Organizational commitment: the key to successful implementation of disability management.

When John Salter, a 50-year-old expreienced railroad worker, sustained a severe tear of his right rotator cuff (muscles surrounding the shoulder) swinging down from the locomotive, he was frightened about what a period of disability might mean to him and his family. But in a bad news/good news scenario, he was grateful that his accident had occurred after the company had enacted a disability management/return to work program. He knew many railroaders who had been retired on permanent disability following an accident such as his. Even with an operation to repair the tear the best he could hope for was a long recovery. At worst, he could expect pain, limitation of motion, weakness, and sufficient atrophy of the shoulder muscles so that he could never again have sufficient shoulder strength to pull himself up onto the locmotive. He was reassured that with a return to work porgram now in effect, some kind of light work would be found for him. The months following injury were a period of increasing disillusionment for John as each department that he thought had responsibility to return him to work found some excuse to turn his case over to another unit. In the end, he opted for retirement like so many of his predecessors, fearful that he might lose all financial security if he pressed any longer for the option of return to work. In John's situation, the disability management promise proved to be a paper giant missing the organization commitment needed to activate its potential. This fatal flaw is not unusual in programs and policies established by large scale organizations, and disability management is no exception to that rule.

Disability management is currently receiving widespread attention from employers, trade unions, policy makers, and social service providers as the problems faced by workers with disabilities and the impact of disability on the workplace become more clearly identified and understood. The ability to implement effective disability management programs, however, remains problematic for most, in part because successful disability management requires that attention be paid not only to workers with disabilities but also to their work organization and its relationship to the community. The authors believe that neglecting this second organizational component sabotages both the worker's effects at job maintenance or return and the organization's interest in productivity and cost containment. Although there are many factors that determine the outcome of a disability management program, the results of a study carried out at the Workplace Center of the Columbia University School of Social Work suggest that unless an organization can assimilate disability management into all relevant aspects of its policies and practices, the disability management initiative will fail. This article will focus on aspects of an organization that affect successful implementation of a disability management program.

Disability management is an early intervention effort, the purpose of which is to assist a newly disabled worker in successful job maintenance or return to work. Current statistics show that the likelihood of return to work for employees after the onset of disability is low. Half of those who experience lost time following the onset or worsening of disability while at work will drop out of the workforce permanently if they do not return within 5 months (Carbine et al., 1989). The reaons for unemployment are not limited to the health problems caused by the disability. Research shows that a wide range of problems arise from the onset of disability and can act as barriers to return to work (Gates, Taler & Akabas, 1989). These problems include meeting financial obligations with significantly reduced income, coping with changing family dynamics and responsibilities as a consequence of disability, overcoming the emotional impact of disability, negotiating with the worksite for transitional employment or permanent job accommodations, establishing new vocational goals when necessary, and maneuvering through the medical and social welfare community to obtain the assistance needed for return to work.

While the needs of the disabled worker are foremost, disability management programs also help the organization. They do so because they can reduce the impact of disability on the worksite by helping to contain costs associated with disability, minimize the negative effects of disability on organizational productivity and maintain employee morale and work group competence. it is estimated that disability costs in income maintenance benefits to the employee and medical care expenses can account for up to 6 percent of a company's budget and these costs will continue to rise by as much as 10 percent over the next year (Carbine et al., 1989). The costs of replacement hiring and training, and the indirect costs of lowered productivity due to lost days at work and low employee morale are also considerable. Further, workforce demographics are changing (Johnston, 1987). The workforce is both aging and dwindling, reflecting the demographics of the baby boom generation and the lower birth rates between 1965 and 1976, and disability among employees can be expected to increase in the future. It is to the employer's advantage, therefore, to establish the means of maintaining workers with disability, many of whom comprise the skilled, knowledgeable labor force. Finally, effective disability management can assist the employer in preparing for the regulations likely to follow passage of the Americans with Disabilities Act.

A Model for Understanding the

Role of the Organization in

Disability Management

One way to understand how the organizational context affects the success of the disability management program is to assess aspects of the organization that promote or constrain program activity. Kurt Lewin's model of force field analysis (Deutsch, 1968) provides a framework for such an assessment. Lewin described a state of organizational equilibrium as a time when, in relation to a particular issue, the forces promoting change are in balance with the forces restraining change. For change to occur the promoting forces must increase, the restraining forces decline or some combination of movement of each must occur. In considering disability management, when the forces promoting effective disability management outweigh the forces constraining disability management, the resulting equilibrium is expressed as successful return to work or job maintenance by the disabled workers. Conversely, when constraining forces outweigh promoting forces the resulting equilibrium is expressed as unemployment or underemployment of workers with disabilities.

The Early Intervention Project of the Workplace Center has helped identify aspects of organizations that act as the forces promoting or constraining program activity. These forces are derived from the ecosystem in which the organization operates. The building blocks of the program are a bio/psycho/social model of assessment, early intervention and a case management strategy that utilizes an ecosystem approach to problem solving. First, the program takes a bio/psycho /social approach which recognizes that disability is only a small element in loss of employment. The assessment helps newly disabled workers return to work by identifying barriers to return in all aspects of the individual's life, including financial, fmaily, health and medical care, or work-related problems. Second, intervention is immediate following onset or worsening of disability in order to avoid the development of a mind set that changes a worker into a self-perceived disabled person unable to work. Early intervention seeks to identify and solve problems before they become insurmountable (Akabas, 1986; Gleason, 1986; Lewis & Mama, 1987). Third, case management in an ecosystem context facilitates the process because the case manager serves as liaison and advocate linking the worker with all relevant systems and their resources in the family, community and worksite and negotiating needed accommodations (Gates, Taler & Akabas, 1989). Having identified the complexity of this approach, a primary objective of the Early Intervention Project has been to document how individual needs and organizational and community policy and practice interact to affect outcome.

Funded by the National Institute on Disability and Rehabilitation Research (NIDRR) and carried out in collaboration with the Human Resources Development Institute (HRDI) of the AFLCIO, the program was implemented in New York City, Baltimore, St. Paul, St. Louis, Houston, and the state of Montana. Newly disabled workers were identified, administered an assessment interview and offered assistance to help cope with problems encountered during the period of disability. The Workplace Center monitored service delivery and collected and analyzed the data set. SOme 256 disabled workers participated in the program, representing 15 unions and 28 insurance carriers.

The data which demonstrates the importance of the organizational context comes from the Center's training for case managers and assistance to them in solving unexpected problems. Although data is qualitative, content analysis of study records reveal patterns supporting the significance of the reported observations.

Three categories of organizational factors and/or community systems that promote or constrain effective disability management are revealed by the analysis. These include:

* organizational commitment to the disability management program;

* responsiveness of the worksite to disabled workers; and

* investment in disability management over time.

The remainder of this article will discuss each of these.

Organizational Factors that Promote

or Constrain Disability Management

Organizational Commitment to Disability Management. The first step towards establishing an effective disability management program is the visible commitment of top management to the process. Commitment is expressed in several ways. First, the employer needs to develop an explicit policy for disabled workers. For example, the position of the employer towards providing accommodated work, temporarily or permanently, needs to be specified. Results of the study show that most disabled workers (73 percent) want to return to work, but feel unable to perform their jobs in their current condition. Yet, most (80 percent) perceive that their employers are "somewhat to very inflexible" when it comes to making needed job accommodations. Over twothirds of program participants (68 percent) assume that they must be able to perform their jobs at 100 percent before they return and, therefore, they wait until they feel able to perform all functions of their jobs. In some instances, however, program case managers negotiated early accommodated return for disabled workers. The worksites tended to be very receptive. This lack of communication, and consequent lengthened period of disability, results in an organizational problem that can be reduced and even eliminated by an explicit and broadly distributed policy that commits the workplace to reinstate disabled workers through the use of necessary accommodations. With a well formulated and well publicized policy, workers are likely to seek assistance from the employer to facilitate their return. Supervisors, or other personnel who would authorize such accommodation, are also more likely to believe it is within their power (and responsibility) to change work requirements. When the policy is tied to performance appraisal of supervisors, the positive results are even greater. At one site the executive supported implementation of the disability management program, but did nothing except instruct managers to proceed. Lower level managers and supervisors were not part of the decision, and explicit guidelines were not provided to define the extent of action they could take. No monitoring of their participation was implemented. The program never became a priority and was not given the attention it needed to take hold in the organization.

Another study of the Workplace Center, which evaluated disability management activity by Employee Assistance Programs (EAP's), identified some of the specific organizational policy areas of importance (Akabas & Krauskopf, 1989). These include:

* the length of time a disabled employee's job will be guaranteed;

* the amount of salary replacement provided by disability coverage;

* the availability of accommodated "light duty"/transitional work;

* the degree to which formal transitional employment arrangements dovetail with disability salary replacement policy; and

* the budget to which salary replacement is charged.

These polices must be designed to provide incentives for employees to return and supervisors to cooperate in that process. For example, linking the availability of "light duty" to encourage early return while charging income maintenance costs to the relevant supervisor's budget can be a powerful assurance of early erturn to work. Clearly, gaining some work from an employee is superior to paying the person the same amount to stay home and make no contribution to the work of the organization. A worker who can be accommodated is better served than one who languishes home in deepening depression. A "win-win" situation is created in which employee and supervisory interests are meshed and the organization emerges as the prime beneficiary.

Commitment by top management is demonstrated by assigning resources to the disability management program. Perhaps most important is the allocation of staff time and availability of training. At some sites, the program was administered by social work professionals; at others, the program was run by benefits officers or union staff who lacked professional training. Where professional staff administered the service, delivery was enhanced, thereby also improving outcome. Professional staff (which would include rehabilitation counselors, although none were involved in the present project) were better equipped to elicit the needed information during the intake process, had a better grasp of the types of services necessary to remediate a particular problem and knew where in the organization and community they were available. In organizations that did not commit funds for professional staff, training was an alternate, but inadequate, allocation of resouces. Training prepared those assigned to administer the intake interview, but they needed a backup consultant to compensate for the skills and power they lacked to harness organizational and community resources and to negotiate policy implementation.

Staff assigned to the program must have not only appropriate skills but sufficient time allocation to fulfill program responsibility. At all study sites disability management responsibilities were added to personnel's existing workloads. This set up a conflict for the case managers. Their inclination was to do the work with which they were familiar and where the expectations and criteria for evaluation were known. Additionally, in some cases, their co-workers were not supportive because co-workers perceived that they would have to pick up the slack left by those working on the program. Supervisors also faced a dilemma. Even if they knew that top management supported disability management, they also knew that the productivity of their departments could not be jeopardized. Supervisors tended, like case managers and co-workers, not to make the program a priority. Managerial commitment is meaningless without specific staff and time allocation.

When top management makes a visible commitment, it "authorizes" changes in the organizational structure which are needed to support the disability management activity. Study results show that communication among departments is one of the most important structural adaptations needed. In most organizations, disparate departments like medical, human resource/personnel, health promotion, benefits, training, rehabilitation, workers' compensation, affirmative action, and risk management may be involved in assisting disabled workers. Case managers require formal connections effectively. For example, at one site the case managers required assistance from the social service department. A formal referral process provided case managers with a step-by-step procedure for identifying cases for referral and for making and maintaining contact with the social services department so that social service could be easily accessed. Training on how to make a referral was also provided to the case managers. Disability management was promoted by these structural changes that formalized linkages within an organization and specified the division of labor among units with complimentary responsibilities.

Responsiveness of the worksite to disabled workers. Worksite responsiveness to the disabled worker is the degree to which the worksite itself can meet the disability related needs of the newly disabled worker. Two aspects to worksite responsiveness include those services and accommodations which suggest the "welcomeness" of the worksite and the degree to which the organization and those involved in disability management use their status to network in the community. The study of the role of EAP's in disability management (Akabas & Krauskopf, 1989) enumerated welcomeness measures such as providing barrier free access; providing new or modified equipment; negotiating changes in job productivity requirements, job design, job location, or work schedule; providing a transitional work program; offering a formal procedure for temporary work accommodation; providing a role for disabled employees and their supervisors in job accommodation; and offering retraining programs when necessary. Early Intervention Program participants confirmed the need for many of these accommodations but perceived their employers as "unlikely" to make needed accommodations (44 percent). When employers were perceived as inflexible, disabled workers also felt that it was unlikely they would be able to return to work. Once again, we see evidence that organizational factors impede successful outcomes.

So too, the more community ties the employing organization develops, the better the referral mechanisms and, thus, the level of service received by the disabled worker.

First, case managers need to have ties with the medical and rehabilitation community. Research results show that the single most important factor that determines when, or if, a disabled worker returns to work is the return to work date set by the physician (Gates, Taler & Akabas, 1989). Physicians, however, often set the date without an understanding of what an individual's job involves. Consequently, some return before they are ready, while others stay out longer than necessary. The current study results show that disabled workers often do talk to their doctors about what their jobs involve (87 percent) but do not go the next step to discuss returning to work in a modified form (27 percent). The employing organization can influence return to work by discussing rehabilitation with the treating physicians and by informing doctors about the requirements of the patient's job and of the possibility for accommodated work. Here, linkage among the medical department, whoever authorizes medical department, whoever authorizes medical care payments and the disability case manager contributes a useful organizational structure. Second, case managers must be familiar with agencies that help disabled workers with the problems encountered after the onset of disability. Having a good understanding of programs and agencies that provide financial assistance, including knowledge of eligibility for public assistance, is a requisite for case managers. The Early Intervention Program study shows that nearly all program participants experienced financial problems. Over 80 percent said their financial situation had been affected at least moderately, and over 90 percent reported they had less money post disability.

Other agencies that respond to personal or disability related problems such as self-help or counseling groups, health service organizations (e.g., Cancer Care or the Multiple Sclerosis Society) and rehabilitation services are also important. Most employing organizations have the potential for stronger ties to community agencies because they and their employees contribute significant funds through United Way campaigns. These ties provide both an avenue for case managers to become informed concerning community services and the power to make demands on these resources in meeting the needs of workers with disabilities. This is particularly relevant when workers are represented by trade unions which have representatives stationed at the United Way.

The disability managers also need ties to the benefit providers whether the employer is self insured, a participant in a collectively bargained health welfare plan or is insured by a private insurance carrier. They must also be knowledgeable about available benefits. Finally, working directly with unions is valuable because it helps to build trust among disabled employees. Unions are viewed as advocates of the workers' interests and, therefore, union support for the program can motivate worker participation.

Investment in disability management over time. At outset, programs need time to gear up, establish policy and procedures and train staff. Monitoring and record keeping sysems must be set in place. Study results show that existing forms often do not collect organizationally relevant information. Froms are needed to gather enough information to fashion appropriate intervention and to track individuals throughout the period so that it is possible to evaluate program effectiveness. Because of the complexity of establishing a disability management program, to observe positive outcomes requires further patience. While reduced lost time may occur quickly in some cases, other program impact may not be immediately evident. Then, it takes an additional period to assess how well the worker has been able to readjust to his/her job. Without long-range commitment it is not possible to carry out the longitudinal evaluation the authors have found is essential to confirm program effectiveness. So too, time is necessary to neutralize the forces restraining potential effectiveness of a disability management program within its organizational context and to promote forces that will encourage the cultural change needed to achieve worksite "welcomeness" for newly disabled employees. Without that organizational commitment our work suggests that a disability management initiative will be washed away with the tide.

Conclusions

Based on the study outcomes, the following recommendations are offered:

* Explicit disability management policy and procedures should be set in place stating employer position toward salary replacement, job accommodation, transitional employment, budgetary responsibility, and vocational retraining when necessary. Where a union represents some of the covered employees, these policies should be negotiated jointly.

* Top level managers should include all management levels in developing the program to insure their understanding of the objectives and enhance their commitment to its implementation.

* Organizational commitment must be highly visible and involve allocation of significant resources of staff and time. Job descriptions should reflect tasks performed.

* Implementation by professional staff whose priority is the disability management team program assures that the fullest range of services will be within the network.

* Formal coordinated channels of communication need to be established among all departments involved in the disability management activity. A disabled worker should never the lost in the system. If assistance is needed from a department other than disability management, clear procedures for accessing that assitance must be in place.

* The employer must develop a climate of welcomeness that involves on-site services and accommodations for disabled workers.

* Supervisors need to be trained and provided with incentives to facilitate work return for disabled workers.

* Disability managers need to develop extensive ties with community resources. Resource books and procedures for how to establish contact must be available.

* Procedures for involving physicians in the return to work process must be established.

* Procedures for involving benefit providers and unions in the return to work process must be established.

* Management must allow a reasonable amount of time before evaluating program effectiveness.

This work was supported, in part, by the National Institute of Disability and Rehabilitation Research grants Nos. DE G0087-20118 and G0085-3512. The authors wish to acknowledge the excellent work done by the staff of the Human Resources Development Institute of the AFL-CIO, including Michael McMillan, Director; Lynn Meyers, Assistant Director; Tony Suazo, National Disability Coordinator; the HRDI field staff; and staff of the 1199 National Benefit Fund For Hospital and Health Care Employees and its Executive Director, Eleanor Tilson.

Bibliography

1) Akabas, Sheila H. (1986). "Disability Management: A Longstanding Trade Union Mission with Some New Initiatives," Journal of Applied Rehabilitation Counseling, Vol. 17, No. 3 (Fall), pp. 33-37.

2) Akabas, Sheila H. and Marian S. Krauskopf (1989). "Managing Disability Costs at the Worksite: The Role of Employee Assistance Programs in Disability Management," issued by The Center For Social Policy and Practice in the Workplace, Columbia University School of Social Work, New York, NY, pp. 34.

3) Carbine, Michael E., Schwartz, Gail E. and Watson, Sara D. (1989). "Disability Intervention and Cost Management Strategies for the 1990's," Washington Business Group on Health/Institute for Rehabilitation and Disability Management, Washington, DC, pp. 47.

4) Deutsch, M. (1968). "Field Theory in Social Psychology" in Handbook of Social Psychology, 2nd Edition. G. Lindzey and E. Aronson (eds.), Addison Wesley.

5) Gates, Lauren B., Taler, Yecheskel and Akabas, Sheila H. (1989). "Optimizing Return to Work Among Newly Disabled Workers: A New Approach Toward Cost Containment," Benefits Quarterly, Vol. V, No. 2, Second Quarter, pp. 19-27.

6) Gleason, Sandra E. (1986). "Labor Market Factors Determining the Employment Opportunities for the Industrially Injured in Michigan," in The Impact of Labor Market and Health Care Economics Upon the Rehabilitation of the Injured/Disabled Worker, Disability Management Project, School of Health Education, Counseling Psychology and Human Performance, Michigan State University, East Lansing, MI, pp. 7-31.

7) Johnston, William B. (1987). Workforce 2000: Work and Workers for the Twenty-first Century, Hudson Institute, Indianapolis, IN.

8) Lewis, Beth M. and Mama, Robin Sakina (1987). "The Cost of Filing: Workers' Compensation and Unmet Need in the Work-Injured/Disabled Population," Social Work Papers, Vol. 20, The School of Social Work, University of Southern California.

Dr. Akabas is Professor and Director and Dr. Gates is Senior Research Associate at the Workplace Center, The Columbia University School of Social Work, New York, NY.