use a case management approach that is proactive, efficient and outcome focused. Their primary focus is to establish supportive and influential relationships in the workplace, working together to set safe and sustainable RTW goals and creating plans that support RTW and recovery.

17. The Long Term Case Manager (LTCM) Role
LTCM’s key focus is to leverage their expertise in managing complex and chronic cases, enabling best possible RTW and recovery outcomes and mitigating the long term effects of injuries/illnesses for the worker.
Cases are transferred to LTCM from STCM when:
RTW options with the employer have been exhausted and Permanent Impairment (PI) anticipated and worker not expected to be fit for pre-injury duties within 26 weeks from date of injury
RTW with the employer remains viable and a PI is anticipated but worker has no capacity to RTW within 26 weeks from date of injury

18. The Return To Work Specialist’s (RTWS) Role
In cases when the worker and employer are experiencing difficulty in setting up a RTW plan or the plan is not progressing as initially laid out, the RTWS is an expert resource available to the workplace parties (WPP’s) through the case manager. The primary objective of the RTWS is to lead the return to work process in those cases that will benefit from a worksite intervention, helping the parties to minimize obstacles and concentrating on achieving a positive RTW outcome.

19. RTWS Responsibilities
To ensure that the RTW obstacles are understood and there is an opportunity for the worker and employer to be heard and participate in the RTW direction, the RTWS will: - invite all necessary parties, including the union if appropriate, to discuss and negotiate RTW options - explain their role - lead collaborative conversations by asking probing questions - involve the in workplace parties in assessing RTW obstacles and opportunities and facilitate discussion to ensure agreement

20. Return to Work 20

21. Why Have a Return to Work (RTW) Program ?
Social and moral obligations
Financial Impacts
Legal obligations
Section 40 - duty to communicate and co-operate
Section 41 - re-employment obligations
Human Rights Code and its policy on Duty to Accommodate
Return to Work A Shared Responsibility
Amount of Chance of
Time off Work Return to Work
6 months to 1 year %
1 year – 2 years %
More than 2 years %
It makes sense
Saves your business money
Fulfills a social and moral obligation
Provides the best outcomes for you and your worker

22. The Workplace Parties (WPP)
The worker and employer are best positioned to develop their own return to work solutions.
In most cases, the WSIB is not involved in the RTW process, except to communicate to the WPP’s their statutory obligations, monitor activities, determine compliance with the obligations to co-operate and re-employ, and provide dispute resolution.
Many of the new or redefined roles in WSIB’s New Service Delivery Model can assist the WPP’s achieve their return to work goals.
The worker and employer are best positioned to develop their own return to work solutions.
In most cases, the WSIB is not involved in the ESRTW process, except to communicate to the WPP’s
their statutory obligations, monitor activities, determine compliance with the obligations to
co-operate and re-employ, and provide dispute resolution.
But when the specifics of a particular case or circumstance require a more in-depth involvement
of the WSIB, many of the new or redefined roles in the New Service Delivery Model are designed
to provide optimal assistance to help the parties achieve their return to work goals.

23. The RTW Goal
The RTW goal in case management is to return the worker to safe and sustainable work with the injury employer based on the following hierarchy:
Return to pre-injury job (starting point and overall goal) with incident employer
Return to pre-injury job accommodated with incident employer
Return to work comparable in nature and earnings to the pre-injury job (with accommodation if required) with incident or other employer
Return to alternate work (with accommodation if required) with incident or other employer

24. Questions? 24