Recovery at Work: reframing the conversation

Key practice points:

• Vocational rehabilitation outcomes have progressively deteriorated in New Zealand over recent years, with injured patients spending more time away from the workplace, and taking longer before they return to normal work hours or tasks.
• A prompt return to, and recovery at, work should be prioritised for most patients with non-complex injuries to improve physical rehabilitation, mental health and to maintain social/vocational connections.
• Clinicians have an important role within the Recovery at Work model by performing initial injury consultations, evaluating work capacity, setting shared expectations and making decisions around medical certification; this information in turn guides ACC claim decision-making and the provision of additional supports such as financial and rehabilitation assistance.
• There are three ACC medical certification categories for patients with accident-induced injuries: (1) Fully fit, (2) Fit for selected work and (3) Fully unfit. The definitions have changed over time; it is important to understand these distinct categories and the criteria that must be met.
  • Patients do not need to be “Fully unfit” to be eligible for ACC compensation. A fully unfit certification is usually only required where a return to work would significantly risk a patient’s health or the safety of others. If this certification is used to support initial recovery in the immediate days post-injury, consider an appropriate timeframe until subsequent review, balancing any potential benefits against the increasing risk of the patient becoming disengaged in returning to work.
  • Being “Fit for selected work” allows patients to earn up to 100% of their pre-injury income through a combination of work income and ACC compensation. This does not mean patients must immediately return to previous levels of work engagement, and sometimes there will be no suitable alternative duties or arrangements available. In these situations, patients still receive 80% of their pre-injury income via ACC, and can access other ACC-mediated support(s), e.g. stay at work services, physical rehabilitation, social assistance.
• Clinicians are not expected to determine whether suitable work tasks are available for patients within their specific workplace when providing a medical certificate; that is for the employer and employee to decide based on the medical certification, with help from ACC and vocational rehabilitation service providers, if required. Instead, the focus should be on building a clinical picture of the patient’s current physical and cognitive capabilities and restrictions.
• The framing of initial injury conversations can have a profound impact on how recovery progresses over time. Clinicians should focus on reinforcing positive recovery expectations, addressing fears around re-injury early and correcting misconceptions (particularly around medical certification definitions). Patients should be involved in decision-making about their care and goals.
• Regular follow up is important for patients who are certified as being “Fully unfit” and “Fit for selected work” to support recovery at work. This provides an opportunity to monitor physical recovery, reinforce positive recovery expectations, ensure workplace accommodations are being implemented and to adjust the treatment plan accordingly, if required.

Supporting a recovery at work following injury

The recovery trajectory for patients following injury can vary significantly. Context-specific factors need to be considered to establish a tailored management plan, rather than clinicians applying a standardised approach. Recognising the best plan for a patient, and adapting to evolving circumstances, is a nuanced skill that builds progressively with experience.

In New Zealand, the Accident Compensation Corporation (ACC) promotes a system where early return to work is emphasised as an important component of recovery for most patients.¹ This is based on the principle that patients experience improved health and wellbeing outcomes when they maintain employment and return promptly to their usual routine (see: “The advantages of facilitating recovery at work”). General practices have a crucial role within this process, ensuring their patients receive appropriate management and support based on their specific clinical and vocational circumstances.

ACC has progressively adapted the “Recovery at Work” initiative over time, including recent changes to referral frameworks, as well as revising definitions around medical certification. Understanding the key components of this initiative from a primary care perspective will enhance decision-making for clinicians and clarify the potential benefits and supports available for patients.

Vocational rehabilitation outcomes have worsened in recent years

ACC accepts around two million new injury-related claims each year in New Zealand; the most common injury types are falls, sports/recreation accidents, work-related injuries and injuries sustained when lifting/carrying objects (Figure 1A).¹ The profile of injury causation has not changed considerably over time, however, vocational rehabilitation outcomes have gradually worsened, particularly since the start of the COVID-19 pandemic (Figure 1B).

Between March, 2020, and March, 2024, the proportion of patients returning to work within ten weeks of an injury decreased by 5% (from 66.5% to 61.5%), and 3% fewer patients returned to work within nine months (from 91.9% to 88.7%).¹ During this four year period, the average days per medical certificate, proportion of days designating the patient as “Fully unfit” and average total duration of ACC compensation, increased.¹

The parallel between prescribing medicines and “prescribing” time off work

In the same way that medicines are often prescribed for pain management after injury, “prescribing” time off work can be considered as a treatment. In some cases, short-term absences from work immediately post-injury can be important for recovery. However, as with any treatment, potential associated harms must be considered before initiation. The concept of rational medicine use outlines that patients should receive treatment “appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and their community”.⁴ This principle can similarly be applied to time off work; rather than following a standardised approach (e.g. routinely signing patients off for a set number of days), balance the type/severity of injury against the specific physical and cognitive restrictions it imposes when determining medical certification.

From this perspective, inappropriately designating a patient as “Fully unfit” rather than “Fit for selected work” could be considered akin to prescribing an opioid analgesic when paracetamol or a NSAID is sufficient, or prescribing a long course of pain relief when discomfort is expected to resolve within a short timeframe. In addition, as with medicine use, it is important to regularly review whether the benefits of continuing to prescribe time off work outweigh the potential risks, thereby limiting the risk of “misuse”, i.e. extended durations disengaged from employment (see: “Follow-up for patients returning to work”). If concerns arise regarding the suitability of either intervention (i.e. medicine use or time off work), the approach should be adjusted accordingly.

Conducting an initial medical certification consultation

Injury assessment is a fundamental skill familiar to all primary care clinicians. A key focus throughout this assessment is what the patient can do despite their injury, not just what they cannot do. This process usually encompasses:⁷

• History – consider the mechanism and details of the injury, including the specific forces involved as this helps to refine the diagnosis. Identify the features of pain (as well as any other symptoms, e.g. paraesthesia, weakness) and how function(s) have been affected since the injury occurred. Consider possible complicating factors such as previous similar injuries, existing dysfunction or disability, relevant co-morbidities or current medicine use.
• Physical examination – dependent on patient history and injury type. Usually encompasses observation (including posture, gait and general demeanour as the patient enters the consultation room, sits down or removes clothing, and whether patterns of movement change during the consultation), palpation and assessment of active and passive movement. Verbal distraction can help distinguish between true functional restriction versus apprehension or fear of movement. Additional investigations may sometimes be required, e.g. neurological examination in patients exhibiting weakness, numbness or radicular pain.

Information obtained during this assessment is used to fill out the initial ACC45 form or subsequent ACC18 forms (see: “Issuing a medical certificate”). Other information such as psychosocial variables (e.g. previous fear avoidance or catastrophising behaviours, social support) should also be considered during the consultation and used to help develop an individualised recovery plan.

If it is suspected that a patient’s physical injury has caused significant behavioural, cognitive or psychological dysfunction (i.e. these mental factors are not pre-existing), patients may be eligible for additional cover from ACC (see: “Support for mental injuries”).

Considerations that inform a work capacity assessment

Following clinical assessment, considering the information in the context of ability, tolerance and risk can be useful to inform work capacity decisions:⁸

• Ability. This encompasses both the physical and cognitive capacity of the patient and how this affects the types of tasks they can perform. Provide a diagnosis, treatment or rehabilitation recommendations and prognosis (if possible or appropriate).
• Tolerance. Consider any appropriate accommodations that could be made to enable the patient to continue working within their current ability level. This may include changes to hours, travel, tasks. Identify key dates for a staged return to work, as applicable.
• Risk. Specify tasks that exceed the patient’s tolerance level, and which must not be performed to keep both themselves and others safe; this may be due to the injury itself or adverse effects of medicines being taken, e.g. opioids. Determine what constitutes a risk, such as specific activities (e.g. lifting heavy objects, prolonged sitting) or situations (e.g. driving, climbing on a roof). Identify any specific actions that should be taken to decrease risk, e.g. changes to the environment, equipment, breaks. Remind patients that restrictions relating to vocational tasks should also be applied at home, e.g. if they cannot lift heavy loads at work, they should not be doing it at home.⁶

This process should focus on building a clinical picture of the patient’s physical and cognitive capabilities and restrictions. Clinicians are not expected to decide whether suitable work tasks are available for the patient within their specific workplace; that is for the employer and employee to decide based on the medical certification, with the help of ACC and vocational rehabilitation service providers (if required).

N.B. Information and options for self-employed patients is available at: www.acc.co.nz/for-business/understanding-your-cover-options/types-of-cover-for-self-employed.

Understanding the medical certification definitions

ACC released revised definitions for medical certifications in February, 2023.⁸ The aim is to encourage a system supporting patients to recover while returning to work at a level suitable for their injury. These definitions apply when lodging ACC45 and ACC18 forms; work incapacity can only be certified by a registered medical practitioner or nurse practitioner (see: “Issuing a medical certificate”). A key challenge is managing patient expectations and understanding around these terms; they should be considered based on their definition, not how the title is perceived, and any misconceptions should be addressed promptly (see: “Navigating recovery at work conversations and decision-making”).

Fully fit

Assessing patients as being “Fully fit” means they are able to functionally perform their full pre-injury work duties and hours.¹ Even though they are not eligible for weekly income compensation from ACC, this certification is still important as it allows patients to receive appropriate ACC-funded rehabilitation support (see: “What support is available from ACC?”).⁸

Fit for selected work

This type of certification should be the first consideration for most injured patients who are not “Fully fit”, i.e. they have some functional restrictions but can complete certain activities safely. Patients assessed as being “Fit for selected work” are able to engage in physical rehabilitation and/or some level of work with support.⁸ This may include:⁸

• Amended duties – changing the type of duties undertaken based on the type of injury, e.g. administrative tasks rather than manual labour
• Workplace adaptations – changing aspects of the workplace to facilitate the performance of specific tasks
• Altering hours – changing the times or duration of work
• A phased return to work – starts back with reduced hours or duties and progressively increases engagement over time

These requirements can be specified on ACC45 and ACC18 forms. Certifying a patient as “Fit for selected work” does not mean patients must immediately return to their previous level of work engagement and there may be instances where, after they have a discussion with their employer, there are no alternative duties or arrangements available. Instead, using this type of medical certification helps establish an expectation that recovery can occur in the workplace (thereby limiting the risk of a delayed return to work), and provides the flexibility for patients to:⁸

• Earn up to 100% of their pre-injury income through a combination of ACC compensation and work-related income for hours spent at work; if alternative duties or accommodations cannot be facilitated by the employer, patients still receive 80% of their pre-injury income via ACC compensation after the first week.
• Maintain a professional and social connection to their workplace, including retaining current skills or developing new ones. Patients who return to work early are much more likely to remain in employment long term.
• Make the most of their recovery and access the full range of ACC-mediated rehabilitation supports available (Table 2). Being certified as "Fully unfit" (see next section) can limit engagement with certain aspects of rehabilitation support, potentially delaying the overall recovery process.

Fully unfit

Of the three ACC medical certification types, the definition of “Fully unfit” has undergone the most significant change. Patients assessed as “Fully unfit” are essentially those who are hospitalised or “house-bound”, and should meet one of the following limited criteria:⁸

1. Total inability to work – the patient is either admitted to hospital or confined to bed. This is not the same as general “rest”; to meet this criterion the patient should be unable to effectively mobilise from their bed.

Example: A person involved in a motor vehicle accident who sustained multiple leg injuries is restricted to bed rest.

2. Contagion risk or quarantine need – the patient is at risk of infection due to their injury and the environment they usually work in and is unable to work remotely.

Example: An apprentice plumber sustains a significant burn to their face. There is an increased risk of infection during the initial recovery phase, and the nature of their job does not allow them to work safely in their usual working environment.

3. Health and safety risk – the patient being in the workplace, even with assistance or modifications, poses a specific health and safety hazard to themselves, their co-workers or the general public (e.g. due to the impact of the injury or the effects of medicines being taken). This criterion does not apply when there are alternative tasks that could potentially be done, even if these do not align with the patient’s usual role in the workplace.

Example: A person who sustained a severe traumatic brain injury (TBI) or who requires strong analgesia as a result of an injury. Regardless of the environment or work performed, these factors will significantly impact a person’s cognitive ability, e.g. ability to make sound, safe, timely and effective decisions. As a result, they could be considered a risk to the public if they drive or operate heavy machinery, or a risk to their co-workers if they cannot respond quickly to high-risk work environments.

In contrast, this criterion, for example, would not apply to a roofer who sustains an arm injury; while they cannot safely be on a roof until their arm has fully recovered, the injury does not prevent safe, productive work if they were to perform other tasks without using the injured limb (therefore they can be “Fit for selected work” regardless of whether the alternative tasks are actually available within their workplace).

Patients who are “Fully unfit” are eligible for ACC-funded general treatment and rehabilitation support to assist in their recovery.⁸ However, while they remain certified as being “Fully unfit”:⁸

• There may be some aspects of ACC-mediated rehabilitation support that the patient cannot engage with
• The patient’s income is capped at 80% of pre-injury earnings (via ACC compensation)
• Their likelihood of a timely and successful rehabilitation progressively decreases

Given these consequences, this certification must be used appropriately. If it is required to support initial recovery in the immediate days post-injury, consider an appropriate timeframe until subsequent review, balancing any potential benefits of time off work against the progressively increased risk of patients becoming disengaged in the return to work process (see: “Determining the duration of medical certification”).

Issuing a medical certificate

Medical certification is first issued as part of the initial ACC45 injury claim and, after obtaining patient consent, can be submitted through the PMS or the ACC online system.⁸ Ensure clear and sufficient information is provided to enable faster approval; if there is inadequate information to establish a causal link between an accident and the injury, ACC will need to follow up with the clinician or patient to clarify, thereby prolonging the acceptance process.

Most treatment providers can lodge ACC45 injury claims assuming the type of injury is within their scope of practice, e.g. registered medical practitioners, nurse practitioners, nurses, physiotherapists. However, only registered medical practitioners or nurse practitioners can certify incapacity for work, i.e. medical certification.

If the patient cannot immediately continue pre-injury levels of work engagement, ACC45 forms can include one period of “Fully unfit” and/or one period of “Fit for selected work”, up to a combined maximum period of 14 days.⁸ An ACC45 may be all that is required for many patients with non-complex or less severe injuries. For those with complex or more severe injuries, follow-up assessment will be needed and an ACC18 form completed for work capacity. In some cases, an ACC18 form can be completed at the initial consultation after completing the ACC45 form, e.g. in patients with more serious injuries where a return to work within 14 days is clearly not appropriate.

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Figure 2. An overview of information relating to (A) the medical certification process in primary care and (B) employee payments if ACC compensation is applicable.¹

* Further information on the types of injuries covered by ACC is available at: www.acc.co.nz/im-injured/what-we-cover/injuries-we-cover. ACC usually only covers injuries caused by a specific identifiable event, not long-term gradual processes. However, ACC can cover injuries and conditions caused by long-term work-related harmful exposures or processes.

† Clinicians are not expected to know whether there are alternative duties or arrangements available in the patient’s workplace; this assessment involves determining whether there are any types of physical or cognitive tasks the patient could potentially undertake without compromising recovery.

** ACC can provide injured employees compensation up to 80% of pre-injury weekly income. If the employee can complete some work, they can top up their weekly income to a maximum of 100% of pre-injury earnings (depending on the hours completed); ACC does not reduce (abate) the first 20% of earnings paid by the employer. ACC will abate weekly compensation payments based on additional income received from the employer beyond the first 20%, i.e. if the employer pays 40% pre-injury income, ACC will pay the remaining 60%.

‡ In rare cases, longer durations between reviews may be appropriate (e.g. 6- or 12-monthly intervals) for patients with stable serious injuries. However, this is subject to strict criteria and usually only applicable much later in the recovery timeline. For further information, see: www.acc.co.nz/for-providers/treatment-recovery/issuing-medical-certificates

Getting the diagnosis right when submitting injury claims

Read Codes are used by ACC to provide a standardised way of grouping injury diagnoses. Most practice management systems have Read Codes embedded within them, or they can be searched at readcode.tubo.nz.⁸ Use a Read Code that represents the physical injury (not the symptoms or cause) where possible and avoid using non-specific Read Codes.⁸ More than one Read Code can be provided per claim (e.g. when there are multiple injuries from the same accident), and the comments field used to clarify the clinical situation, if required.

N.B. SNOMED Clinical Terms (CT) will likely replace Read Codes in the future; work is currently being undertaken to co-ordinate this transition. SNOMED CT can be used by certain providers if they have SNOMED enabled software, however, they will be translated into Read Codes by ACC. For further information, see: www.acc.co.nz/for-providers/lodging-claims/using-snomed-clinical-terms/.

What support is available from ACC?

Support provided in primary care will often be sufficient to enable successful recovery and return to work. Following an injury, many patients require stretching, strengthening and functional exercise to regain normal function, and this can be co-ordinated via referral for physiotherapist treatment. However, ACC can provide a range of additional support(s) for patients following injury if they do not have straightforward vocational or physical circumstances. Types of assistance include more comprehensive return to work support, compensation for lost earnings, travel costs, childcare, personal care, equipment provision and home modifications and additional treatments, e.g. surgery (Table 2).

Making a referral for recovery support. Clinicians can indicate the need for further assistance initially by selecting “Rehabilitation assistance required” when filling out the ACC45 form. However, this need may not be known until later in the recovery process. Instead, the requirement for rehabilitation or return to work assistance is usually specified on subsequent ACC18 forms, or by filling out the dedicated referral form for a specific service.

Clinicians can specify the type of treatment or support that would meet the patient’s needs on the ACC18 form, or request that ACC contacts the clinician directly. The ACC Recovery Support team can liaise with the patient, employer or clinician at any point to make a referral for rehabilitation services.

MyACC

Following claim approval, ACC will email or text the patient to confirm the outcome, and provide information on registration details for MyACC.¹⁶

This online service allows patients to:¹⁶

• Update contact details
• Access claim information (from 2007 onwards)
• Apply for weekly compensation (if applicable based on medical certification)
• Enter hours worked (if gradually returning to work)
• View upcoming payments
• Upload new medical certificates
• Apply for other forms of ACC support, e.g. prescription and travel reimbursement, assistance at home
• Access additional support via a live chat feature

For further information on MyACC, see: www.acc.co.nz/im-injured/myacc

Support for mental injuries

Most ACC cover relates to physical injuries, however, in some cases additional support can be provided for patients with “mental injuries” (i.e. mental health condition or difficulty, mental illness). Mental injury involves persistent clinically significant behavioural, cognitive or psychological dysfunction that is causally linked to a specific accident or event. There are three main instances involving mental harm that ACC may cover, including when it is caused by:⁸

• An ACC-covered physical injury. The physical injury already covered under an ACC claim is a contributing factor to the mental injury; a mental injury will not be covered if it is solely caused by the experience of being in an accident. Cover is not available for mental injuries resulting from witnessing physical injury suffered by other people unless it occurs at work (see below).
• Sudden traumatic events at work. The mental injury must involve a single, sudden, traumatic event at work, likely to cause shock, horror or extreme distress to most people. The person does not need to be physically injured, but it must have happened during their work.
• A criminal act listed in Schedule 3 of the Crimes Act 1961, e.g. depression, anxiety, post-traumatic stress disorder caused by rape or sexual abuse. Patients do not need to have suffered physical injury to be covered under this category.

Characterising mental injury can be challenging as multiple factors often contribute to mental distress. To be eligible for ACC cover, mental injuries cannot be caused by gradual processes (e.g. bullying or stress) or involve pre-existing mental health conditions which were exacerbated by an injury.⁸ If mental injury is suspected, clinicians can lodge a claim with ACC who assess whether it meets the criteria for cover. Patients with an accepted mental injury claim will receive support tailored to their specific needs, e.g. one-on-one talk therapy, body-based therapy, group therapy, Rongoā Māori, social work support. Counselling or psychological support can be accessed while patients await a cover decision (for options, see: www.findsupport.co.nz/).

For further information, see: www.acc.co.nz/for-providers/lodging-claims/understanding-complex-cover.

Follow-up for patients returning to work

Regular follow up is essential to facilitate a successful return to work.⁷ This presents an opportunity to monitor physical progress, reinforce positive recovery expectations, enquire if workplace accommodations are being implemented and to adjust the treatment plan accordingly. In general, more regular consultations are often necessary initially, with the frequency gradually reduced as improvements become apparent.⁷

The primary setting for follow up can vary depending on the injury, but ongoing physical rehabilitation needs and progress are often supported by input from a physiotherapist, e.g. for patients with musculoskeletal injuries. General practice review then often occurs to align with the duration of each medical certificate (e.g. re-considering physical and vocational capacity, pain management) unless an event occurs triggering the need for earlier assessment (e.g. aggravation of the injury, insufficient analgesia). Some patients require more regular general practice review, e.g. those with burns or open wounds who require regular appointments for dressings, analgesic review or for consideration of antibiotics.

• The role of telehealth. ACC generally encourages in person assessment in the context of injury follow up and medical certification, particularly if the patient’s condition or circumstances change, or if recovery progress was expected but has not occurred. For further information on ACC expectations around telehealth use, see: www.acc.co.nz/for-providers/provide-services/providing-services-via-telehealth/telehealth-criteria.

Determining the duration of medical certification

A return to work “template” will not meet the needs of every injured patient, therefore definitive guidance around the ideal duration of medical certification is not possible. Clinical judgement is key, and decisions may also be guided by physiotherapy or return to work service input.

If time off work is required to support initial recovery, a pragmatic approach is that most patients with non-complex musculoskeletal injuries should not be signed off work for more than a few days to one-week post-injury before attempting a transition to “Fit for selected work” or “Fully fit”. In patients with concussion, an early return to some form of vocational engagement following the required 24 – 48 hour rest period is recommended, assuming the work environment or duties do not put them or others at risk of injury.¹⁷

Ideally, any period of “Fit for selected work” should be sufficiently long enough to enable rehabilitation while gradually reintegrating the patient into their usual work, but not so long that they experience deconditioning, dependency on restricted tasks and delays in returning to full productivity. This can be a delicate balance. In non-complex cases, patients may work through a defined period of “Fit for selected work” and then return to full duties without the need for a follow-up consultation. However, patients should preferably be reassessed to obtain “Fully fit” certification before returning to their previous tasks; this may sometimes be requested by the employer and is particularly important if they were unable to perform high-risk tasks safely due to their injury, e.g. operate heavy machinery.

Additional resources:

• ACC information hubs for:
  • Health providers – www.acc.co.nz/for-providers
  • Injured patients – www.acc.co.nz/im-injured
  • Employers/businesses – www.acc.co.nz/for-business also see: www.acc.co.nz/for-business/supporting-your-injured-employee-to-recover-at-work/resources-recovery-at-work)
• ACC Q/A document for health providers – www.acc.co.nz/for-providers/treatment-recovery/how-we-support-clients-throughout-their-recovery
• ACC “Quick guides” on a range of topics: www.acc.co.nz/for-providers/getting-started/quick-guides
• Information on MyACC – www.acc.co.nz/im-injured/myacc/
• Medical Council of New Zealand standards for medical certification: www.mcnz.org.nz/our-standards/current-standards/medical-certification/