Committee for a Responsible Federal Budget
Social Security_SSDI_Job Interview

Implementing a Community-Focused Health & Work Service (HWS)

by Jennifer Christian, Thomas Wickizer, and Kim Burton

Read the full paper.


This paper is a follow-up to our original proposal for the development and refinement of a Community-Focused Heath & Work Service (HWS). It focuses on implementation issues at two levels. This is Part I, in which we provide the rationale for our proposal, describe some relevant intervening events since it was proposed, and then briefly summarize the specific features we envision for the HWS. The rest of Part 1 asks and answers five questions that policymakers might reasonably pose before deciding whether and how to implement (create) something like an HWS via legislation and/or other processes available to them.

In Part 2, we discuss some issues that a state agency or similar entity charged with actually implementing (operationalizing) an HWS as a program would need to address, while Part 3 covers design and evaluation issues. In doing so, we make suggestions for how to optimize the likelihood the program will fulfill its purpose and produce the expected outcomes. Lastly, the online Technical Appendix contains more practical information at a level of detail we hope will be useful for those actually carrying out those tasks.

Overview of Proposed Health & Work Service (HWS)

Our society today offers little help to workers who are struggling with work disruption, especially those experiencing common health problems (CHP) that are the most frequent causes of short- and long-term work absence: musculoskeletal disorders (MSK) like back, shoulder, and knee pain, and common mental disorders (CMD) like stress, anxiety, and depression. As a result, too many of these workers end up with unexpectedly poor recovery and job loss – both of which can often be avoided.

Recent reviews of the evidence show that work promotes positive physical, mental, family, and social wellbeing for working-age adults, including those with chronic health conditions (Waddell and Burton 2006) – and how worklessness does the opposite (Rueda et al. 2012, Waddell and Burton 2006, Strully 2009). Thus, in addition to supporting people with longstanding disabilities enter into employment, a major effort should be made to help working adults preserve their work ability when health problems start disrupting their ability to work so they can stay in the workforce. Avoidable impairment and loss of livelihood are not yet recognized as very poor outcomes of medical care and employer-based disability benefits programs, but we believe they should be.

Policy and program changes can be made to increase the likelihood that workers with new health-related work disability get timely help and keep their jobs or promptly find new ones – similar to the way that policy changes have been made to support more people with longstanding disabilities enter into competitive employment. A program in Washington State has confirmed under real-world conditions what research studies have already shown: rapid response to new episodes of health-related work disruption and delivery of evidence-based simple, short-term interventions can improve both health and work outcomes and even reduce eventual job loss and entry onto Social Security Disability Insurance (SSDI) by as much as 30 percent (Wickizer et al. 2018). The designers of that program realized that change needs to occur in systems at the community level because that is where workers live and work, and it is also where their health care is delivered face-to-face.

The HWS we propose will offer something that is presently missing in most communities: access to simple and short-term services by experts in the stay-at-work and return-to-work process (SAW/RTW) soon after those individuals begin struggling with the simultaneous challenges of:

  • Dealing with a common health problem that has started interfering with their work,
  • Navigating today’s complex health care and benefits systems, and
  • Wondering what the future holds and whether this means their livelihood is in peril.

In order to operate cost-effectively, the HWS must be able to:

  • quickly recognize and release with a just bit of guidance the large group of workers likely to get back to work as expected and the resources already available to them;
  • focus its energies and effectively assist the subset of individuals who need help because they are vulnerable or in difficult situations that may derail recovery and SAW/RTW; and
  • refer elsewhere those workers with medical, bio-mechanical, legal, or other risk factors for prolonged work disability that require more expertise and resources than the HWS has to offer.

By responding with alacrity and providing limited assistance during the critical early period of situations that fit its eligibility criteria, the HWS can reduce the number of workers going on to prolonged work disability. This means the HWS will exert greater leverage with much less effort and expense per case than existing programs that are geared for people who have been living with disabilities for a significant period of time: months, years, or a lifetime.

In addition to providing assistance in individual situations, the HWS we propose will also drive ongoing positive change: bridging gaps and enriching existing local systems of care while strengthening each community’s ability to keep people functional, productive, and employed despite the occurrence of CHP. In doing so, the HWS will also build capacity and interconnections within and across the health care, employment, and insurance sectors, strengthening the community’s ability to support its working people when they need help managing the impact of CHPs on their lives and livelihoods.

The design of the HWS is a synthesis of desirable features of two innovative initiatives: one the Centers for Occupational Health & Education (COHE) in Washington State, and the other the Fit for Work Service in the United Kingdom. Although the core issues that the HWS addresses and the interventions it delivers will be similar across the entire program, some specific features will differ due to variability in laws among jurisdictions, in geographic realities, and local cultures. Our original proposal and its three appendices offered rationales and suggestions for the program’s design, orderly development, testing, evaluation, and implementation, and is available at

Below is a summary description of how the HWS will look when it is in operation:

  • HWS will be a secondary prevention program: averting adverse secondary consequences and avoidable work disability. HWS will get involved very early in individual episodes of health-related employment disruption – ideally after one week of work disability, and never later than the sixth week. In general, the program will end by the three-month mark, though it may occasionally extend to six months for a specific medical reason. The purpose of HWS involvement is to ensure episodes unfold in a way that puts the worker on track, given their circumstances, for optimal restoration of functional ability and participation in society, including retention in the workforce.
  • HWS will be a multi-disciplinary membership organization that augments and enhances the existing system of care for working people in a specific geographic area or region. It will be a magnet for workers, physicians, employers, labor groups, and claims payers because of its independence, impartiality, and expertise as well as its explicit commitment to “best practices” and a philosophy that minimizing life and work disruption due to illness and injury has substantial benefits for workers, their employers, and the community – and that job loss should be avoided.
  • The target population served by the HWS is not “people with disabilities.” Instead, it is working people who at the moment see themselves as too sick or injured to go to work and do their usual tasks – and might develop prolonged work disability. HWS will solicit referrals of individuals with new health-related employment disruption (no matter the cause of the health problem, whether work-related or not) from any party involved in the episode. The HWS will not provide any hands-on medical care. HWS will offer special expertise in multi-party communication, coordination, and problem solving to facilitate functional recovery and the stay-at-work and return-to-work process (SAW/RTW).
  • The HWS will conduct most of its interactions in individual cases telephonically and online, since this has been shown to be as effective and lower cost than services delivered in person at a particular location.
  • As referrals are received, HWS staff will identify the subset of workers in situations that pose a risk for unusually poor outcomes. For that group, HWS staff then serve as guides and interlocutors with a purpose, which is to identify the reasons for reduced work ability, develop a plan of action to overcome those obstacles, and assist in carrying it out. The interactions will take a human-centered (biopsychosocioeconomic) approach and include demonstrating empathy, concern, and care; providing empowering information and practical tips; facilitating communications among the worker and any professionals who are involved; and coordinating the SAW/RTW process between the medical office and the workplace.
  • Physician members of the HWS will agree to adopt the HWS’s set of recommended occupational health best practices that have been shown to improve work ability – and will be paid every time they perform one. As members, physicians also gain access to HWS staff to help them deliver appropriate SAW/RTW outcomes for their patients.
  • Employer members of the HWS will also gain access to HWS staff for assistance with implementing SAW/RTW plans and will receive financial incentives when they refer eligible workers and agree to provide temporary work adjustments and/or reasonable accommodations that enable SAW/RTW.
  • The staff within the HWS consist of: (a) Recovery Coordinators who focus on resolving obstacles to SAW/RTW in individual worker’s situations, (b) Community Relations staff who build and nurture collaborative working relationships between the HWS and community physicians, employers, benefits payers, labor groups, and community and government agencies; and (c) Administrative staffers who manage and deliver financial and/or other types of incentives to physicians and employer members and support the general operations. HWS will also contract with consulting physician specialist advisors as well as various professionals offering specific services and solutions that may be required to effect a successful SAW/RTW.
  • Based on findings from actual programs as well as research studies, we estimate the level of effort required will vary from 30 minutes for processing new referrals to eight hours of HWS professional effort for the predicted 5 percent of complex cases, with a median level of effort per referred case of 1.5 hours (Wickizer et al. 2011, Wynne-Jones et al. 2018). The very few cases requiring different kinds of services or more intensive or longer-term services will be referred out to other existing programs.

Relevant Developments Since Our Original Proposal

In the interval since we made our original proposal, three relevant developments have occurred. First, a new analysis of eight years of follow-up data from Washington’s COHE program confirmed that it substantially reduced withdrawal from the workforce and reduced award of total disability pensions or SSDI benefits by roughly 30 percent (Wickizer et al. 2018). Second, the UK’s checkered experience with the launch of its Fit for Work Service offers important lessons. That program was canceled due to critical failings in details of its implementation and operations, even though the conceptual design had a solid evidence base and strong political support. Funding constraints resulted in some critical deviations in actual operations from the evidence-based model. The main problems included low referral rate, inadequate funding for staff training, and worker perceptions that the service as delivered was unhelpful (U.K. Department for Work & Pensions 2018). Third, the U.S. government decided to invest more than $100 million in a five-year demonstration project in eight states called RETAIN – a project that appears to have significant similarities to our HWS proposal (U.S. DOL 2018). However, RETAIN allows states to propose their own programs and has an extremely accelerated (and in our view unrealistic) timeline for design, development, rollout, and evaluation. See the Technical Appendix for key details about these developments, especially quantitative data from an eight-year follow-up of the Washington COHE program showing the beneficial impact on long-term outcomes.

Read the full paper.

Read the Technical Appendix.