Background
Internationally there is a trend towards building more integrated health care, focusing on improving the linkages between functions, institutions and professions in the health and social services [
1]. This type of integration of services is described as vertical, referring to coordination across various levels and institutions [
2,
3]. Another type of organization of services is horizontal integration, which refers to coordination across one level or service [
1]. Hvinden (1994) defines coordination as vertical integration [
2,
3], while Kärrholm (2007) describes coordination as including both vertical and horizontal integration, with the focus on vertical across levels coordination [
2]. Although the aim of integration is to improve coordination and integration of services, the scope of what is to be integrated varies across different services [
1]. Today best practice of RTW-programs include social and contextual factors as well as workplace interventions, in a biopsychosocial framework [
4‐
7]. RTW-interventions require cooperation between several stakeholders and across arenas and levels at the workplace, the health care services and the welfare system [
6,
8,
9]. Ideally, interventions from these three arenas should be vertically integrated and experienced as one seamless RTW-process for each individual [
1,
10].
Several intervention components are found to be essential for facilitating RTW, including centralized coordination of the employees RTW, formal individual psychological and occupational interventions, workplace-based interventions, work accommodations, contact between various stakeholders and interventions to foster concerted action [
8,
11,
12]. Facilitation of RTW is hence a complex practice facing several obstacles. One strategy to overcome challenges with integrated care has been to provide a coordinator [
1]. Provision of a coordinator has been positively associated with time to RTW in occupational rehabilitation [
11,
13‐
16], and is described as one of the core components for successful return to work [
16]. However, a recent review concluded that evidence does not support that RTW-coordination programs that provide a RTW-coordinator promote RTW [
17]. The evidence in the review is reported to be of low quality, and more comprehensive studies focusing on sustainable RTW and the workplace are therefore recommended [
17]. In contrast, another review concluded that there is strong evidence for recommending service coordination (ex. RTW plans, case management) in multiple component RTW-models together with health-focused and work modification components [
18]. RTW is not only an aim for the individual due to health, social and economic reasons, but also for society. The costs of sickness absence and disability are considerable, and RTW-coordination is reported among cost-effective RTW-intervention components [
19‐
21]. Even though there is an ongoing debate on the effect of RTW-coordination and provision of a RTW-coordinator, there is still a continuing need for integration of services and workplace focus in the return to work processes.
Internationally, integration of services is often solved by RTW-coordinators employed by insurers, employers, or governmental agencies [
22], with RTW-coordinators being a well-established part of the RTW-process [
16]. Reviews of RTW-coordinators revealed the activities of workplace assessment, planning transitions and facilitating stakeholder cooperation with focus on communication and problem solving [
16,
22]. Still, a recently published Canadian paper concludes that the integration of services is far below recommendation [
23]. Instead, the RTW-coordinators in large companies mostly focused on the employee-supervisor dyad, a horizontal integration, and did not coordinate towards health and welfare services or other stakeholders [
23].
In Scandinavia, coordination between stakeholders in RTW-processes is lacking [
2,
24‐
27]. The coordinating agent in RTW is in most cases the social insurance agency, a service separated from health care. However, the responsibility for providing a coordinator is not designated to a specific organization or authority [
2]. Although vertical integration of services has been outlined in several policy documents, as the Coordination reform in Norway exemplifies [
28], the practice, responsibilities and organizational structures of coordination are still reported to be inadequate [
9,
27,
29]. Studies of coordination and provision of a coordinator are often performed in trials where the coordination is provided as a component in RTW-programs [
15,
16,
30]. However, few have examined the coordination and cooperation between stakeholders in a real setting with observational design. A Swedish study of Social Insurance agency actions towards employees on long-term sick leave concluded with limited use of both vocational rehabilitation suggestions from the medical assessments, and active rehabilitation measures. Furthermore, of the activities undertaken by the social insurance agency, few actually enhanced RTW [
31]. The focus on work rehabilitation and effect on RTW in the Norwegian Social Insurance agencies (NAV) have similarly been questioned [
32,
33]. The reform in NAV has actually been found to have a negative impact on RTW [
33], and failure to achieve the goal of more people in work seems to be rooted in structural challenges in NAV [
32].
As shown above, coordination of services are reported to be inadequate, at the same time coordination and provision of a RTW-coordinator are emphasised as important intervention components in research as well as in policy documents. Accordingly, there is still a need for more comprehensive research in the field of coordination and provision of a coordinator in RTW-processes [
17,
34]. Studies on the prevalence of coordinators in RTW-programs, and on predictors for being provided with a coordinator, have to the best of the authors’ knowledge not been published. In Norway, the limited number of guidelines for how RTW-programs should evolve also made it imperative to describe the current model in two levels; the provision or not of a coordinator, and the vertical versus horizontal integration in coordination. We do not know how frequent and to whom a coordinator is provided in RTW-programs, what the coordinator coordinates, or which personal or intervention characteristics impact the provision of a coordinator. Which factors may be associated with some employees being assigned a coordinator but not others? In order to develop RTW-programs in line with best available evidence, it was therefore imperative to explore the prevalence of coordinators, and investigate if there were any patterns in the rapid-RTW-programs’ provision of coordinators.
Aim
The aim of this study was therefore to explore and describe if and how a coordinator was provided in RTW-programs in Norway, and whether the provision of a coordinator was associated with certain employee, program or intervention characteristics.
Results
In total, 68% of the participants (
n = 335) reported that they were provided with a coordinator. As shown in Table
1, the coordinators were most often provided by the RTW-program (69%,
n = 156), meaning the coordinator’s role was managed by one of the professionals involved in the RTW-program. Furthermore, the coordinators were mostly responsible for coordinating their own programs (68%,
n = 186), and to a lesser extent other services or stakeholders (see Table
1).
Table 1
Frequencies of which services provided the coordinator and which services the coordinator did coordinate
The Rapid-RTW program | 156 (69) | 186 (68) |
Specialist health care | 7 (4) | 15 (6) |
General practitioner | 1 (0.5) | 15 (6) |
Community health care | 1 (0.5) | 2 (1) |
Workplace | 4 (2) | 21 (8) |
Social Insurance (NAV) | 10 (5) | 23 (9) |
Occupational Health Services | 1 (0.5) | 8 (3) |
Other service | 4 (2) | 9 (4) |
Personal characteristics associated with being provided with a coordinator
There were no statistical significant differences between those who were provided with a coordinator, compared to those who were not, concerning gender, social status, educational level, or history of sickness absence except for age. See Table
2 for an overview of personal characteristics and provision of a coordinator. The employee’s age was associated with provision of a coordinator. The median age was lower for those provided with a coordinator compared to those not provided with a coordinator, 45 versus 47 years respectively (
p = 0.01). In the adjusted analysis, the odds for being provided with a coordinator were reduced for each additional year of age of the employee (OR 0.97, 95% CI 0.96–0.99).
Table 2
Personal characteristics associated with being provided with a coordinator
Gender n (%) | Women | 360 (72.9) | 248 (74.0) | 112 (70.4) | 0.42 |
Men | 134 (27.1) | 87 (26.0) | 47 (29.6) | |
Age median (min-max) | | 46 (21–70) | 45 (21–66) | 47 (21–70) | 0.01* |
Social status n (%) | Live alone | 112 (23.2) | 78 (23.9) | 34 (21.7) | 0.58 |
Live with others | 371 (76.8) | 248 (76.1) | 123 (78.3) | |
Educational level n (%) | Elementary school (up to 9 years) | 49 (10.1) | 31 (9.5) | 18 (11.4) | <0.01** |
Upper secondary school (12 years) | 211 (43.4) | 149 (45.4) | 62 (39.2) | |
University degree (up to 4 years) | 153 (31.5) | 111 (33.8) | 42 (26.6) | |
University degree (> 4 years) | 73 (15) | 37 (11.3) | 36 (22.8) | |
Diagnosis n (%) | MSD | 270 (54.8) | 198 (59.3) | 72 (45.3) | <0.01** |
Mental disorders | 80 (16.2) | 46 (13.8) | 34 (21.4) | |
Cancer | 43 (8.7) | 22 (6.6) | 21 (13.2) | |
Other disorders incl. Neuro- and heart diseases | 52 (10.5) | 40 (12.0) | 12 (7.5) | |
Common or unspecific disorders | 21 (4.3) | 13 (3.9) | 8 (5.0) | |
No or missing diagnosis | 27 (5.5) | 15 (4.5) | 12 (7.5) | |
Symptoms | Pain at rest | 397 (84.5) | 282 (88.1) | 115 (76.7) | <0.01** |
Pain in activity | 414 (88.8) | 290 (91.2) | 124 (83.8) | 0.02* |
Depressive mood | 373 (78.9) | 252 (79.0) | 121 (78.6) | 0.92 |
Anxiety | 285 (60.1) | 193 (59.6) | 92 (61.3) | 0.72 |
History of sickness absence | Yes | 473 (95.7) | 324 (96.7) | 149 (93.7) | 0.12 |
Sickness absence before RTW-program N = 433 median days (range) | | 147 (0–935) | 159 (0–802) | 119 (0–935) | 0.04* |
Sick-leave baseline n (%) | | | | | <0.01** |
| Full-time (100%) | 326 (66.1) | 237 (71.0) | 89 (56.0) | |
| Part-time (20–90%) | 105 (21.3) | 72 (21.6) | 33 (20.8) | |
| Not on sick-leave | 65 (12.6) | 25 (7.5) | 37 (23.3) | |
Almost half (43%) of the employees reported upper secondary school (12 years of schooling) as their highest educational level. There was no statistical difference between those provided with and those not provided with a coordinator (neither unadjusted nor adjusted results) when comparing low and high educational levels. See Table
3 for employee-related factors associated with having a coordinator.
Table 3
Employee-related factors associated with having a coordinator
Age | 0.97 | 0.96–0.99 | <0.01* | 0.97 | 0.95–1.00 | 0.03* |
Gender |
Women | 1.20 | 0.79–1.82 | 0.40 | 1.030 | 0.62–1.71 | 0.91 |
Men (ref) | | | | | | |
Educational level |
Elementary or Upper secondary school (up to 12 years) | 1.19 | 0.81–1.73 | 0.38 | 1.27 | 0.80–2.02 | 0.32 |
University degree (ref) | | | | | | |
Diagnoses |
MSD | 1.76 | 1.20–2.58 | <0.01* | 1.51 | 0.92–2.47 | 0.11 |
Other diagnoses (ref) | | | | | | |
Pain at rest | 2.26 | 1.36–3.75 | <0.01* | 2.01 | 0.77–5.23 | 0.15 |
Pain in activity | 2.01 | 1.12–3.60 | 0.02* | 0.96 | 0.32–2.89 | 0.94 |
Sickness absence days before RTW-program | 1.00 | 1.00–1.00 | 0.05* | 1.00 | 1.00–1.00 | 0.03* |
Sick-leave at baseline |
Full-time (100%) | 1.91 | 1.30–2.85 | <0.01* | 1.06 | 0.63–1.79 | 0.82 |
Part-time (0–90%) (ref) | | | | | | |
Diagnosis was statistically significant associated with the provision of a coordinator, compared to not being provided with a coordinator. The highest proportion of employees who were referred to a RTW-program were those diagnosed with Musculoskeletal disorders (MSD) (55%). Employees with MSD were 1.8 times more likely to be provided with a coordinator compared to employees with other diagnoses in the unadjusted analysis (OR 1.76, 95% CI 1.20–2.58). However, this association did not remain statistically significant in the adjusted analysis. Regarding symptoms, both depressive mood and anxiety were not associated with higher odds for being provided with a coordinator, compared to not being provided with a coordinator. Employees who reported having pain were twice as likely to be provided with a coordinator compared to those who did not report pain, OR 2.26 (95% CI 1.36–3.75) and 2.01 (95% CI 1.12–3.60) for those with pain at rest and pain in activity, respectively. However, neither pain at rest nor pain in activity remained statistically significant in the adjusted analyses.
Nearly all participants (96%) had a history of sickness absence during the last three years prior to participation in the program. There was statistically significant differences between those provided with and those not provided with a coordinator related to days of sickness absence before the RTW-program started, and related to being on sick leave at baseline (RTW-program start). Those provided with a coordinator had been on sick leave for more days (median 159 days) before the RTW-program compared to those not provided with a coordinator (median 119 days), and this association remained statistically significant in the adjusted analysis. The odds for having a coordinator for employees on sick leave (100%) compared to those not on sick leave or on graded sick leave did not remain statistically significant in adjusted analysis (OR 1.06 95% CI 0.63–1.79).
Program predictive factors for being provided with a coordinator
There was a statistically significant difference between those provided with a coordinator versus those who were not regarding the type of RTW-program provided. See Table
4 for program characteristics and provision of a coordinator. Employees who received “Occupational rehabilitation” and “Follow-up and Work clarification” were more often provided with a coordinator, compared to those not provided with a coordinator. The odds for being provided with a coordinator when receiving “Occupational rehabilitation” were almost four times higher compared to such odds for “Treatment inclusive assessment and surgery” (OR 3.87 95% CI 2.42–6.24). This association remained statistical significant in the adjusted analysis.
Table 4
Program characteristics and provision of a coordinator (employees, n and %)
Type of intervention n (%) | | | | | <0.01* |
Occupational rehabilitation | 275 (56.7) | 221 (67.0) | 54 (34.8) | |
Medical or psychological treatment, including assessment, and surgery | 172 (35.6) | 77 (23.3) | 95 (61.3) | |
Follow-up and Work clarification programs through NAV | 38 (7.8) | 32 (9.7) | 6 (3.9) | |
Professionals involved n (%) | Medical doctor | 301 (85.0) | 216 (88.5) | 85 (77.3) | <0.01* |
Physical therapist | 299 (83.3) | 226 (90.8) | 73 (66.4) | <0.01* |
Nurse | 177 (56.9) | 128 (58.4) | 49 (53.3) | 0.40 |
Nutritionist | 171 (54.1) | 132 (58.9) | 39 (42.4) | <0.01* |
Others | 164 (50.6) | 121 (52.8) | 43 (45.3) | 0.21 |
Psychologist | 141 (42.5) | 91 (39.2) | 50 (50.0) | 0.07 |
Vocational consultant | 139 (42.4) | 109 (47.6) | 30 (30.3) | <0.01* |
Social worker | 127 (39.0) | 91 (40.1) | 36 (36.4) | 0.53 |
Occupational therapist | 91 (28.5) | 72 (31.7) | 19 (20.7) | 0.05* |
Pedagogue | 88 (31.4) | 77 (37.7) | 11 (14.5) | <0.01* |
Work instructor | 42 (13.2) | 30 (13.5) | 12 (12.5) | 0.84 |
Provision of a coordinator from other services n (%) | Social Insurance (NAV)^ | 24 (7.1) | 20 (8.5) | 4 (3.9) | |
Workplace^ | 3 (0.9) | 3 (1.3) | 0 (.0) | |
Occupational Health Services ^ | 3 (0.9) | 3 (1.3) | 0 (.0) | |
Others^ | 3 (0.9) | 3 (1.3) | 0 (.0) | |
General Practitioner^ | 2 (0.6) | 2 (0.9) | 0 (.0) | |
Specialized health care^ | 1 (0.3) | 0 (.0) | 1 (1.0) | |
Community based health care^ | 0 (.0) | 0 (.0) | 0 (.0) | |
Contact with other instances n (%) | General Practitioner | 191 (90.5) | 149 (92.0) | 42 (85.7) | 0.19 |
Social Insurance consultant (NAV) | 116 (81.7) | 96 (84.2) | 20 (71.4) | 0.12 |
Leader/supervisor | 76 (71.0) | 63 (75.9) | 13 (54.2) | 0.04* |
Specialized health care^ | 19 (33.9) | 15 (36.6) | 4 (26.7) | |
Others^ | 14 (26.9) | 10 (27.0) | 4 (26.7) | |
Occupational Health Services ^ | 8 (16.7) | 7 (19.4) | 1 (8.3) | |
Family^ | 8 (17.0) | 4 (12.1) | 4 (28.6) | |
Community based health care^ | 7 (14.9) | 2 (6.5) | 5 (31.3) | |
Work-life center (NAV arbeidslivssenter) ^ | 6 (13.6) | 3 (9.7) | 3 (23.1) | |
Adaptions n (%) | No adaptations were performed | 234 (84.5) | 149 (78.4) | 85 (97.7) | <0.01* |
Work time^ | 49 (48.5) | 48 (58.5) | 1 (5.3) | |
Work tasks^ | 30 (33.0) | 27 (38.6) | 3 (14.3) | |
Leisure activities^ | 23 (28.0) | 19 (30.6) | 4 (20.0) | |
Physical work environment^ | 17 (20.2) | 16 (24.6) | 1 (5.3) | |
Psychosocial work environment^ | 6 (7.6) | 6 (9.8) | 0 (0.0) | |
Home^ | 4 (5.1) | 3 (5.0) | 1 (5.3) | |
The RTW-programs provided the coordinator in most cases. However, a few participants were provided with a coordinator from other programs, where NAV was the second largest provider of coordinators (7%).
In the programs that provided coordinators, more contact with other stakeholders (i.e. general practitioner, NAV and leader/supervisor) was reported, compared to the programs that did not provide a coordinator. However, only having “contact with supervisor” was statistically significant for those provided with a coordinator compared to those not provided with a coordinator, but this association did not remain statistically significant in the adjusted analysis (OR 1.69 95% CI 0.31–9.27). See Table
5 for program characteristics associated with being provided with a coordinator.
Table 5
Program characteristics* associated with being provided with a coordinator
Age | 0.97 | 0.96–0.99 | <0.01* | 0.97 | 0.95–0.99 | 0.01* |
Gender |
Women | 1.20 | 0.79–1.82 | 0.40 | | | |
Men (ref) | | | | | | |
Type of program |
Occupational rehabilitation | 5.05 | 3.31–7.71 | <0.01* | 3.87 | 2.41–6.24 | <0.01* |
Follow-up and Work clarification programs (NAV) | 6.58 | 2.62–16.55 | <0.01* | 4.77 | 1.83–12.44 | <0.01* |
Treatment incl. Assessment and surgery (ref) | | | <0.01* | | | <0.01* |
Professionals involved |
Medical doctor | 2.27 | 1.25–4.11 | <0.01* | 1.81 | 0.84–3.89 | 0.13 |
Vocational consultant | 2.09 | 1.27–3.45 | <0.01* | 1.61 | 0.78–3.34 | 0.20 |
Nutritionist | 1.95 | 1.19–3.19 | <0.01* | 1.52 | 0.79–2.93 | 0.21 |
Physical therapist | 4.98 | 2.78–8.93 | <0.01* | 4.75 | 1.82–12.41 | <0.01* |
Occupational therapist | 1.79 | 1.00–3.18 | 0.05* | 2.58 | 1.21–5.50 | 0.02* |
Psychologist | 0.65 | 0.40–1.04 | 0.07 | | | |
Pedagogue | 3.58 | 1.78–7.21 | <0.01* | 2.02 | 0.85–4.81 | 0.11 |
Adaptations |
No adaptations | 0.09 | 0.20–0.36 | <0.01* | 0.08 | 0.01–0.60 | 0.01* |
Contact with other instances |
Leader/supervisor | 2.67 | 1.03–6.88 | 0.04* | 1.69 | 0.31–9.27 | 0.54 |
Furthermore, the employees with a coordinator received more adaptations at the workplace. Programs providing a coordinator were more likely to make adaptations in their intervention: It was about 90% less likely that the answer to the question “Did this program provide one of the following types of adaptations?” were “No adaptations were performed” for employees provided with a coordinator, compared to those not provided with a coordinator (OR 0.08 95% CI 0.01–0.60). This association remained statistically significant in the adjusted analysis.
In general, employees provided with a coordinator met more professions in the RTW-programs. The association between those provided with, compared to those not provided with a coordinator was statistically significant related to medical doctor, vocational consultant, occupational therapist, nutritionist, physical therapist and pedagogue. Meeting a psychologist was more common in the group without a coordinator compared to those with a coordinator, however, this association was not statistically significant. In this study, the odds for being provided with a coordinator when having a physical therapist in the program were more than four and a half times higher compared to not having a physical therapist in the program (OR 4.75, 95% CI 1.82–12.41). This association remained statistically significant in the adjusted analysis.
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