Urgent message: Keeping patients able to perform their jobs is critical to the success of an urgent care occupational medicine program.
Donna Lee Gardner, RN, MS, MBA
To best meet the needs of employers, an urgent care occupational medicine (UCOM) clinic should feature five basic product lines:
• health surveillance
• injury/loss management
• rehabilitation
• prevention services
• on-site services
This article will address the first of these product lines, health surveillance; the other four will be discussed in subsequent articles in JUCM. The health surveillance product line is critically important to employers because it helps ensure that employees are physically capable of performing their jobs without posing undue risk to themselves or others. Essential components of the health surveillance product line include physical exams, drug screening and breath-alcohol testing, and exams mandated by the Occupational Health and Safety Administration (OSHA).
Pre-placement Screening
The UCOM clinical staff should be prepared to provide preplacement/post-offer physicals to evaluate a potential employee’s physical fitness for a specific job. Certain aspects of these exams are standardized. For example, a basic preplacement physical typically includes a medical and occupational history, a physical and functional exam, and reports vital signs, height, weight, and visual acuity.
Each standard exam should be customized based on the functional demands of the job in question. At a minimum, the examining provider should obtain functional job descriptions from the employer for each position for which examinations will be performed.
If such descriptions are not available, a comprehensive UCOM practice should be equipped to assist the employer with job analyses and the preparation of written job descriptions, which sup- port many of the components involved in an effective job-placement process.
There are two classifications of job analysis:
Quantitative job analysis involves measurements such as weight, distance, force, repetition, and speed.
Qualitative job analysis may be used to identify specific physical factors that can be addressed through ergonomic interventions and must be done by a professional with evaluation skills.
The importance of taking a functional approach to a preplacement exam cannot be underestimated. An evaluation based on a functional job description protects both the prospective employee and the employer by identifying pre-existing conditions that may put the worker at risk of further injury.
In addition, to comply with the Americans with Disabilities Act, an employer may need to take reasonable steps to accommodate a disabled applicant who is otherwise qualified for a job. Physicians, nurse practitioners, or physician assistants perform the physical exams; clinical technicians provide screening and testing.
In addition to knowledgeable examiners and technicians, however, the UCOM practice will find that physical and occupational therapists are valuable team members. These rehabilitation professionals may either be on staff or under contractor to the practice.
It is incumbent upon UCOM practitioners to educate employers in their market about the need for functional job analysis and other appropriate assessments for job applicants.
DOT Screening
The U.S. Department of Transportation’s (DOT) physical examination, urine drug screening, and breath-alcohol testing requirements can generate a considerable amount of business for a UCOM practice or clinic network that is able to handle high patient volumes efficiently.
The Omnibus Transportation Employee Testing Act of 1991 requires urine drug screening and breath alcohol testing of transportation employees in the aviation, trucking, railroad, mass transit, pipeline and other transportation industries. The DOT publishes rules on who must conduct these tests, how to conduct them, and what procedures to use when testing. These regulations cover more than 12 million people.
A DOT physical examination is conducted by a licensed medical examiner. The term medical examiner includes, but is not limited to, MDs, DOs, PAs, advanced practice nurses, and chiropractors. The required medical examination report form may be downloaded off the Internet by visiting the Federal Motor Carrier and Safety Administration’s website (www.fmcsa.dot.gov/documents/ safetyprograms/medical-report.pdf).
Medical review officer (MRO) services must also be provided as part of any DOT drug screening service. Many UCOM practices sell drug screening and MRO services as a package. The MRO may be an in-house physician who has obtained certification or a subcontractor. The professional MRO is a licensed physician (MD or DO) who is an expert in drug and alcohol testing and the application of federal regulations to the process.
When called upon, the MRO serves as a consultant to business, industry, labor, government, or academia on issues relating to prevention, detection, and control of drug abuse in the workplace. Sources for MRO training include the Medical Review Officer Certification Council (www.mrocc.com), the American Association of Medical Review Officers (www.aamro.com) and the American College of Occupational and Environmental Medicine (www.acoem.org).
The DOT’s Office of Drug & Alcohol Policy & Compliance provides authoritative interpretations of drug and alcohol-screening rules, which are contained in 49 Code of Federal Regulations, Part 40 (refer to www.dot.gov/ost/dapc).
For non-regulated employers, the UCOM practice may assist employers by offering drug screening in compliance with established standards and providing policies and procedures for the development of a drug-free workplace program. (For a sample policy, visit www.dol.gov/elaws/asp/drugfree/drugs/screen2.asp)
Other Mandated Exams
Many workplaces are subject to medical surveillance requirements under the Occupational Safety and Health Act. UCOM practitioners must be prepared to evaluate exposure hazards and develop appropriate health exams and screenings to provide employers with baseline data in compliance with federal regulations, which are en- forced by OSHA. Testing must be performed by certified staff and supported with documentation.
Key components include respiratory surveillance and hearing conservation. Respiratory surveillance involves pulmonary function screening and respirator monitoring. Technicians are considered competent in this area upon completion of a National Institute of Occupational Safety and Health (NIOSH)-certified training course. Licensure of health professionals is typically the function of a state board, and issuance of a course certificate does not imply that NIOSH has certified that student as a pulmonary function technician. (For resources, visit www.cdc.gov/niosh.)
The hearing conservation program includes certified audiology screening, annual monitoring, employee education, and policies and procedures for hearing- protection devices and documentation. This service also requires specialized training; certification is typically obtained through the Council for Accreditation in Occupational Hearing Conservation (www.caohc.org). Hearing testing and conservation services may be provided by internal staff or certified vendors.
Steps to Success
When establishing a health surveillance product line, taking the following steps will get your practice off to a good start:
- Identify companies that are likely to produce high volumes and schedule at least one company visit per week in which the UCOM medical director can The objective is to identify applicable workplace regulations and mandatory and optional health surveillance service needs.
- Establish policies, procedures, and processes for delivering each product line
- Develop written forms for each
- Define clinical roles for staff; designate functions that require special training, and establish a process to maintain clinical
- Coordinate entry of client information into the UCOM clinic database to ensure compliance with company protocols and accuracy in
- Establish processes for client feedback
Review costs-per-procedure and seek out quality vendors for services such as radiology, lab, MRO, hearing conservation, and occupational rehabilitation, as necessary.
