WSIB, The Service Delivery Model

&Return to Work

A Presentation to the PSHSASafety Group

September, 2010

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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 inNorth America.

• Since its creation of the Workman’s Compensation Board in 1915 (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.

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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.

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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

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Prevention

• Safety Groups

• Safe Communities Incentive Program (SCIP)

• Experience Rating Programs (NEER, CAD-7, MAP)

• JHSC Certification & First Aid

• Prevention Contact Centre

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The Life of a Claim

Registration ,Determining Eligibility And Payment

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

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

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

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

Account Analysts

Short Term Case Managers

Service Delivery Manager

Nurse Consultant

Eligibility Adjudicators

Eligibility Manager

Revenue Manager

PreventionManager

Claims Services

Account Specialists

Revenue Manager

Account Specialists

Long Term Case Management

Short Term Case Management

Initial Entitlemen

tCCP / Primar

y

DOI

30days

180days

Eligibility Area

Supporting Roles:Investigator RTW Specialist Medical

Consultant

Account Services Workplace Program Services

Service Delivery Manager

Long Term Case Managers

Nurse Consultant

How Are Services Being Delivered?

Case Management Framework

Primary Adjudication

•Claims that are straightforward in accident history are directed to Primary Adjudication

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.

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

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.

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

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.

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  

Return to Work

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Why Have a Return to Work (RTW) Program ?

1. Social and moral obligations2. Financial Impacts3. 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

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 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

Questions?

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