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Report from the WP8-WP6 Expert meeting: Employment in the multi-morbidity care model for people with chronic conditions

Università Cattolica del Sacro Cuore, Policlinico A.Gemelli, Rome, Italy

Graziano Onder, MD, PhD., WP6 LeaderKatie Palmer, PhD., Epidemiologist

Fondazione IRCCS Istituto Neurologico ''Carlo Besta'', Milan, Italy

Matilde Leonardi, MD, WP8 LeaderFabiola Silvaggi, PhD, Researcher and PsychologistChiara Scaratti, PsyD, Researcher and Psychologist

Erika Guastafierro, PsyD, Researcher and Psychologist

chrodis.eu

Emplo ym ent in the Mu lti M orbid i ty Ca re Mo del

Table of contents

Chronic diseases 3

Multimorbidity 4

Employment and Chronic diseases 5

Multimorbidity and employment 6

Employment in the multimorbidity chronic care model 7

Aims 8

Invited experts 9

Panel discussion methodology 11

Introductory session 11

Panel Discussion – Key Points 11

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Chronic diseasesChronic diseases, or non-communicable diseases (NCDs), are broadly defined by the World Health Organization (WHO) as “diseases of long duration and generally slow progression that are not passed from person to person”1. NCDs pose a serious threat to society and future development. Long-term health problems constitute to a greater risk of income poverty, social exclusion, severe material deprivation, and lower work intensity (ANED, 2013)2. Persons with longstanding health problem face higher rates of unemployment and inactivity (Corral et al., 2014)3. Based on the data of the 2011 ad hoc module of the EU Labour Force Survey, the employment rate in EU-28 for persons with limitations in work caused by a health condition was 29.6 percentage points less than for people with no such limitations.

With the ageing of the population, more and more people leave with chronic diseases in the EU. However, despite the accumulation of diseases is an age-related phenomenon, in absolute numbers, the amount of younger adults – those in their working age – suffering from chronic diseases, overcomes the amount of older adults with chronic diseases. Notably, one third of the European population aged 15 years or older lives with a chronic disease and 23.5% of the working population in the EU suffers from a chronic illness, while two out of three people at retirement age have at least two chronic diseases, a condition referred to as multi-morbidity.

As the age of countries' populations tends to increase over time, they will become increasingly ill and consume an ever-larger proportion of the national budget in healthcare costs, the so-called compression of morbidity mostly due to NCDs. Chronic diseases pose a serious societal problem in Europe: the direct costs of care for chronic diseases coupled with lower employment rates of people living with chronic health problems generate loss for economies. In order to buffer such negative impact, people living with chronic diseases need early and accurate diagnosis as well as appropriate treatment and management. The organization and delivery of healthcare plays an essential part in chronic disease management.

While chronic diseases are the main causes of longstanding health problems in the working-age population, existing national policies, in most cases, do not address chronic illnesses specifically nor the specific needs of patients with highly cyclic conditions where periods of normal life (e.g. during remission) and periods of frailty (e.g. during treatment cycles) alternate. The mapping of policies, systems and services facilitating the inclusion of persons with NCDs done within the 3 year EU project PATHWAYS, has revealed that in most cases, people from this group are considered as part of a group of persons with disabilities, including persons with reduced work capacity due to illnesses. In many cases, persons with chronic health problems

1 World Health Organization (WHO). Global Status Report on Noncommunicable Diseases 2014; WHO: Geneva,Switzerland, 2014; Available online: http://apps.who.int/iris/bitstream/10665/148114/1/9789241564854_eng.pdf?ua=12 Academic Network of European Disability Experts (ANED) (2013) “European comparative data on Europe 2020 & People with disabilities”, Final report prepared by Stefanos Grammenos from Centre for European Social and Economic Policy (CESEP ASBL), Available at: http://www.humanconsultancy.com/_layouts/15/WopiFrame.aspx?sourcedoc={EAFFD3CF-6972-47A4-9BAC-44805B6E0B07}&file=ANED%202013%20Task%206%20-%20comparative%20data%20synthesis%20report%20-%20Europe2020_final.doc&action=default3 Corral, A. Durán, J. and Isusi, I. (2014) “Employment opportunities for people with chronic disease”, IKEI Research and Consulting, Eurofund, Available at: http://www.eurofound.europa.eu/sites/default/files/ef1459en.pdf

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are eligible for specialized support in employment only when their condition is recognized as a disability (reaching a certain eligible degree of disability) or has a negative impact on their work ability, depending on national and regional regulations. The study showed that countries considered in this report do put in place provisions to support activation and greater labour market participation by vulnerable groups, but they do it in different ways. (www.path-ways.eu). The growing prevalence of chronic diseases and their impact on productivity and labour market participation necessitates an increased awareness of the need for extensive policy level strategies for the inclusion of persons with chronic conditions in employment. Above all, no policies, indications and actions from governments are available regarding the relationship between multi-morbidity and working life.

Multimorbidity and chronic conditionsMulti-morbidity is defined as the co-occurrence of multiple diseases in one same person and is highly prevalent in older persons, representing a major challenge for healthcare systems. It has been highly studied in the past years in many European and international projects and studies between which the Joint Action Chrodis which devoted a work package to study it and its consequences. In high-income Countries, up to 20% of the population develops multi-morbidity before the age of 40, thus affecting an important share of the population in its working age.

The absolute number of people affected by multi-morbidity is expected to double by 2035, and at least two-thirds of the gain in life expectancy above 65 years will be spent with four or more chronic conditions.

In low income countries multi-morbidity occurs 15 years earlier than in richer ones, making those living in deprived areas in their working age at a higher risk of developing negative consequences associated with multi-morbidity. Similarly, multi-morbidity is more frequent in women than in men.

According to a large collaborative study involving 1.2 million participants, many of which are still of working age, any combination of co-occurring cardio-metabolic conditions (i.e. myocardial infarction, diabetes and stroke) was associated with a multiplicative mortality risk. The impact of multi-morbidity on individuals’ health profiles surpasses the impact we would expect from the summed effect of single conditions.

Multi-morbidity does not only play a negative impact on people’s survival but affect also their physical and cognitive functions, eventually affecting quality of life, life satisfaction and the ability of carrying out proper working activity.

Multi-morbidity is associated with poorer physical function. On average, older people with multi-morbidity spend 81% of their remaining years of life with disability. Unfortunately, so far, no data have been published regarding the amount of life spent with disability of younger adults with multi-morbidity.

The speed at which diseases accumulate has been associated with faster health deterioration. Women and those with a poorer social network are more susceptible to the detrimental consequences of a fast accumulation of diseases. Once again, this supports the idea of the need for special policies targeting specific groups of the population.

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Different groups of diseases have a differential impact on functioning. Neuropsychiatric diseases (including depression and dementia, but not only), alone or in association with each other, are major determinants of disability, more than cardiovascular diseases and cardiovascular multi-morbidity.

Community-dwelling older adults with multi-morbidity have two-fold higher odds of being frail than those without multi-morbidity. Frailty is a condition of increased susceptibility to the negative consequences of external or internal stresses, which limits the functional ability of people, especially when affected by multiple chronic diseases.

More than two-thirds of older adults with frailty have multi-morbidity, but less than one-fifth of those with multi-morbidity are frail. In other words, people with frailty are likely to suffer from multiple chronic disease, but not all the individuals suffering from multi-morbidity will develop a condition of frailty. Such evidence will be of extreme importance in planning policies of participation and reintegration of multimorbid individuals at work.

People with multi-morbidity are also more likely to have poorer cognitive status in both midlife and old age than those without multi-morbidity. Multi-morbidity is associated with all stages of the cognitive dysfunction continuum, from the preclinical phase to cognitive decline, mild cognitive impairment and established dementia.

The association between multi-morbidity and poor cognitive performance may have clear potential detrimental effects on the ability to carry out an effective and safe work activity.

In the planning of policies addressing people in their working life with multi-morbidity, it will be extremely important to take into account the interplay between multi-morbidity, functional status (both physical and cognitive) and issues related to their medical care. In fact, each of these domains may differentially affect the participation of people in working activities, thus requiring ad hoc measures.

Employment and Chronic diseases It has been extensively observed that employees presenting one or more chronic condition have

reduced employment prospects, as many of them experience difficulties either staying at work or returning to work after a long period of absence. Chronic-illness can result in increased welfare payments for disability, sick leave, absenteeism, presenteism, unemployment, or early retirement according to the specific situation of the person.

People with a well-managed chronic disease are able to work normal hours and, if reasonable accommodation in terms of flexibility of working times or of workplace adaptation is enabled, they can often stay at work, return to work, maintain a work.

The ability in the health as well as in the welfare sector, in particular in the employment sector, to manage complex and chronic conditions brings important returns to individuals, employers and indeed society as a whole (e.g. retaining the experience and knowledge of a worker with a chronic illness is essential to the business outcomes of a company and the overall economic productivity of a country).

The management of chronic diseases at work includes both actions for work retention and return to work (RTW):

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a. Work retention aims to keep a person with a chronic condition in the work system as much as his/her health status/functioning/capacities allow. Workers in such situations have not yet experienced a (long-term) absence or sick-leave from work but are at risk of dropping out of the labor market because of their chronic illness.

b. Return to work initiatives aim to ease the reintegration in professional life 1) of persons out of employment resulting from a prior/ongoing health condition or 2) after a sick-leave – which can be a long-term leave – due to one’s chronic condition. Evidence shows that return-to-work initiatives play a vital role in maintaining or improving the health status andcan even contribute to recovery, reducing the risk of a long-term disability in a worker with a chronic illness.

Company strategies can outline a management plan/disability management plan for workers with chronic conditions and provide details on the person(s) responsible for managing sick leave and accompanying the worker throughout his/her career pathway. Such plans keep the worker engaged in the workplace and productive, or help ill workers return to work as soon as possible and have a strong impact on the workers’ morale and dedication.

Training and reskilling schemes can enable workers to expand their capabilities and skills and adapt to their changing health situation by changing role in the company or moving to other areas of business better suited to their needs. While management styles differ between companies, training programs should be encouraged and access to tailored training, seminars or workshops for workers with chronic diseases should be part of a public or private company’s program for the professional development of the staff, as they have the potential to be considerable sources of support for chronically-ill workers.

Multimorbidity and employment People who experience multiple long-term health conditions have poorer outcomes for a range of

employment-related measures and the chances of being in employment are dramatically reduced, particularly when there is a combination of mental and physical health conditions.

The cumulative effect of having multiple conditions and the complexity faced by people in managing multiple health conditions in the labor market affects their employment outcomes.

Having multiple health conditions is linked to increased absenteeism, presenteeism, a reduced likelihood of returning to work – particularly with co-morbid mental and physical long-term health conditions.

Considering this background, one of the main priorities for action at EU and national levels identified also in the Recommendations of the EU Pathways Project4 and into the Joint Statement on “Improving the employment of people with chronic diseases in Europe”5 should be improving the integration of primary and 4 Leonardi M, Scaratti C. (2018), “Employment and People with Non Communicable Chronic Diseases: PATHWAYS Recommendations and Suggested Actions for Implementing an Inclusive Labour Market for All and Health in All Sectors”, International Journal of Environment Research Public Health, Vol.15, No.8.5 European Chronic Disease Alliance (2017), Joint Statement on “Improving the employment of people with chronic diseases in Europe” – Framing paper. Available at https://ec.europa.eu/health/sites/health/files/policies/docs/2017_chronic_framingdoc_en.pdf

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specialist care to strengthen rehabilitation, recovery and employment of people with chronic disease. Support services for employment should be integrated within the care pathway, and legislative provisions should promote such an integration. Patients’ treatment plans and care pathways should include a return-to-work and work retention component, which should be part of an integrated care supply and should be discussed in the phases of the care trajectory with the empowerment and involvement of the patient. A variety of changes for the management of chronic disease care have been advocated6 (Wagner et al. 1998; World Health Organization 2002).

Renders et al. (2001)7 concluded after a Cochrane review that the most effective interventions for improvements in chronic disease care include the combination of multi-pronged strategies. The Chronic Care Model (CCM) is an example of this type of approach. In the CCM, improved functional and clinical outcomes for disease management are the result of productive interactions between informed, activated patients and the prepared, proactive practice team of clinicians and healthcare professionals The model has been implemented by a large number of organizations in the United States, the United Kingdom and Sweden, however patients with multimorbidity have complex health needs but, due to the current traditional disease-oriented approach, they face a highly fragmented form of care that leads to incomplete, inefficient, ineffective and possibly harmful clinical interventions, and are likely to receive complex drug regimens which increase the risk of inappropriate prescribing, drug drug interactions, and poor adherence8. As the care and treatment of multimorbidity patients is complex, it often involves a large number of healthcare providers and resources. There is limited evidence on the currently available care pathways for multimorbidity; there are few examples of integrated care programs for chronic diseases implemented in relatively small populations and this was the challenge faced by the Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS). This project specifically focuses on development of common guidance and methodologies for care pathways for multimorbid patients: the CHRODIS multimorbidity care model. (Multimorbidity care model: Recommendations from the consensus meeting of the Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS) 9: https://www.sciencedirect.com/science/article/pii/S0168851017302348 )

Employment in the multimorbidity chronic care model

6 Wagner, E. H. 1998. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract, 1, 2-4.

WHO, 2002. Innovative care for chronic conditions: building blocks for action: global report. ISBN 92 4 159 017 3; WHO, Geneva Switzerland

7 Renders CM, Valk GD, Griffin S, Wagner EH, Eijk JT, Assendelft WJ (2001). Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings, Cochrane Database Syst Rev, (1). doi: 10.1002/14651858.CD0014818 Fortin M, Dubois MF, Hudon C, Soubh Hi, Almirall J.(2007). Multimorbidity and quality of life: a closer look, Health and Quality of Life Outcomes, 5 (52). doi: 10.1186/1477-7525-5-529Palmer K, Marengoni A, Forjaz MJ, Jureviciene E, Laatikainen T, Mammarella F, Muth C, Navickas R, Prados-Torres A, Rijken M, Rothe U, Souchet L, Valderas J, Vontetsianos T, Zaletel J, Onder G, Joint Action on Chronic D, Promoting Healthy Ageing Across the Life C (2018) Multimorbidity care model: Recommendations from the consensus meeting of the Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS). Health Policy 122 (1):4-11. doi:10.1016/j.healthpol.2017.09.006

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https://www.sciencedirect.com/science/article/pii/S0168851017302348


Several components of the Chrodis Multimorbidity Care Model have been explored and in the new JA CHRODIS PLUS are now implemented in Italy, Spain, and Lituania.

A number of required elements can be identified to establish successful integration of care9: patient centricity; multidisciplinary team based approach; pre-defined coordination of the total care process; clearly defined roles and responsibilities; good communication among all care providers; adequate education, clear guidelines/protocols on management/follow-up care; rapid access back to secondary care; and adequate IT systems.

Widespread and improved integrated care may help reduce the impact of the disease and support people with chronic diseases successfully managing their condition in their everyday life, in accordance with their health status, including living a normal working life, returning to/retaining work when appropriate

However one of the issues arising from previous Joint Action was that it was agreed by all experts, from more than 60 EU Countries, that access to social and community resources are relevant aspects of the care of patients with multimorbidity, but these are not included in the formal care process and the availability of these services is extremely variable. That is why including employment in the multimorbidity care models seems a response to the need highlighted by countries. In the care pathways there could be 2 possible ways of introducing the issue of employment the first is along all the care pathways, the second is within one of the phases of the rehabilitation program. Following the identification of these 2 possible entry points within the JA CHRODIS PLUS two instruments are proposed to be used at different entry points of the Multimorbidity Care model: the Work Ability Index (WAI) and the Work Rehabilitation Questionnaire (WORQ) respectively.

In the frame of the Chrodis Plus Joint Action, implementation is needed so as to fight the burden of chronic conditions. In this frame collaboration between two work packages dealing respectively with Care pathways and Employment for people with NCDs was needed.

In collaboration between WP6 and WP8 the CHRODIS PLUS Expert meeting was organized to address the problems of chronic patients with multi-morbidity, to define how the employment might impact on the care process of these patients and to make aware the employment sector of their situation. Millions of European with NCDs will benefit of a more holistic biopsychosocial, inclusive approach aiming to achieve and prevention of disability due to NCDs.

AIMSAn Expert meeting was held on 28th February, 2019 in Rome, Italy. The aims of the CHRODIS+ Expert Meeting were to i) discuss integrating health and welfare policies: the issue of chronic diseases in the work sector; ii) identify elements that are fundamental to guarantee inclusion, maintenance, and reintegration of people with chronic diseases in the workplace and; iii) assess how to include these issues in the Chrodis Multimorbidity Care Model [1]. The main emphasis was on discussing the role of the health sector to

9 European Cancer Organization (2017), Position Statement: Integrated Cancer Care: Bringing Primary Care and Secondary Care Together. Available at: http://www.ecco-org.eu/~/media/Documents/ECCO-sections/Policy/Positions-and publications/2017/ECCO_Position_Statement_Integrated_Cancer_Care.pdf?la=en

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support people with chronic conditions along their care pathway rather than other players such as employers or policy makers.

INVITED EXPERTSA group of Experts was invited to participate in a panel discussion, including healthcare professionals from European healthcare sectors such as physicians, nurses, and dieticians, representatives from patients and health education organizations, and researchers working in the field of chronic diseases and multimorbidity. For a full list of participants please see the attached file entitled: “List of Participants” (appendix 1).

PANEL DISCUSSION METHODOLOGYIn preparation for the discussion a background paper was prepared based on scientific literature (see appendix 2). It provided the rationale for the discussion and set the scene for all participants to understand the issue of introducing employment in the care model. A literature search was conducted to identify examples of studies that have evaluated interventions aimed at persons with chronic conditions returning to or continuing employment. Out of 361 publications assessed, there were fourteen studies that

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corresponded to this aim and were selected and briefly analyzed and presented. 10 11 12 13 14 15 16 17 18 19 20 21 22 23These covered a range of general (e.g., long term sickness) and specific (e.g., cancer, pain, mental health disorders) chronic conditions. Each paper was read in order to extract potentially relevant information to provide background and support to the panel discussion. Individual components of the back-to-work models were identified (e.g., multidisciplinary team, comprehensive interviews examining health and work situation, self-help tools, workplace intervention etc). For a full list of the selected 14 papers please see the attached file (appendix 2). These were compared with the Multimorbidity Care Model (Palmer et al 2018)9 developed by CHRODIS WP6.

Prior to the meeting all participants were also provided with a copy of all preparatory material, including the meeting agenda (appendix 3), Background and Rationale (appendix 4), the Multimorbidity Care Model

10 Leensen MCJ, Groeneveld IF, Heide IV, Rejda T, van Veldhoven PLJ, Berkel SV, Snoek A, Harten WV, Frings-Dresen MHW, de Boer AGEM. Return to work of cancer patients after a multidisciplinary intervention including occupational counselling and physical exercise in cancer patients: a prospective study in the Netherlands. BMJ Open. 2017 Jun 15;7(6):e014746.11 Stapelfeldt CM, Christiansen DH, Jensen OK, Nielsen CV, Petersen KD, Jensen C. Subgroup analyses on return to work in sick-listed employees with low back pain in a randomised trial comparing brief and multidisciplinary intervention. BMC Musculoskelet Disord. 2011 May 25;12:112.12 Johansson P, Lindahl E. Locking-In Effects Due to Early Interventions? An Evaluation of a Multidisciplinary Screening Programs for Avoiding Long-Term Sickness. Evaluation Review, v36 n5 p323-345 Oct 2012.13 Hees HL, de Vries G, Koeter MW, Schene AH. Adjuvant occupational therapy improves long-term depression recovery and return-to-work in good health in sick-listed employees with major depression: results of a randomised controlled trial. Occupational & Environmental Medicine. 2013;70:252–260.14 Martin HT, Nielsen MD, Madsen IE, Petersen SM, Lange T, Rugulies R. Effectiveness of a Coordinated and Tailored Return-to-Work Intervention for Sickness Absence Beneficiaries with Mental Health Problems. J Occup Rehabil (2013) 23:621–63015 Vlasveld MC, van der Feltz-Cornelis CM, Adèr HJ, Anema JR, Hoedeman R, van Mechelen W, Beekman AT. Collaborative care for sick-listed workers with major depressive disorder: a randomised controlled trial from the Netherlands Depression Initiative aimed at return to work and depressive symptoms. Occup Environ Med 2013;70:223–230.16Brendbekken R, Eriksen HR, Grasdal A, Harris A, Hagen EM, Tangen T. Return to Work in Patients with Chronic Musculoskeletal Pain: Multidisciplinary Intervention Versus Brief Intervention: A Randomized Clinical Trial. J Occup Rehabil (2017) 27:82–91.17 Jensen C, Jensen OK, Nielsen CV. Sustainability of return to work in sick-listed employees with low-back pain. Two-year follow-up in a randomized clinical trial comparing multidisciplinary and brief intervention. BMC Musculoskeletal Disorders 2012, 13:156.18 Jensen LD, Maribo T, Schiøttz-Christensen B, Madsen FH, Gonge B, Christensen M, Frost P. Counselling low-back-pain patients in secondary healthcare: a randomised trial addressing experienced workplace barriers and physical activity. Occup Environ Med 2012;69:21e28.19 Pedersen P, Nielsen CV, Jensen OK, Jensen C, Labriola M. Employment status five years after a randomised controlled trial comparing multidisciplinary and brief intervention in employees on sick leave due to low back pain. Scandinavian Journal of Public Health, 2018; 46: 383–388.20 Vermeulen SJ, Anema JR, Schellart AJ, Knol DL, van Mechelen W, van der Beek AJ. A Participatory Return-to-Work Intervention for Temporary Agency Workers and Unemployed Workers Sick-Listed Due to Musculoskeletal Disorders: Results of a Randomized Controlled Trial. J Occup Rehabil (2011) 21:313–324.

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(appendix 5)9, and a table summarizing the individual components extracted from the 14 papers identified from the literature (appendix 2). This information formed the basis of the qualitative discussion in the Expert meeting. During the meeting the Experts discussed some of the specific components and identified a range of challenges and barriers relating to persons with multimorbidity returning to employment, as outlined below under “expert meeting key points”.

INTRODUCTORY SESSIONThe panel meeting included four oral presentations from Chrodis Plus workpackages 6 and 8 leaders to introduce the key topics to the Experts. Dr Matilde Leonardi discussed employment in persons with chronic diseases from a European perspective and presented the Work Rehabilitation Questionnaire (WORQ)24 . Dr Graziano Onder and Dr Rokas Navickas presented the strengths and weaknesses of the CHRODIS Multimorbidity Care Model (Palmer et al 2018)9. Ms Eeva Rantala gave a presentation on how the working environment can support employees with chronic diseases to adopt and maintain healthy lifestyles. Dr Davide Vetrano and Dr Fabiola Silvaggi provided an overview of multimorbidity and its association between socioeconomic status and work strain, the impact of chronic disease on the labour market, and the Work Ability Index.

PANEL DISCUSSION – KEY POINTS1. General issues relating to the integration of employment issues in the health care pathway

a. There was general consensus among the Experts that multiple actors need to be involved in the process of persons with multimorbidity returning to work; namely, the health system, employers, policy makers, and the patients (and/or caregivers) themselves.

b. The roles and responsibilities of three of the key players (patient, health system and employers/ employment sector) need to be better identified. Each specific component of a multi-dimensional intervention needs to specify at which level the intervention should be applied and who should be involved in the implementation. For example, if an intervention has a component for “education/counseling” it should include education of both the patient and healthcare professionals; this might include for example a self-help book for patients, developed by multiple partners including patient organizations and GPs, former chronic disease patients, occupational therapists etc.

21 Steiner AS, Sartori M, Leal S, Kupper D, Gallice JP, Rentsch D, Cedraschi C, Genevay S. Added value of an intensive multidisciplinary functional rehabilitation programme for chronic low back pain patients. Swiss Med Wkly. 2013;143:w13763.22 Poulsen OM, Aust B, Bjorner JB, Rugulies R, Hansen JV, Tverborgvik T, Winzor G, Mortensen OS, Helverskov T, Ørbæk P, Nielsen MB. Effect of the Danish return-to-work program on long-term sickness absence: results from a randomized controlled trial in three municipalities. Scand J Work Environ Health 2014;40(1):47-56.23 Zwerenz R, Becker J, Johansson R, Frederick RJ, Andersson G, Beutel ME. Transdiagnostic, Psychodynamic Web-Based Self-Help Intervention Following Inpatient Psychotherapy: Results of a Feasibility Study and Randomized Controlled Trial. JMIR Ment Health. 2017 Oct-Dec; 4(4): e41.

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c. The Experts felt that Governments and policy makers also have an important relevant role in terms of defining clear policies and anti-discrimination legislation that can support people with multimorbidity returning to the workforce. These may relate to discrimination due to disability and also ageism in employment.

d. There is currently little integration between the healthcare and employment sectors in this field. As previously identified in the CHRODIS Multimorbidity Care Model, an integrated process is essential for the care of persons with multimorbidity. The involvement of the employment sector needs to be better integrated with healthcare services.

2. Identification of gaps within the healthcare sectora. There was wide agreement that a thorough, comprehensive assessment of both the patient

and their working environment is an essential component needed in an intervention to assist persons with multimorbidity to return to work. The Experts discussed this specific component in depth to provide an illustrative example of the different elements that would need to be considered when designing an intervention. This example (see figure 1) can be used as a model for designing future components related to strategies to maintain or return to work in the Multimorbidity Care Model.

3. Coordination and case management a. There is a need to get healthcare professionals, in particular all specialists and those

involved in rehabilitation ( occupational or vocational) , more involved in the process of their patients returning to work or continuing to work during long-term illness. Currently healthcare professionals often do not clearly emphasize their roles and responsibilities in this process. It emerged from the discussion that is also often unclear which healthcare professional is responsible (e.g., Primary Care physicians or those providing specialist care for specific chronic diseases).

b. Although it was agreed (point 1) that multiple actors need to be involved in the process, this raises issues as to who should be involved in making decisions and implementing work-based changes (e.g., occupational health physicians employed by the company or the patient’s Primary Care physician?)

c. One component of the original CHRODIS Multimorbidity Care Model was the need to appoint a “case manager”, who should act as the primary contact point for the patient and family, representing a single entry point into the system. This case manager acts as coordinator between the patient and members of the multidisciplinary team to manage care, actively linking the patient to providers, medical services, residential, social, behavioral, and other support services in the most effective way. When adding employment to the Multimorbidity Care Model this “case manager” role must be better defined, so that it specifies the responsibility and level of contact that they must have with the patient’s employer and/or occupational physician.

4. Patients empowerment and rightsa. Patient empowerment was emphasized as an important element to be included more

actively in the Multimorbidity Care Model. The experts felt that patient empowerment could be increased by including patient self-assessment in the assessment of work readiness (see point 2, figure 1).

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b. They also highlighted how the patient plays an important role in their return to work through self-care and by increasing their own health education. Successful work reintegration must include the patient as part of the multidisciplinary team, taking an active part of his/her decisions.

c. The rights of patients need to be taken into consideration. These rights also need to be communicated to, and shared with, the patient and their employer. It is currently unclear who should be responsible for ensuring that patients’ rights are met or for communicating relevant information to the patient and their employer.

5. Privacy issues a. Patient privacy and confidentiality is an extremely important challenge that limits the

application of intervention strategies in the workplace. Patients returning to work may not wish for their employers to be informed of specific medical issues due to privacy or fear of discrimination. This may be particular pertinent for particular medical disorders. This issue is also very relevant under the new European law on privacy, the General Data Protection Regulation (GDPR).

6. Uniform terminologya. There is a difference in the type of language and terminology used by health and

employment sectors. This limits the possibility for completely integrated interventions, (see point 1). A common lexicon needs to be developed and utilized across multiple players. This could be overcome by appropriate and clear legislation able to tackle an intersectoral approach.

7. Economical aspectsa. Lack of Government funding to support employment schemes for persons with

multimorbidity is a relevant barrier. The Experts proposed that studies proving the economical viability of such schemes are needed. Good quality studies should be conducted to demonstrate the long-term financial benefits of aiding persons with multimorbidity to return to/continue work.

b. In order to increase the chance of successfully developing a model that enables people with multimorbidity to return to work (or continue working) the labour market needs to be convinced of the benefits. Different economical aspects could be focused on, for example i) the financial disadvantages of losing people with long-term experience; ii) the loss of knowledge that companies might face when losing long-term employees; iii) the cost of retraining new employees etc.

8. Different characteristics of patientsa. Specific differences in patient characteristics were raised as a challenge. Firstly, there may

be age differences in job market scenarios (for example younger workers might be more likely to have flexible work contracts, home-office, temporary contracts etc). Secondly, there are likely to be differences in health literacy and other fundamental elements that are needed for the success of any intervention. Levels of self-care differ between individuals and access to health education may also vary.

9. Differences in European healthcare systems and work sectors

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a. There are differences within European countries in terms of their health and social care structures (for example, rehabilitation is provided by the public health sector in some countries but by social services in others). This limits the possibility of developing a single, Europe-wide Multimorbidity Care Model. However, general guidelines that can consequently be adapted to specific countries’ systems can be proposed, as was done with the original CHRODIS Multimorbidity Care Model.

b. It will be difficult to develop a single model that can be adapted to white or blue collars, skilled, semi-skilled, and manual workers with different levels of work complexity and responsibilities. Assessments and interventions are likely to substantially differ and, therefore, there might not be one pathway to fit all types of workers. Similarly it will be a challenge to find a single model that works for all types of enterprises including all work sectors, small, medium, large enterprises, private or public sector, small companies, family run business, and large corporations, who have different resources available to account for employees’ needs within the workplace.

10. Future directions. The Experts identified a number of avenues that should be prioritized when developing future employment components in the Multimorbidity Care Model:

a. A multidimensional approach is needed in care pathways for persons with multimorbidity. Interventions aimed at helping persons with multimorbidity return to work (or continue to work) need to have multidimensional designs that take into account all relevant actors, including the health system, employers, policy makers, and the patients and/or their caregivers. This could be integrated into Component 2 of the original Multimorbidity Care Model: “Multidisciplinary, coordinated team”.

b. Information and Communication Technology (ICT) can help to increase communication between the different actors (healthcare sector, employers, and patients). Thus, care models need to specify how ICT can be used to enhance interventions and care pathways. These must take into account potential privacy issues relating to confidentiality (see point 5). This could be integrated into Component 12 of the original Multimorbidity Care Model: “Exchange of patient information (with permission of patient) between care providers and sectors by compatible clinical information systems”.

c. Care models must clarify who is responsible for informing patients about their rights within the employment sector. This may potentially be multimodal (Primary Care physicians, Occupational health, patient groups, unemployment officers etc) or may be communicated via different mediums (e.g., self-help books, individual counseling etc). This should increased patient empowerment, health education, and self-help. This could be integrated into Component 9 of the original Multimorbidity Care Model: “Providing options for patients and families to improve self-management.”

d. Increased education is needed within the healthcare system to improve knowledge on employment-related issues in multimorbid patients. This could be integrated into Component 8 of the original Multimorbidity Care Model: ”Training of care providers to tailor self-management support based on patient preferences and competencies”

e. Interventions aimed at enabling patients with multimorbidity to continue working or return to work need to be flexible but complex and comprehensive, with multiple components.

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Due to the multidimensional nature of care model pathways, a clear definition is needed regarding who will act as “case manager” in relation to employment interventions. Options could be a Primary Care physician, an occupational health physician, or other relevant professionals that can be locally identified. This could be integrated into Component 3 of the original Multimorbidity Care Model: ”Professional appointed as coordinator of the individualized care plan and contact person for patient and family (case manager).”

f. A specific assessment for self-evaluation of health need in relation to the work sector is the Work Rehabilitation Questionnaire (WORQ). This was discussed as a potentially useful instrument to be included during assessment in the patient´s care pathway. The instrument has been validated and is based on the WHO International Classification of Functioning Disability and Health (ICF) and a biopsychosocial model, see below.

11. Work Rehabilitation Questionnaire (WORQ) and Work Ability Index (WAI) The Experts discussed the possibility of introducing the following tools in the care pathway assessment:

a. WORK REHABILITATION QUESTIONNAIRE (WORQ)24 25 Work functioning should be viewed from a biopsychosocial perspective (ICF) to gain a comprehensive view of the needs of the worker, the nature of the task, and the environment or the workplace. The Work Rehabilitation Questionnaire (WORQ) was developed, using the ICF, to capture work functioning and provide information to inform strategies on work engagement, return-to-work, and sustainable employment. WORQ was intended to be a generic measurement instrument and can be self-reported or interviewer administered. WORQ has been found to be valid and reliable in various community, outpatient and inpatient settings.26 Multiple studies are ongoing using WORQ in various work and employment settings and in predicting employment status and work performance. WORQ was developed in 2011 and has been translated in multiple languages including English, German, French, Portuguese, Dutch, Russian, etc. Multiple translations are ongoing including Italian. WORQ is free to use and can be downloaded at www.myworq.org. A summary of the scoring is shown in Table 1.

b. WORK ABILITY INDEX (WAI)27 Workability is a dimension that evaluates if an employee is able to do his/her job in the present and in the future, in relation to the demands of this job, to the work environment, and to his/her own mental and physical resources. Work ability can be assessed using the Work Ability Index (WAI), a questionnaire developed by the Finnish Institute of Occupational Health (FIOH) and based on employees' self-assessment of their current work capacity in 7 dimensions: 1) Current work ability compared with the lifetime best; 2) Work ability in relation to the demands of the job; 3)

24 Finger ME, et al. Cross-Cultural Adaptation of the Work Rehabilitation Questionnaire (WORQ) to French: A Valid and Reliable Instrument to Assess Work Functioning. J Occup Rehabil. 2018 Jun 26. 25 Finger ME, et al. Work Rehabilitation Questionnaire (WORQ): Development and preliminary psychometric evidence of an ICF-based questionnaire for vocational rehabilitation. J Occup Rehabil. 2014 Sep;24(3):498-510.26 Vermeulen K, et al. Cross-Cultural Adaptation and Psychometric Evaluation of the Dutch Version of the Work Rehabilitation Questionnaire (WORQ-VL). J Occup Rehabil. 2018 Oct 15.

27 J. Ilmarinen, Work ability – a comprehensive concept for occupational health research and prevention, Scandinavian Journal of Work, Environment & Health, vol. 35(1), pp. 1-5, 2008

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http://www.myworq.org/


Number of current diseases diagnosed by physician; 4) Estimated work impairment due to diseases; 5) Sick leave during the past (12 months); 6) Own prognosis of work ability two years from now; 7) Mental resources. The tool has been inserted within the Chrodis Plus Training tool to help employers to define work ability of their companies by proposing this assessment to employees. This evaluation can help to design targeted actions for the inclusion, integration and reintegration of people suffering from NCDs. Moreover this tool can help to outline a care pathway for a person with a chronic condition in order to keep on participating in the labour market.

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FIGURE 1. EXAMPLE OF A SPECIFIC EMPLOYMENT COMPONENT TO ADD TO A MULTIMORBIDITY CARE MODEL

Component: Assessment of a person’s working ability and evaluation of their working environment/situation.

Aim: To assess a person’s ability to work (e.g., to remain at work or be reintegrated).

Intervention level (policies, health system, employer?): Health service and employer.

Person/service that should conduct the assessment: Assessment should include an evaluation by an occupational physician or Primary Care physician but should also include an element that involves self-evaluation by the patient, as this increases self-efficacy.

Potential tool/assessment instrument/intervention/approach: Multiple tools are required including i) WORQ Work Index Questionnaire; ii) an assessment of willingness to work, and self-perception of what the patient is able to do; iii) assessment of mental health symptoms such as anxiety and depression; iv) medical evaluation of the person by an occupational physician, and/or Primary Care physician, and/or a rehabilitation professional; v) general evaluation of the person’s workplace done by these professionals in collaboration with the patient.

Timing/ follow up of the assessment: The timing of the assessment needs to be well designed so that it is implemented at the optimum time to increase chances of the patient returning to work. It may be necessary to do follow-up evaluations on a regular basis also after the patient returns to work.

Issues to consider: i) There must be a clear definition of the objective of the assessment in terms of whether it is evaluating work tasks or role, income, work environment changes and needs etc; ii) There are several privacy issues regarding what can be communicated from the healthcare provider to the employer – the patient must give consent before information is shared. The assessment must take into account the risk that a patient might not wish to disclose all information to their employer due to fear of discrimination.

Technological support: To enhance this component, technological solutions may need to be developed and utilized. For example, digital information sharing might help to communicate information between persons performing the multiple assessments.

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Table 1. Scoring for the Work Rehabilitation Questionnaire24 (WORQ)

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