Objectives: Aging workforces with increasing numbers of chronic conditions require health initiatives with greater workplace focus. A regional pension insurance introduced a Return To Work (RTW) strategy for insurants with chronic conditions. The objective was to identify the degree of implementation of work related measures in medical rehabilitation and the extent of RTW outcomes. Methods: 5883 insurants were considered. Severe Restriction of Work Ability (SRWA), Work-related Medical Rehabilitation (WMR), and Case Management (CM) were examined for 2008 and 2012. An Index of Employment status (IoE) was used in a logistic regression. Results: Utilization of WMR raised from 12.3% in 2008 to 66.1% in 2012. The proportion of insurants with SRWA and WMR grew from 8% up to 40.1%. In 2008, 14.7% of insurants with SRWA received WMR; in 2012, it grew to 76.6%. On the other hand, in 2012 26% got WMR without SRWA and 12.2% had SRWA and got no WMR. CM was not conducted in 2008 but reached 20.2% in 2012. Across all indications, WMR resulted in positive RTW as measured by IoE: OR = 0.75 (KI-95%: 0.67 - 0.86). Conclusion: WMR was successfully implemented according to the German guideline. There is a need to optimize the linkage between SRWA and WMR and CM to provide need-based care.
Due to demographic changes―like those in many industrialized societies―Germany is facing a reduction and aging of the population [
With a higher age, the incidence of chronic conditions rises [
Therefore, government initiatives and employers, especially health care and social security, are creating new strategies to support continued participation and return to work for older persons and workers with disabilities or/and chronic conditions [
Workplace orientated interventions have been developed and evaluated internationally and nationally over a long period. According to a meta-analysis of Waddell et al. (2008), the basic components for successful RTW are early intervention, cooperation of all stakeholders, multidisciplinary intervention, work-related measures as well as the combination of different measures rather than isolated measures [
In the field of medical and vocational rehabilitation carried out by the German pension insurance, the focus on participation in work is defined by social law. Thus, concepts and interventions are largely work-related [
Due to historical development and social law, the German health care system is divided into different health services sectors. Therefore, suitable management among the triangle of service providers, service payers and insurants are needed to provide demand-orientated and cost-effective health care for persons with health problems and chronic condition of working age [
The main focus of the pension insurance due to Germany’s social laws is to sustain the ability to work and to sustain the population’s earning capacity through medical and vocational rehabilitation measures for people with chronic conditions (§ 9 Abs. 1 SGB VI). For this reason, as a central player, this insurance is predestined to play a coordinative and integrative role between the health system and other stakeholders who are addressing return to work. Last, the financial structure of the service provider is secured through contributions of their insurants. Therefore, an extended and healthy work life with an earning capacity and a gainful employment status is of high socioeconomic interest.
Based on these findings, the pension insurance developed a RTW1 strategy [
The following questions were addressed:
1) How many insurants were recipients of the RTW intervention (WMR/CM with or without SRWA) in 2008 compared to 2012?
2) Are there changes in RTW (employment status one year after rehabilitation) between the two observation periods?
3) What are the most important factors for a RTW?
An observational retrospective study was conducted collecting data of 5883 insurants with chronic conditions in 2008 or in 2012. The group received inpatient medical rehabilitation and/or further RTW measures e.g. WMR. Provider of the RTW intervention was the regional statutory pension insurance Braunschweig-Hannover. In 2008 RTW as a comprehensive strategy was barely implemented (“historical control group”) whereas in 2012 the implementation of the strategy was almost completed by the insurance provider.
We separately analyzed different groups out of the study sample. First we compared a group of working age rehabilitants in 2008 and another sample in the second half of 2012 concerning implementation and effect of the RTW strategy and intervention. In a second analysis, we took a closer look only on the impact of WMR. We built a sample of rehabilitants receiving WMR and rehabilitants not getting WMR (
Due to regional conditions and partial autonomy in addition to the national requirements, it was possible to establish a comprehensive RTW strategy for the federal state of Lower-Saxony. Nevertheless, these initiatives are embedded in procedures performed on the federal level. The strategy implemented by the regional German Pension Insurance includes both a conceptual approach as well as practical implications.
RTW as strategy involves a large amount of stakeholder cooperation in all areas of the health system. Through networking, cooperation and inter-sectorial actions with e.g. companies, general practitioner and health insurances RTW of the insurants with chronic conditions is supported.
Within the scope of the RTW strategy, the pension insurance initiated RTW interventions in their own management, administration and rehabilitation clinics. WMR was implemented according to the federal guidelines of the German Pension Insurance for WMR. These are described in detail in the PoR [
To support the effectiveness of the work-related therapeutic services in rehabilitation centers, additional CM
as a further tool has been implemented. The CM program involves an individual case manager helping the insurant identify further obstacles for a return to work and their possible solutions. The person is given an individual action plan. During this process, the insurant’s case manager contacts other caregivers to promote integrated care [
Patients were included if they received inpatient medical rehabilitation in 2008 or 2012. The considered diagnosis were musculoskeletal disorders (according to ICD M00 - M99), cardiovascular diseases (according to ICD I00 - I99), cancer (according to ICD C00 - D48) or psychosomatic disorders (according to ICD F00 - F09, F17, F20 - F45, F48 - F99). Insurants who were retired or received benefits due to reduced earning capacity were excluded, as were rehabilitants who received post-acute care.
Out of the total group of insurants with rehabilitation in 2008 and 2012, a total sample of 5883 insurants was included. A random sample was drawn for indications of musculoskeletal and psychosomatic disease. The complete sample was included for persons with cardiovascular disease and cancer because this group was too small for randomization.
In 2008, 3149 insurants fulfilled the inclusion criteria, and 2734 fulfilled the criteria in 2012.
Administrative data routinely produced for the insurance records was provided by the regional pension insurance. These data records include information on therapeutic services from the discharge report as well as socio-economic data. Data was available at three times: the years before, during and after medical rehabilitation.
We analysed person-related socio-economic data, discharge report information and employment status. The discharge report includes information regarding the work situation as well as the amount of work-related rehabilitation measures received during an inpatient stay.
Age group (years) | Male | |||||||||
---|---|---|---|---|---|---|---|---|---|---|
2008 | 2012 | |||||||||
MD | CV | CA | PS | all | MD | CV | CA | PS | all | |
>15 - 25 | 10 | 0 | 0 | 8 | 18 | 7 | 1 | 3 | 8 | 19 |
>25 - 35 | 53 | 7 | 8 | 25 | 93 | 49 | 1 | 6 | 39 | 95 |
>35 - 45 | 181 | 55 | 26 | 141 | 403 | 159 | 12 | 22 | 95 | 288 |
>45 - 55 | 305 | 186 | 83 | 147 | 721 | 360 | 90 | 41 | 149 | 640 |
>55 - 65 | 218 | 133 | 78 | 62 | 491 | 214 | 73 | 56 | 71 | 414 |
all | 767 | 381 | 195 | 383 | 1726 | 789 | 177 | 128 | 362 | 1456 |
Age group (years) | Female | |||||||||
2008 | 2012 | |||||||||
MD | CV | CA | PS | all | MD | CV | CA | PS | all | |
>15 - 25 | 8 | 0 | 1 | 11 | 20 | 13 | 0 | 1 | 11 | 25 |
>25 - 35 | 33 | 1 | 1 | 37 | 72 | 34 | 0 | 2 | 35 | 71 |
>35 - 45 | 175 | 12 | 42 | 109 | 338 | 125 | 2 | 17 | 75 | 219 |
>45 - 55 | 351 | 35 | 91 | 157 | 634 | 385 | 12 | 56 | 143 | 596 |
>55 - 65 | 187 | 38 | 68 | 66 | 359 | 229 | 8 | 51 | 79 | 366 |
all | 754 | 86 | 203 | 380 | 1423 | 786 | 22 | 127 | 343 | 1278 |
Total 3149 | Total 2734 |
All relevant general and work-related medical rehabilitation therapeutic services are documented via the classification of therapeutic services (KTL) [
To define SRWA, we used the indicators of work ability from the discharge report. As proposed by Müller- Fahrnow and Radoschewski (2009), SRWA is determined if one of three criteria is fulfilled: 1. inability to work for at least three months in the year before rehabilitation; 2. work ability in the last job under six hours; or 3. unemployment in the year before rehabilitation for at least three months [
The amount of WMR was measured by using the classification of therapeutic services (KTL) [
To measure whether a person returns to paid work after rehabilitation, an Index of Employment (IoE) was developed. The IoE indicates the degree of returning to work. To describe the index as precisely as possible, different variables were considered. Periods with employment, unemployment, sickness benefits or transitional allowances were included and recorded in days per year. Then all variables of the IoE were weighted by factors as follows: days with employment (1.0), days with sickness benefits or transitional payments (0.7), days with unemployment I (0.4), and days with unemployment II (Hartz IV) (0.1). Subsequently, the sum of all weighted periods was divided by the total number of days. This compounded IoE can take values from 0 to 1. An IoE of 1 is associated with a high level of return to work.
For the groups of insurants of 2008 and 2012, via a descriptive evaluation, we identified who received WMR and/or CM and whether there were differences between an insurant with SRWA and one without.
The IoE was calculated for each year for all participants before, during and after rehabilitation. The course of the two samples, 2008 and 2012, was compared.
To identify the influence of different parameters on returning to work (e.g., SRWA, WMR, CM, age, and sex), the median IoE of the year after rehabilitation was used in logistic regression models. Rehabilitants with WMR in 2008 and 2012 (subgroup with WMR) were compared with rehabilitants in 2008 and 2012 without this offer (subgroup without WMR). Odds ratios (OR) under 1 show that these factors reduce the risk of a negative IoE. Values over 1 indicate that these factors hinder rehabilitants regarding returning to work.
The proportion of insurants with SRWA, WMR and CM are shown in
More than half of all rehabilitants in both observation periods suffered from SRWA. In 2008, 54.6% had SRWA, and in 2012, the percentage was 52.3%. The prevalence of SRWA differs between indications, with higher proportions in cancer and musculoskeletal disorders.
In 2008, 12.3% of all rehabilitants received WMR; however, these were only patients with musculoskeletal disorders. In 2012, the percentage of rehabilitants with WMR increased in all indications (66.1%), particularly for psychosomatic patients (97.4%) (
Indication | 2008 | 2012 | ||||
---|---|---|---|---|---|---|
n | % | n | % | |||
Across indication | ||||||
all | 3149 | 100.0 | 2734 | 100.0 | ||
Patients with SRWA | 1718 | 54.6 | 1429 | 52.3 | ||
and WMR | 253 | 8.0 | 1095 | 40.1 | ||
no WMR | 1465 | 46.5 | 334 | 12.2 | ||
Patients without SRWA | 1431 | 45.4 | 1305 | 47.7 | ||
and WMR | 135 | 4.3 | 712 | 26.0 | ||
Patients with WMR | 388 | 12.3 | 1807 | 66.1 | ||
Patients with CM | 0 | 0.0 | 553 | 20.2 | ||
Musculoskeletal Disorders | ||||||
all | 1521 | 100 | 1575 | 100 | ||
Patients with SRWA | 833 | 54.8 | 888 | 56.4 | ||
and WMR | 253 | 16.6 | 726 | 46.1 | ||
no WMR | 580 | 38.1 | 162 | 10.3 | ||
Patients without SRWA | 688 | 45,2 | 45.2 | 43.6 | ||
and WMR | 135 | 8.9 | 285 | 18.1 | ||
Patients with WMR | 388 | 25.5 | 1011 | 64.2 | ||
Patients with CM | 0 | 0.0 | 343 | 21.8 | ||
Cardiovascular Diseases | ||||||
all | 467 | 100.0 | 199 | 100.0 | ||
Patients with SRWA | 229 | 49.0 | 70 | 35.2 | ||
and WMR | 0 | 0.0 | 36 | 18.1 | ||
no WMR | 229 | 49.0 | 30 | 15.1 | ||
Patients without SRWA | 238 | 51.0 | 129 | 64,8 | ||
and WMR | 0 | 0.0 | 34 | 17.1 | ||
Patients with WMR | 0 | 0.0 | 66 | 33.2 | ||
Patients with CM | 0 | 0.0 | 17 | 8.5 | ||
Cancer | ||||||
all | 398 | 100.0 | 255 | 100.0 | ||
Patients with SRWA | 283 | 71.1 | 174 | 68.2 | ||
and WMR | 0 | 0.0 | 38 | 14.9 | ||
no WMR | 283 | 71.1 | 136 | 53.3 | ||
Patients without SRWA | 115 | 28.9 | 81 | 31.8 | ||
and WMR | 0 | 0.0 | 5 | 2.0 | ||
Patients with WMR | 0 | 0.0 | 43 | 16.9 | ||
Patients with CM | 0 | 0.0 | 12 | 4.7 | ||
Psychosomatic Disorders | ||||||
all | 763 | 100.0 | 705 | 100.0 | ||
Patients with SRWA | 373 | 48.9 | 297 | 42.1 | ||
and WMR | 0 | 0.0 | 295 | 41.8 | ||
no WMR | 373 | 48.9 | 2 | 0.3 | ||
Patients without SRWA | 390 | 51.1 | 408 | 57.9 | ||
and WMR | 0 | 0.0 | 392 | 55.6 | ||
Patients with WMR | 0 | 0.0 | 687 | 97.4 | ||
Patients with CM | 0 | 0.0 | 181 | 25.7 | ||
Based on the total group of rehabilitants per year, the proportion of persons with SRWA and WMR grew from 8% in 2008 up to 40.1% in 2012 (
On the other hand in 2012 26% got WMR without SRWA and 12.2% had SRWA and got no WMR.
Looking at the subgroup of persons with SRWA (2008: n = 1718; 2012: n = 1.429) as a reference following picture emerges. From 2008 to 2012 the proportion of rehabilitants with SRWA obtaining WMR increased from 14.7% up to 76.6%.
Considering the subgroup of rehabilitants receiving WMR (2008: n = 388; 2012: n = 1.807) the proportion of rehabilitants getting WMR without SRWA in 2008 was 34.8%; whereas 39.4% in 2012. There were great differences between the indications, with higher proportions particularly for rehabilitants with psychosomatic disorders; here, 57.1% of rehabilitants who received WMR had no SRWA and musculoskeletal disorders (28.2%). Lower proportions can be observed in rehabilitants with cancer; 10.4% of those who received WMR had no SRWA (data not shown in tables).
CM was initiated in 2012. For a total of 553 (20.2%) rehabilitants, a case management service was recommended. The highest proportion of CM can be observed in the group of rehabilitants with psychosomatic disorders (25.7%), followed by musculoskeletal disorders (21.8%), cardiovascular disease (8.5%) and cancer (4.7%). Men received CM more often than women, except for musculoskeletal disorders.
The course of employment status as a RTW indicator is shown for the two periods. The IoE decreases from the year before rehabilitation until the year of rehabilitation in both periods. In the first group 2008 (less RTW Strategy), the IoE is still decreasing the year after the rehabilitation, whereas in the insurants group in 2012 (implementation of the RTW Strategy), the IoE is increasing in the year after rehabilitation (
Odds ratios (OR) under 1 show that the risk of a negative IoE is reduced. Values over 1 hinder rehabilitants regarding returning to work. In our study, we found that WMR across all indications has a positive effect on returning to work. WMR reduces the risk of a lower IoE (OR = 0.75; CI: 0.67 - 0.86). In contrast, SRWA has five times higher risk of a lower IoE (OR = 4.98; CI: 4.44 - 5.59). CM also shows a negative effect on the IoE (OR = 2.29; CI: 1.84 - 2.87). Regarding influences by sex on the IoE, there was a positive effect for men (OR = 0.66; CI: 0.59 - 0.74) and a negative effect for women (OR = 1.52; CI: 1.34 - 1.70). Most commonly, the rehabilitants in the middle age group had the highest benefit (OR = 0.58; CI: 0.43 - 0.80) (
To meet demographic challenges and the burden of chronic diseases it is necessary to develop new processes and structures in the current health system [
The results indicate that the RTW intervention was largely implemented in the observation period.
In both samples, we found that more than half of the insurants showed SRWA. Compared to other studies, our findings were higher (
In 2012 the amount of WMR measures was five times as high as 2008 and reaches 66.1%. It can be assumed that in 2012 in administrative allocation centers and rehabilitation clinics of the pension insurance RTW interventions were implemented as planned. The proportion of rehabilitants with SRWA and WMR reached 40.1%.
This exceeds the proposed minimum requirements for WMR described in the PoR (WMR Level B: 30%; WMR Level C: 5%).
When it comes to the need-based matching of WMR and SRWA in 2012 the findings show a missing link. In 2012 e.g. 26% got WMR without SRWA and 12.2% had SRWA and got no WMR. This finding can be viewed as an over-, under- or misuse of WMR for insurants with and without SRWA. Different reasons for the overachievement of the proposed requirement for WMR for rehabilitants as well as the undersupply of WMR for rehabilitants without SRWA might play a role. It can be assumed that screening methods used to identify rehabilitants with SRWA in the rehab centers might be more sensitive than the discharge report criteria used in our study. Moreover, it cannot be ruled out that specific concepts in the clinics might play a more decisive role. A recent analysis conducted by Streibelt und Brünger (2014) concluded that the receipt of WMR might still largely dependent on the clinic concept [
CM was initiated only in the second period (2012). We found the highest proportion of CM in psychosomatic disorders. One explanation could be that in psychosomatic disorders, CM was developed and implemented primarily [
During the course of chronic conditions, it can be expected that the prevalence of sick leave and the incapacity to work will increase. Consequently, due to sickness benefits, unemployment compensation, and transitional payments, the pension insurance does not receive the full contribution to its rehabilitation fund. After use of rehabilitation, health status and ability to work, and, therefore, contribution to the pension insurance fund, should increase again. In our findings, the IoE as an indicator decreases from the year before rehabilitation until the year of rehabilitation receipt in both periods. In the first period in 2008 (less RTW strategy), the IoE continues to decrease the year after rehabilitation, whereas in 2012 (implementation of the RTW strategy), the IoE increases during the post-rehabilitation year (
WMR has a protective effect on returning to work as expected. In contrast, SRWA has a negative influence on the IoE (
A successful RTW program interchangeable vocational rehabilitation positively influences the potential labor force. Nevertheless, it depends on the economic situation if an enhanced potential is exploited. In a weak economic situation e.g. economic crises in 2009 with a high rate of unemployment, the chance of RTW for individuals with chronic disease might be lower. In this case, even a successful RTW strategy would have little effect. This could be an explanation for the lower IoE in 2009 of the insurants who received WMR in 2008 compared to the higher IoE of the insurants in 2013 who received WMR in 2012.
Coordinated reintegration initiatives like the described RTW strategy are more useful and are recommended compared to isolated measures. They also intend a fair allocation of health related measures and distribution of the costs for all social security institutions in the system. For medical insurance companies in Germany, it could mean to extend prevention and early intervention for patients with chronic conditions; especially for individuals in risk of losing their earning capacity. This is associated with higher costs in the first place. In the long run, however this could prevent and save costs―e.g. intensive rehabilitation measures. A weakness even of a coordinated strategy across social systems could be that the guiding lies in one hand instead of a neutral service center [
This study has certain limitations. The meaningfulness of the results is limited because the available sample size was lower than the planned calculated sample size estimation. However, the random drawing of the sample from the main indications of MSD and psychosomatic disorders was as accurate as possible. Therefore, here a selection bias can be excluded. In addition, we could not develop a concomitant control group because of the already widely spread intervention programme. Therefore, we consider data from rehabilitants of the year 2008 which could be seen as a historical control group.
In general, the comparison of the outcome of different RTW programs is difficult because used instruments in studies differ greatly. Moreover, there is no single outcome parameter to measure because RTW is a complex parameter [
As in our study in which RTW outcomes are measured only by administratively based data, the perspective of workers and other stakeholders is not included [
The implementation of RTW strategy was successfully established. The degree of fulfillment of WMR has increased over the time of observation. WMR as a significant component of the RTW strategy has a high impact on return to work, which is demonstrated by the positive development of the employment status. To clarify whether the effect is due to WMR, further studies, such as randomized controlled trials, should be conducted. Further investigations should also focus on a tailored matching of WMR and SRWA because there only is evidence that insurants with SRWA are benefiting from WMR.
The study was approved by the Ethics Committee of the Hannover Medical School, Germany.
This article does not contain any studies with human participants performed by any of the authors.
For this type of study, formal consent is not required.
This paper is based on a project supported by the German Pension Insurance. The authors fondly thank Prof. Dr. Christoph Gutenbrunner for his support and Prof. Dr. Matthias Bethge for his valuable input. The German Pension Insurance Braunschweig-Hannover we thank for providing the data used.
From the authors of this study no conflicts of interest are reported.
CorneliaGerdau-Heitmann,MonikaSchwarze, (2016) Implementation of a Return to Work Strategy in Germany—Are There Changes in Work-Related Rehabilitation Measures and Employment Status in Chronic Conditions?. Open Journal of Therapy and Rehabilitation,04,55-66. doi: 10.4236/ojtr.2016.41005