Topic 7: Healthcare journey
The scope of this chapter is the worker-patient journey through the system, from the workplace, through the healthcare system for diagnosis and management to the outcomes of OD and the review of what is known about physician practice — from both the perspective of the physician and the worker. A review of the WSIB processes is specifically excluded from our mandate.
The worker’s healthcare journey starts in the workplace with training related to the adverse health effects of exposure. An understanding of the possible adverse health effects related to the worker’s workplace exposure is an important first step. This topic is addressed in detail in Chapter 2, Workplace Training. Depending on the workplace exposures, medical screening may be important to identify the possibility of very early disease before it is clinically manifest to the worker. This topic is addressed in detail in Chapter 3. Screening is the activity that first clearly bridges the OHS system and HC system.
The worker’s journey in the healthcare system related to OD usually starts when they have symptoms that cause them to seek care or may occur because of positive screening tests that lead to further investigation to determine if the worker has an occupational disease. In cases of acute events, this may be obvious to all, and they are sent to the emergency department or to a primary care provider for acute care. For many ODs, the presentation is not acute, and they will first develop symptoms of the disease. At some point, they will seek care, again usually starting in the primary care system. Depending on the disease, further investigation involving a variety of specialists may occur, leading to a diagnosis and treatment. In addition to medical treatment and management, management of workplace exposures is also a necessary part of management.
For example, a worker with respiratory problems such as asthma or silicosis would likely be first seen
in the primary care system and then referred to a respirologist. Similarly, a worker with dermatitis would likely be first seen in the primary care system and then referred to a dermatologist. In these cases, the occupational nature of the diagnosis requires the work association to be part of the diagnostic process. Another example is cancer. In this case, the worker would usually be diagnosed and treated in the cancer system by the appropriate specialists (for example oncologist, radiation therapist, surgeon). In the case of diseases like cancer, the work association is usually not critical to the diagnosis and disease management.
Once the diagnosis is made and treatment advice provided, the follow-up of the worker in the healthcare system may vary. In some instances, they will return to the primary care provider or community specialist for ongoing care (for example, asthma, dermatitis), while in other cases, they may remain with the specialists (for example cancer).
Depending on the disease, for chronic diseases like cancers, the healthcare journey may eventually end in palliative care.
As part of this journey, communication is vital to provide timely and effective care. In most healthcare encounters, the main communication occurs between the provider and the patient and their other care providers in the healthcare system. However, in the case of a work-related disease, the communication links are broadened and may include the WSIB and employer expanding the work for the healthcare provider.
The past several decades have seen the development of clinical practice guidelines for many diseases. While some systematic reviews and consensus statements exist for some ODs, these do not link the recommendations with the HC system. The WSIB has developed Programs of Care which are generally for musculoskeletal problems and injuries.
From previous chapters, we know that:
- OD is under-recognized and under-reported.
- health human resources are limited and decreasing with respect to clinical expertise (occupational medicine and other relevant specialists) related to OD diagnosis and management
- the HC system is generally overburdened and going through transition to new models of care
Consultation and review summary
Note a comprehensive summary of CREOD research is provided on the CREOD website.
Key findings include:
- research of the worker healthcare journey for Ontario workers/patients shows that the worker with occupational disease typically is in the healthcare system for some time before a definitive diagnosis is made. They see a number of physicians, both primary care and specialists
- clinical research has improved our diagnostic practices related to OD
- clinical tools have been developed to facilitate the diagnosis and management of OD
Reports and reviews
No formal reports or reviews of this part of system.
Australia has responded to the recent outbreak of silicosis with a National Dust Disease Taskforce.
This includes a number of documents providing guidance to the healthcare providers at the various stages of the worker healthcare journey.
Stakeholder focus groups
- Need for better care pathway for worker health assessment and treatment.
- Need to increase healthcare capacity.
- Need for clarity and protection of worker rights to protect their health.
- Need for education.
- Clarify and simplify the worker health journey.
- Make the pathway visible/known.
- Clarify roles at each step of the pathway.
- Improve and simplify reporting — of exposures and symptoms.
- Address the potential for conflict of interest for physicians to ensure they are not caught between advocating for the health of a worker and protecting the employer.
- Create some level of independence.
- Need transparent collection (why, what, how) of personal and workplace health data.
- Create tools to empower workers throughout the health journey/pathway.
- Develop worker exposure history tool (passport… like vaccine and pharmacy records).
- Develop a questionnaire or anonymous self-screening tool that helps workers make the link between their symptoms and designated substances in their workplace and provides guidance on next steps if they are concerned (reporting, access the healthcare, etc.).
- Improve HCP education.
- Build awareness of the link between work and health.
- Provide patient/worker-specific exposure information (passport).
- Provide diagnostic trees/supports — what tests to order when.
- Reporting obligations.
Summary review findings
- We know that currently, there are challenges for workers with OD journeying through the HC system. We have an understanding of some of the factors that lead to delays. These include some understanding of the worker’s reasons for seeking or not seeking care and physician practices relating to the diagnosis and management of OD, including the barriers and facilitators.
- While there are guidelines for the diagnosis and management of some ODs, these are not necessarily linked with the HC care system so implementation is limited.
- There are some tools that have been developed to assist with diagnosis and management, but they have not been integrated into care.
- Early recognition of possible OD leading to timely diagnosis and treatment to achieve the best possible outcomes for the worker.
- Use of best practice or evidence-based care throughout the worker healthcare journey.
- Continued applied clinical research to continue to improve diagnosis and management of ODs.
Short term recommendations
7.1 Develop clinical pathways for common ODs
- The clinical pathway would start with the worker first being exposed to a hazard and the need for education about the adverse effects and prevention strategies (Topic 2).
- The pathway would include screening, if appropriate, then diagnosis and management.
- A key component of the pathway is not just these steps but also the identification of the roles of various healthcare providers along the pathway.
- Convene a group of clinical specialists from the academic OD hub (see Topic 6) supplemented by additional clinical experts as needed, practicing primary care providers and a worker for the particular disease.
- Start with respiratory diseases, silicosis and asthma.
- Learn from Australian model (use the Dust Disease Taskforce guidance as a start for silica).
- From the start, address implementation issues with those with expertise in clinical implementation.
7.2 Pilot the use of tools already developed and evaluated in Ontario for use in primary and specialist care
- Start with the asthma screening tool (WRASQ(L).
- Using respirology network (Topic 6), engage in learning about the tool and facilitating its use in practice.
- As part of primary care initiative (Topic 6), understand the barriers and facilitators for its potential use of the tool in the primary care setting.