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Back medical exam (BME)
A back medical examination (BME) is a medical assessment performed by a physician who has received specialized training. A back medical exam can be used to: - Establish or confirm the worker’s diagnosis
- Determine the worker’s health status prior to return-to-work program.
- Expedite a consultation, where possible, if there will be a long wait to see a surgeon (within 30 days of the referral).
- Clarify the worker’s fitness to return to work and/or work restrictions.
A back medical exam includes: - A comprehensive history and physical examination.
- Coordination of any required diagnostics or further medical services.
- Education for the worker about their injury and the return-to-work process.
- Contact with the treating physician to obtain treatment consensus.
- Development of a medical treatment plan.
The back examiner can also request a spinal surgery review (SSR), where an independent orthopedic specialist provides an opinion on whether the worker requires back surgery. Eligibility: - The worker’s primary injury is their back or neck and all other injuries have been resolved.
- The worker needs to be assessed prior to entering a return-to-work program.
- The worker requires a surgical consult through the Visiting Specialist Clinic.
- The worker has been referred to a surgeon or community specialist and the appointment is more than four weeks from time of assessment.
- The worker has experienced recent and significant changes in their medical status.
- All diagnostics are on file.
In some cases, a repeat exam can take place as necessary or as medically indicated. Such as when the examiner requests a reassessment or there is a new and substantial change in medical status.
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Administrative tasks
Complete the Return-to-work Referral (FM733) script from the eCO Create Referral screen. For an out of province request, select Out of Province in the provider drop-down box and a task is sent to the Health Care Services (HCS), Out of Province Referral, Team Desk. Send the Specialist Clearance - MSE/FCE and Program (SP235H) letter to obtain a written release of care when the worker is under the care of a community specialist (non-Visiting Specialist Clinic surgeon). Confirmation is required to ensure a referral is accepted. Refer the worker directly to a surgical specialist instead of a back medical exam when required by the Decision Review and Dispute Resolution Body.
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Brain injury assessments
When a worker has a suspected brain injury, they are referred for a brain injury medical exam. The results of the exam will determine whether additional assessments should be done. Specialized assessments require approval from Health Care Strategy. Moderate to severe brain injuries are assigned to the Special Care Services (SCS) team who may refer a worker for any combination of neurological and psychological assessments to determine the barriers a worker may experience going forward. A Brain Injury Program can only be recommended following a brain injury assessment, including at a minimum both a brain injury medical exam and a traumatic brain injury assessment. Brain injury functional capacity exam (BI-FCE) A brain injury functional capacity exam compares critical activities to the worker’s expected job tasks and work conditions to determine their sustainable abilities and includes a functional cognitive screen based on the conclusions. Brain injury basic functional capacity exam When the exam is done in the early stages of a claim, it establishes a baseline to determine a worker’s physical and functional abilities, cognitive abilities and identify further rehabilitation to support the worker’s recovery. Brain injury complex functional capacity exam The exam can be done in the later stages of a claim when the worker has reached a plateau in their recovery and the exam supports the return-to-work process. The two-day exam evaluates a worker’s physical functional and cognitive abilities to identify any work restrictions based on the expected job tasks and working environment. Brain injury medical status examination (BI-MSE) A brain injury medical status examination is conducted by a physician and is used to determine the current medical condition, diagnosis, work restrictions as well identify any other medical conditions that may impact rehabilitation and successful return to work. Based on the results, the examining physician may recommend further brain injury assessments as appropriate following the results. Brain injury return-to-work planning meeting (BI-RTWPM) A return-to-work planning meeting includes the worker, employer and the treatment provider. The meeting is required for a worker who has experienced a brain injury, to clarify the worker’s pre-accident job demands and identify suitable modified duties and return-to-work opportunities. Eligibility: - The worker is not working.
- The employer is having difficulty identifying modified duties.
- The worker is performing modified duties, but there is no plan to progress to full duties.
- The worker or employer has concerns about the return to work.
Neurological vestibular assessment A neurological vestibular assessment is performed by a physiotherapist who has received specialized training. The assessment is used to confirm diagnosis and treatment recommendations when the worker presents with symptoms of dizziness and is not already referred to a contracted physiotherapy provider with ability to complete this specialized assessment. The brain injury service provider arranges the neurological vestibular assessment in conjunction with the brain injury program. However, a family physician or community physiotherapist may make the recommendation, or a decision maker may consult with a physical therapy consultant to confirm this referral is appropriate. Traumatic brain injury (TBI) A traumatic brain injury intake assessment is done by a psychologist or neuropsychologist who reviews the worker’s current symptoms, their accident history and any treatment or services they’ve received. The information is used to outline any additional assessments, a treatment plan going forward and to educate the worker about expectations for recovery and return to work.
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Administrative tasks
Complete the Return-to-work Referral (FM733) script from the eCO Create Referral screen. Include any other appropriate assessments on the initial referral to provide the physician authorization to proceed if the assessment is considered appropriate. Decision maker approval is required when a brain injury medical examiner (ME) recommends an assessment that was not included in the initial referral. Provide authorization verbally or via email.
For assistance in locating a physiotherapist with specialized training for vestibular assessment, choose the Physical Therapy Consultant Referral (FM555G) form from the eCO Create Referral screen or contact the physical therapy consultant directly.
Document the most likely diagnosis, the supporting rationale such as tests, investigations or medical evidence.
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Comprehensive psychological assessment (CPA)
A comprehensive psychological assessment can help assess the psychological impact of the worker’s injuryIf more than one year has passed since the worker’s date of accident, refer the file to a clinical consultant to review and identify any missing medical information. and recommend a treatment plan. This assessment can be combined with a neuropsychological assessment and/or a psycho-vocational assessment. Consult a psychological assistant to discuss if it is appropriate, and/or to determine the best timing. Please see the psycho-vocational assessment section below for criteria. The comprehensive psychological assessment is conducted by an experienced, independent psychologist over one to two days and determines the relationship between the worker’s workplace accident and their psychological diagnosis. It can also assess their fitness for work. The assessment involves a review of the worker’s relevant medical history and a series of psychological tests and clinical interviews to assess the worker’s symptoms. It is recommended when: - The worker has a medically indicated psychological condition without a confirmed psychological or psychiatric diagnosis as defined in the most current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM).
- The worker’s DSM diagnosis needs to be clarified.
- The worker has a pre-existing psychological condition, and it is unclear if it was aggravated by their work duties.
- There is a need to clarify or confirm the connection between the diagnosis and the work injury.
- There is a need to confirm fitness for work and temporary or permanent work restrictions.
- The worker has psychosocial issues posing significant barriers to returning to work.
Potential invalid exam Should the assessor note any concerns about the validityThe findings of the examination may not be an accurate reflection of the true situation which may be due to a number of factors. of the exam results, contact the psychological assistant or consultant for clarification, or the assessor if needed. The assessor may still be able to comment on fitness, based on a combination of the file information and history, the interview and examination and their expertise in the field. When the examiner is unable to provide the requested information, reach out to the psychological assistant or consultant as necessary to discuss the results, recommendations and to clarify when to repeat the assessment. Contact the worker to discuss the next steps. These may include a psychiatric independent medical exam, a case conference with the treating physician or a repeat assessment if a consensus cannot be met. In the event an assessment has to be repeated, confirm the exam and ensure the worker understands the importance of their participation.
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Administrative tasks
Complete a Psych Referral Assessment (FM008A) form from the eCO Create Referral screen. Review the mental health risk portlet for any active or resolved risk incidents. The psychological assistant organizes the referral: - Identifies a provider
- Adds a file note confirming the provider’s name.
- Sends the appropriate referral letter.
- Requests a medical package
Ensure the medical professional receives any new medical reporting and/or investigation unit reporting: - Psycho-vocational Referral (SP021I) letter
- CPA/NPA Referral (SP021M) letter
- CPA Referral (SP026B) letter
- Confirm CPA referral (CL026P) letter
Send the appropriate letter to request information on a worker’s DSM diagnosis. - DSM Confirmation Physician (SP026J) letter
- DSM Confirmation Psychologist letter (SP026K)
Send the First Invalid CPA (CL026Q) letter when there are concerns about the validityThe findings of the examination may not be an accurate reflection of the true situation which may be due to a number of factors. of exam results and the assessor is unable to comment on fitness. Refer the worker for a psychiatric independent medical exam when the reporting supports ongoing disability, but a repeat assessment is not recommended.
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Concussion symptom assessment (CSA)
A concussion symptom assessment is an early brain injury medical assessment for workers who have suffered a mild head injury and is completed by a medical status exam physician. Workers who have suffered moderate to severe brain injuries are assigned to the Special Care Services (SCS) team who may refer a worker to a neuropsychologist or psychologist who has experience working with head injuries. When the worker has experienced a concussion or has ongoing symptoms and needs further services, a referral for a CSA should be completed. The examination must take place within 21 days following the date of accident. The referral can be sent by day 14. The concussion symptom assessment includes three parts. The assessor reviews the worker’s accident history and current symptoms, as well as treatment to date. They also educate the worker about their recovery expectations and treatment recommendations, which may include a return to work as appropriate. Indicators of a mild traumatic brain injury can be: - Any period of loss of consciousness.
- Any loss of memory for events immediately before or after the incident.
- Any alteration in mental state at the time of the accident (e.g., feeling dazed, disoriented or confused).
- Any symptoms like dizziness, headaches or tinnitus.
- Focal neurological deficit(s) (weakness, loss of balance, change in vision, dyspraxia paresis/plegia [paralysis], sensory loss, aphasia, etc.) which may or may not be temporary.
If the results of the assessment determine the worker has sustained a more serious brain injury, consult a Special Care Service supervisor to determine whether the claim qualifies to be transferred.
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Administrative tasks
Complete the Return-to-work Referral (FM733) script from the eCO Create Referral screen. Indicate concussion symptom assessment in the Referrals section. A follow up concussion symptoms assessment is available if there are ongoing symptoms within four weeks of the initial assessment, by completing a new script (FM733).
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Functional capacity evaluation (FCE)
A functional capacity evaluation is completed after a medical status exam and compares activities to the tasks a worker is expected to do as part of their job. The assessment determines which work activities the worker can and cannot perform safely and how often they can do those activities given their injury. There are two types of functional capacity evaluations. Basic functional capacity evaluation (BFCE) A half-day assessment done early in the claim, often used with a medical status exam, to determine a baseline for the worker’s abilities, the need for any work modifications and identify if the worker requires rehabilitation treatment. A comprehensive functional capacity evaluation (CFCE) A two-day assessment of the worker’s performance, done later in the claim when a worker has reached a medical plateau. The exam determines the worker’s sustainable abilities and reasonable working conditions and outlines any restrictions in support of their return to work.
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Administrative tasks
Complete the Return-to-work Referral (FM733) script from the eCO Create Referral screen. For an out of province request, select Out of Province in the provider drop-down box and a task is sent to the HCS, Out of Province Referral, Team Desk. Consult with the treating physician when there is a return-to-work referral. Send the Specialist Clearance - MSE/FCE and Program (SP235H) letter to obtain a written release of care when the worker is under the care of a community specialist (non-VSC surgeon). Confirmation is required to ensure a referral is accepted.
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Gait assessment (GA)
A gait assessment can provide specific recommendations for the provision of footwear, braces and other gait aids to help improve a worker’s comfort and function when the injury affects the lower extremity (hip, leg, ankle joint). Testing is individualized to each worker, but may include any of the following: - Evaluating the current footwear and/or walking aids.
- Evaluating any swelling or skin conditions.
- Functional test such as squatting and balancing.
- Testing mobility, strength, and/or stability.
There are two types of gait assessments. Basic assessment This type of gait assessment is recommended when the worker has a(n): - Mild to moderate strain and/or chronic lower extremity swelling.
- Uncomplicated toe or mid-foot fracture not affecting the ankle joint.
- Gait assessment within the last six months without surgical intervention.
- Older claim requiring periodic follow-up.
- Spinal injury unaffected by a neurological involvement.
- Low back strain/sprain, impacting weight bearing tolerance.
Comprehensive gait assessment This type of gait assessment is recommended when the worker has a: - Strain that is severe on the lower extremity.
- Surgical intervention recently of the lower extremity.
- Fracture that is significant on the lower extremity.
- Neurological involvement (drop foot, complex regional pain syndrome (CRPS) etc.).
- Crush injury to the foot or other lower extremity.
- Burns to the foot and/or lower leg.
A gait assessment may be necessary when a worker requires the use of footwear, orthotics, braces or gait aids in order to continue activities comfortably in the following areas: WCB does not fund gait devices for sporting activities.
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Administrative tasks
Complete the appropriate referral form from the eCO Create Referral screen - For Millard Health – send referral by completing the eCO return-to-work referral (FM733) script.
- For all other providers – complete the Gait Services Referral (FM889A) form.
For help finding an out of province provider, complete the Out of Province Services Referral (FM957A) form to send an automatic task to the HCS Out of Province Referral, Team Desk. The referral coordinator will email contact information for an appropriate provider. Contact the provider to arrange the Gait assessment and the worker with appointment and provider details.
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Independent medical examination (IME)
An independent medical exam is performed by a specialist that has not been involved in the worker’s care and will not be actively involved after. Its main purpose is to provide impartial answers to specific medical questions about a work-related injury or illness. The process is overseen by the Medical Panels Office through legislation. An independent medical examination might be requested when: - There is a need to weigh medical evidence.
- There is a difference of opinion between medical providers.
- There are concerns with the worker’s treatment.
An independent medical examination is used to assess or determine a worker’s: - Fitness to work.
- Work restrictions.
- Primary diagnosis.
- Appropriate medical treatment and/or investigation.
- Complex medical issues.
- Relationship between the injury and work duties.
Difference in medical opinions web page The worker will be offered a choice of up to three available examiners from a roster of physicians. Potential invalid exam Should the assessor note any concerns about the validityThe findings of the examination may not be an accurate reflection of the true situation which may be due to a number of factors. of the exam results, contact the appropriate internal consultant for clarification, if needed. The assessor may still be able to comment on fitness, based on a combination of the file information and history, the interview and examination and their expertise in the field. If the examiner is unable to provide the requested information, reach out to the medical consultant to discuss how to move the plan forward. An exam may be repeated if appropriate and approved. Any specialist exam that is arranged by a third party is considered a Specialist Consultation and will only be considered and covered if deemed relevant to the claim. When an employer is requesting an independent medical exam be done, they may be expected to cover any associated cost.
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Administrative tasks
Complete an IME Referral Request (FM555A) form from the eCO Create a Referral screen. For Appeals Commission directed IMEs, complete the IME referral request and check the box that indicates Appeals Commission directed and reassign the autotask to the Appeals Commission Directed IME, Team Desk. The Resolution Specialist may make the referral. Medical Services sends the Advise of Appointment -- IME (CL023l) letter to the worker. Out of province exams are approved and arranged by the medical manager and only under special circumstance. Ensure the medical professional receives any new medical reporting and/or investigation unit reporting. Inform the worker that all belongings, including cell phones will be locked in a security locker at check-in. Workers who require access to a cell phone that is paired with a medical device must communicate this to the scheduling team before the appointment.
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Medical status examination (MSE)
A medical status examination determines the worker’s current medical condition including diagnosis and work restrictions. It also identifies other health concerns prior to any additional consultations, assessments or treatment. A medical status exam is usually completed prior to a functional capacity evaluation to ensure appropriate medical screening. A medical status exam can also be used to: - Expedite a consultation, where possible, if the wait to see a surgeon is more than 30 days from the referral.
- Clarify the worker’s fitness to return to work and/or work restrictions.
Once a treatment provider receives a referral for assessment, the provider uses the worker’s information to determine if the assessment is appropriate. Eligibility: - The worker is in or has completed a community acute care program and is not progressing as expected.
- The worker needs to be assessed prior to entering a return-to-work program.
- The worker’s treatment provider requests an assessment.
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Administrative tasks
Complete the Return-to-work Referral (FM733) script from the eCO Create Referral screen. Send the Specialist Clearance - MSE/FCE and Program letter (SP235H) to obtain a written release of care when the worker is under the care of a community specialist (non-VSC surgeon). Confirmation is required to ensure a referral is accepted. When the worker is recommended to the traumatic brain injury program, complete a new eCO return-to-work referral script.
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Medical testing (MT)
Medical testing includes various methods of diagnostic testing such as: - Computerized tomography (CT) scan
- Electromyography (EMG) / nerve conduction studiesA written request from the worker's treating physician can also be accepted for a referral.
- Magnetic resonance imaging (MRI)
- Ultrasound (US)
- X-ray
Medical tests are ordered to establish or confirm the worker’s diagnosis. In some instances, the testing can be expedited through health care providers that WCB has partnered with when an exam cannot be booked within the timelines noted below: - MRI: one week
- CT scan: one week
- EMG/NGS: three weeks
- US: one week
Eligibility: - There is a requisition from a physician who has assessed the worker. In some cases, the practitioner or physician may arrange the exam.
- The request corresponds with the worker’s diagnostic history and entitlement information on their claim.
Medical Services will contact the worker and arrange the exam and any needed translators and travel -- unless there are special requirements or an extended stay. Note: All lumbar MRI requests made by a family physician must have a lumbar spine imaging screening record completed by the physician, in addition to the standard MRI requisition form, before the MRI can be expedited. The lumbar spine imaging screening record is located on the Alberta Health Services (AHS) website: Diagnostic Imaging | Alberta Health Services. Note: All shoulder MRI requests made by a family physician or general practitioner are reviewed by a medical consultant to determine if there is enough information to support the procedure being expedited or if a shoulder medical exam (SME) is required. A task will be sent by the medical consultant to the decision maker and booking expeditor advising if the MRI has been approved. Invoices or expedited referrals from a non-contracted provider are covered when the test is confirmed to be related to the accepted work injury. The provider is to reimburse the worker for any testing paid out of pocket and resubmit billing to WCB under Section 86 of the Workers' Compensation Act. When there are questions about a referral, call or refer to the medical consultant who will assist when a decision cannot be made about whether to accept it.
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Administrative tasks
Complete the Expedited Testing and Imaging Referral (FM555K) form from the eCO Create Referral screen. Contact the booking expeditor for urgent test requests.
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Neuropsychological assessment (NPA)
A neuropsychological assessment is an independent assessment completed by a registered psychologist or a return-to-work provider. It is requested when the worker has suffered a head injury, concussion or compromised cognitive function such as stroke or other neurological effects as part of their workplace injury. A neuropsychological assessment can be combined with a comprehensive psychological assessment and/or psycho-vocational assessment. In some case when the worker may be experiencing a barrier related to a cognitive or psychological deficit resulting from a traumatic brain injury, stroke, epilepsy, or any other neurological injury. These assessments can also be completed by a community provider or as part of a return-to-work center assessment. A neuropsychological assessment can confirm or rule out a brain injury when the worker is experiencing a psychological condition. The assessment can also provide treatment recommendations. In most cases, the neuropsychological assessment is done within two to six months after the date of accident. However, it can be conducted at any time once a brain injury is suspected. The assessment is scheduled over a one to three day period and is used to examine the worker’s: - Cognitive ability (memory, problem-solving skills, attention, concentration and intelligence).
- Social and emotional functioning.
- Motor skills.
- Personality.
The worker may require a neuropsychological assessment if: - There is medical information on their file that suggests a head injury such as bruising of the head, skull and/or facial fractures or bleeding on the brain.
- Loss of or change in consciousness at the time of their injury.
- They experience amnesia after the accident.
- There are signs of cognitive defects such as memory loss, concentration difficulties, fatigue or changes to behaviour or personality.
The recommendations in the neuropsychological assessment report are reviewed to address any outstanding issues. Potential invalid exam Should the assessor note any concerns about the validity of the exam results, contact the psychological assistant or consultant for clarification, or the assessor if needed. The assessor may still comment on fitness, based on a combination of the file information and history, the interview and examination and their expertise in the field. When the examiner is unable to provide the requested information, reach out to the psychological assistant or consultant as necessary to determine the next steps. If a repeat assessment is appropriate, it can take place six months after the initial assessment for the following reasons: - Recommended based on results of previous testing.
- Evidence of a brain injury, despite an inconsistent outcome in a previous assessment.
- To confirm cognitive fitness to return to work.
- To determine the level of permanent clinical impairment related to a brain injury (24 months post-date-of-accident).
Make referrals for any repeat neuropsychological assessments to the original authorized psychologist. When the results of the previous assessment noted validityThe findings of the examination are inconsistent or incomplete and are not a trustworthy representation of the true situation. concerns, refer the worker to a different psychologist. A repeat assessment is not required when no brain injury is identified in the original assessment. Neuropsychological Screen (NPS) A neuropsychologist may complete a neuropsychological screen (NPS) when a worker is experiencing potential cognitive difficulties that may impact their recovery and return to work. The screen will clarify the worker's diagnosis, outline the current cognitive status, outline potential exams and treatments, and comment on the prognosis in order to determine the supports the worker will need going forward. A neuropsychological screen is done when it has been less than eight weeks since the acute hospital or inpatient rehabilitation phases. After eight weeks, a neuropsychological assessment is done.
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Administrative tasks
Complete a Psych Referral Assessment (FM008A) form from the eCO Create Referral screen. Review the mental health risk portlet for any active or resolved risk incidents. Sending the referral letter auto adds the (mental health line) to the file. The psychological assistant organizes the referral: - Identifies a provider.
- Adds a file note confirming the provider’s name.
- Sends the appropriate referral letter.
- Requests a medical package.
Send a Neuropsychological Assessment (SP021E) letter when the referral only includes a neuropsychological assessment. Send a CPA/NPA Referral (SP021M) letter when the referral is the neuropsychological assessment and the comprehensive psychological assessment combined. Ensure the medical professional receives any new medical reporting and/or investigation unit reporting. Send the Claimant – Custom (CL000A) letter outlining the need for a valid presentation if a repeat assessment is required.
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Occupational therapy assessment
Occupational therapists are an injured worker’s solution to the challenges they face. With the help of an occupational therapist, workers can increase their ability to take care of themselves, be productive, and enjoy what their homes and communities have to offer. There are a number of assessments occupational therapists do to identify a worker’s current abilities and provide solutions to help them improve their independence with managing activities of daily living, including self-care. Solutions may include assistive devices, new ways to complete tasks and self-care, changes to the home set-up and community supports. The following assessments are available through occupational therapy providers: - Home maintenance assessment
- Housekeeping assessment
- Personal care allowance assessment
- Home equipment assessment
- Combined personal care allowance and home equipment assessment
- Home modifications assessment
- Wheelchair assessment
- Seating/pressure mapping assessment
- Scooter assessment
- Palliative care assessment
- New vehicle modifications assessment
- Driving assessment
- Pre- and post-accident profile assessment
- Ergonomic assessment
- Exposure therapy
- Cognitive therapy
- Hand assessment/therapy
- Splinting assessment
- General assessment
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Administrative tasks
CompleteWhen completed, the eCO system sends the completed form to the claim file and generates a task to the OT Referral, Team Desk. The OT expeditor arranges the appointment sends the medical package to the provider. the occupational therapy (OT) referral (FM956A form) from the eCO Create a referral screen. Note any special requests, including if the referral is out of province, if an interpreter is needed, etc. Resources: Policy 04-07, Part I Services for Workers with Severe Injuries [PDF] Policy 04-07, Part II Services for Workers with Severe Injuries [PDF] Follow the appropriate procedure based on the recommendations from the occupational therapy assessment.
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Orthopedic expertise referral (DTC and ESC)
This exam supports a worker’s diagnosis and treatment in the case of an injury that requires orthopedic expertise. It is considered a diagnostic and treatment consultation (DTC) when an external community physician completes a Diagnostic and Treatment Consultation Referral form in the RapidReportRapidReport is the electronic injury reporting system that is used by employers and providers. system initiating the exam. A separate form is required for each referral to WCB to ensure effective tracking. When the consultation is initiated internally by the decision maker or is recommended by the medical consultant it is considered an expedited specialist consult (ESC). Eligibility: - It has been less than eight weeks since the date of accident and the worker is not already in the care of an orthopedic specialist.
- The injury is exclusively orthopedic (no secondary psychological or neurological effects) and does not affect the back or shoulder.
- There is complex medical evidence that surgery is unlikely to be successful, such as multiple or age-related issues, conflicting or ambiguous diagnoses.
- The worker would benefit from an in-person assessment.
The exam takes place in either Edmonton or Calgary and is performed in person by an orthopedic specialist also capable of performing independent medical examinations. The examiner provides a report with recommendations for diagnosis and treatment that excludes an opinion about causation. Contact the initiating physician who will carry out the recommendations for treatment to offer support if necessary.
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Administrative tasks
Complete the ESC referral (FM555E) form from the eCO Create Referral screen. Send the Expedited Specialist Consult (SP200A) letter to the treating physician after the referral has been made.
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Permanent clinical impairment (PCI) evaluation
A permanent clinical impairment evaluation measures the worker’s physical and/or psychological function and determines whether their injury has resulted in a lasting functional impairment. The evaluation can be completed by a trained WCB specialist or general practitioner examiner and can be done simultaneously with an independent medical exam for multiple issues or questions. A permanent clinical impairment evaluation typically takes place 24 monthsSome examinations can occur earlier than 24 months post-injury such as amputations and discectomies. after the worker’s date of accident or most recent surgery to ensure that adequate time has passed to allow the worker to reach their maximum medical recovery. The evaluation involves a review of the worker’s medical file, a physical and/or psychological examination and a discussion with the worker about their injury. In some cases, when there are sufficient records, the permanent clinical impairment assessment can be completed by reviewing the documents on file, and the physical and/or psychological examination and discussion with the worker are not necessary. Eligibility: - The worker suffered a loss of a body part.
- The worker lost the use of a body part, system or function, or
- The worker experienced a change or disfigurement of any body part, system or function.
Potential invalid exam Should the assessor note any concerns about the validityThe findings of the examination may not be an accurate reflection of the true situation which may be due to a number of factors. of the exam results, contact the appropriate internal consultant, if needed. The assessor may still comment based on a combination of the file information and history, the interview and examination and their expertise in the field. When the results of a permanent clinical impairment examination are invalidThe findings of the examination may not be an accurate reflection of the true situation which may be due to a number of factors., a further assessment can be arranged 6 – 12 months later. If the results of the second examination are also compromised, no reassessments will be arranged.
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Administrative tasks
Complete the PCI Referral (FM555B) form from the eCO Create Referral screen. Book a PCI exam combined with and IME through the IME Referral Request (FM555A) form and select PCI/FFW combo. Ensure the medical professional receives any new medical reporting and/or investigation unit reporting. Send the Claimant – Custom (CL000A) letter outlining the need for a valid presentation if the exam comes back compromised.
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Physical suitability assessment (PSA)
A physical suitability assessment is used to determine a worker’s functional abilities and test them against current or future job targets to ensure they are suitable. The assessment can be done as part of a return-to-work program or as a stand-alone. In some cases, a review of the file is adequate to decide a worker’s ability to perform in the identified job without an assessment. A physical suitability assessment can be arranged for workers currently attending a return-to-work program and up to 30 days after the worker has been discharged. When an assessment is requested more than 30 days after discharge, the worker may first need to repeat the functional capacity exam.
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Administrative tasks
Complete the eCO return-to-work referral script (FM733) to make the referral. Ensure the intended future position or intended future job target is vocationally suitable. Indicate the worker’s job option and provide the essential job demands (EJP) or Labour market profile (LMP) number.
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Post-covid rehabilitation (PCR) triage
The Post-covid rehabilitation triage is an initial assessment and is used to determine the best treatment plan to support a worker’s recovery from COVID-19. The results of the assessment identify whether there’s a need for further medical referrals, and whether the worker would benefit from community supports or admission to the Post-Covid Recovery Program. Covid-19 and Return to Work [PDF]
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Administrative tasks
Complete the Return-to-work Referral (FM733) script from the eCO Create Referral screen and select (Other). Enter (Post-Covid Assessment) in the blank text box.
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Psychological injury (PI) screen
A psychological injury screen is a triage tool to determine the best treatment to facilitate recovery and return to work when the worker suffers a psychological injury caused by either a single traumatic event or cumulative exposure to a series of traumatic incidents or chronic psychological stress, like harassment. The screen outlines factors that may affect the worker’s recovery and return to work planning and determines any requirements for further assessments and/or treatment, such as a psychological injury program. A psychological injury screen is considered when, - A psychological injury is accepted as compensable and work-related.
- The symptoms have not resolved significantly and there is no return to work planned within the next six weeks.
- The return-to-work plan is not progressing, and the barriers cannot be addressed through other means (collaborative conversations, exposure therapy, adjustment of modified duties, etc.).
The nature of the injury determines which program is recommended. (1) A worker has experienced chronic psychological stress in the workplace caused by one or more of the following types of incidents over time: - Bullying
- Harassment or sexual harassment
- Ongoing stress
They may require treatment through a cumulative psychological injury (CPI) program. (2) A worker has experienced a single traumatic work-related incident. This might include, but is not limited to, one of the following types of incidents. - Assault, robbery or sexual violence
- Disaster, either man-made or natural
- Disfigurement, crush injury or significant burn
- Fall from a significant height or other life-threatening injury
- Motor vehicle accident
- Physical disfigurement or dismemberment
- Repeated traumatic emergency response calls
These injuries may require treatment through a traumatic psychological injury program. The screen is completed by a registered psychologist who interviews the worker and completes several evaluations with them. In rare circumstances this may be done by a community provider. In most cases, recommended treatment could be a combination of the following: - Educating the worker on how to manage their injury or symptoms.
- Further assessments.
- A rehabilitation program, such as the Traumatic Psychological Injury or Cumulative Psychological Injury Program.
- A recommendation to extend treatment with a community provider that includes counselling.
Eligibility: - A psychological injury is accepted as compensable and work-related.
- The primary cause of the injury or ongoing disability is consistent with a traumatic incident and the injury is not acutely physical.
- The treating community psychologist confirms the worker has not seen significant progress or it has plateaued and there is no return to work planned within the next six weeks.
- The return-to-work plan is not progressing, and the barriers cannot be addressed through other means (collaborative conversations, exposure therapy, adjustment of modified duties, etc.).
- Generally, a psychological injury screen is more suitable for a worker who has no significant pre-existing psychological conditions or substance abuse issues.
Traumatic psychological injury worker fact sheet [PDF] Psychological injuries - chronic onset (occurring over time) [PDF] Psychological injuries employer fact sheet [PDF]
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Administrative tasks
Complete the Return to Work Centre Referral (FM733) script from the eCO Create Referral screen and select Traumatic Psychological Injury screen. Review the Mental Health line, Risk Incidents for any mental health safety concerns. Attach the psychological injury fact sheets to the Confirm TPI Referral (CL026O) letter. Fact sheets can be found on the WCB website or below. Send the Psych Assess & Treat letter (SP026A) when a referral is accepted. Ensure the medical professional receives any new medical reporting and/or investigation unit reporting and any information about safety concerns. Make alternate arrangements if there are safety concerns. Arrange to have the exam at the WCB offices (Edmonton or Calgary) or at Millard Health.
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Psycho-vocational (P-VOC) assessment
A psycho-vocational assessment includes the primary components of a comprehensive psychological assessment or of a neuropsychological assessment and also identifies a worker’s vocational barriers affecting their return to work. Consider a psycho-vocational assessment when a worker has compensable or non-compensable psychosocial or cognitive barriers to determining a suitable or academic path during re-employment planning, confirm a job is psychologically suitable, or there is a need to identify new job options to match a worker’s psychological profile. Combine a psycho-vocational assessment with a comprehensive psychological assessment request when the psychological diagnosis includes, but is not limited to, one of the following: - Post-traumatic stress disorder (PTSD),
- Major Depressive Disorder,
- Chronic Adjustment Disorder,
- Personality disorder or learning disability such as ADHD or dyslexia (suspected or confirmed).
Include a psycho-vocational assessment with a neuropsychological assessment request when there is a vocational barrier related to a cognitive or psychological deficit resulting from any of the following: - Traumatic brain injury
- Stroke
- Epilepsy
- Neurological injury
If the assessment is needed, discuss the benefit with the worker and make the necessary arrangements. In some cases, this assessment can be completed virtually. Review the recommendations in the psycho-vocational report and address anything outstanding. Potential invalid exam Should the assessor note any concerns about the validity of the exam results, contact the psychological assistant or consultant for clarification, or the assessor if needed. Consider whether repeating the exam is appropriate. Comprehensive psychological and psychological-vocational assessments [PDF]
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Administrative tasks
Complete a Psych Referral Assessment (FM008A) form from the eCO Create Referral screen. Review the mental health risk portlet for any active or resolved risk incidents. Sending the referral letter auto adds the Mental Health Line to claim file. The psychological assistant organizes the referral: - Identifies a provider.
- Adds a file note confirming the provider’s name.
- Sends the appropriate referral letter.
- Requests a medical package.
Ensure the medical professional receives any new medical reporting and/or investigation unit reporting. Send the Claimant -- custom (CL000A) letter outlining the need for a valid presentation if a repeat assessment is required.
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Return-to-work planning meeting (RTWPM)
The Return-to-work planning meeting is collaboration between the worker, employer and treatment provider (e.g., physical therapist, occupational therapist, etc.). The focus is to develop a customized early, safe and sustainable plan that supports a worker’s individual skills, abilities and unique circumstances in support of a successful and sustainable return to work. The meeting will, - Educate the employer about to the return-to-work process.
- Confirm the physical demands of the worker’s pre-accident job.
- Identify possible modified work opportunities.
- Discuss and address any barriers the worker might face with recovery and/or their return to work.
- Educate the worker on injury prevention, directed at how to avoid re-aggravating their injury.
- Create a return-to-work plan that supports the worker’s recovery and return to work.
- Confirm the worker's English-speaking ability.
The results of the meeting are documented and used to monitor and support the worker’s progress. Return-to-work planning discussion (RTWPD) A return-to-work planning discussion is held when a formal return-to-work planning meeting cannot be held. The meeting includes the employer, worker and the treatment provider and is held as either a phone conversation or in person at the treatment provider’s site. There are criteria that have to be met before scheduling a return-to-work planning discussion: - The decision maker has confirmed a discussion is adequate when a meeting cannot be arranged.
- There is a physical demands analysis for the worker’s pre-accident job.
- There are confirmation and documentation of modified duties, if any.
In cases when a clinician’s involvement is not needed, a referral to an industry specialist can be made in place of a return-to-work planning discussion. Microprocessor (knee) or myoelectric device (upper extremity) The return-to-work planning meeting for a worker who is requesting a Microprocessor Knee or a Myoelectric Device includes an additional assessment and report. The evaluations in the report confirm: - There is a medical need.
- The device is functional.
- The device is appropriate for the work environment.
- The device meets safety requirements.
The results compare the operation of the microprocessor (knee) or myoelectric device (upper extremity) to the work environment to confirm the device is safe for use.
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Administrative tasks
Complete the Return-to-work Referral (FM733) script from the eCO Create Referral screen.
Submit the following information to the treatment provider prior to the discussion:
- A copy of the employer's Physical Demands Analysis.
- Confirmation and documentation of modified duties.
- Current fitness for work level.
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Shoulder medical exam (SME)
A shoulder medical evaluation is a medical assessment performed by a physician who has received specialized training from a shoulder surgeon. As part of the shoulder medical exam, the physician will examine how the worker's shoulder moves and the strength in their shoulder muscles. They will then determine which treatment stream the worker should be triaged into. In most cases, recommended treatment could be a combination of the following: - Educating the worker on how to manage their injury or symptoms.
- Community physical therapy.
- Further diagnostic imaging.
- Non-surgical rehabilitation.
- Return-to-work services.
- eConsult (if the SME physician would like a specialist opinion on treatment recommendations (i.e., surgical vs. conservative measures) a documentary review will be completed by an orthopedic specialist.
- Surgical consultation at a Visiting Specialist Clinic.
Eligibility: - The worker’s predominant injury is their shoulder.
- The worker needs to be assessed prior to entering a return-to-work program.
- The worker may potentially require a surgical consult through the Visiting Specialist Clinic.
- The worker’s relevant medical reporting is on their file (medical history, diagnostic imaging, physical therapy).
In some cases, a repeat exam can take place as necessary or as medically indicated.
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Administrative tasks
Complete the Return-to-work Referral (FM733) script from the eCO Create Referral screen. Send the Specialist Clearance - MSE/FCE and Program (SP235H) letter to obtain a written release of care when the worker is under the care of a community specialist (non-VSC surgeon). Confirmation is required to ensure a referral is accepted.
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Visiting Specialist Clinic (VSC) referral
A Visiting Specialist Clinic is a facility that WCB has partnered with to ensure the worker’s timely access to specialist consultations and surgical procedures. The Visiting Specialist Clinic also provides non-surgical consultations that can provide specialists opinions regarding the worker’s diagnosis and ongoing treatment needs. In most cases, the specialist that performs the assessment will also provide the treatment or procedure, if required. Available specialties include: - Orthopedic Back and shoulder injuries must have completed a BSE or SME prior to referral.- foot/ankle, knee, hip, spine, shoulder, elbow, hand/wrist.
- Plastics - hand/wrist and carpal tunnel syndrome.
- General surgery - hernia.
Surgical consult (SC) Eligibility: - The worker does not have a referral to a surgeon or they are waiting for surgery or a consult by a public physician.
- The worker has previously had a back medical exam or a shoulder medical exam when the injury affects that part of body.
- The worker’s booked surgeryThe worker’s current specialist must sign a release of care form before the worker can be referred to the Visiting Specialist Clinic for surgery. wait time is more than eight weeks.
- The worker was identified for surgery through an independent medical examination, medical status examination, shoulder medical examination, eConsult or spinal surgery review.
- There’s a documented physician on the claim and an adjudicator or case manager has been assigned to the claim.
Non-surgical consult (NSC) Eligibility: - The worker requires a non-surgical referral, and it has been more than eight weeks since the date-of-accident. If it is fewer than eight weeks, see diagnostic treatment consultation or expedited specialist consultation.
- The worker has previously had a back medical exam or a shoulder medical exam when the injury affects that part of body.
- The worker’s diagnosis and next steps in the treatment plan need to be determined.
Special considerations: - When the worker is under the care of a general practitioner or a community specialist (non-VSC surgeon), written confirmation releasing the worker from care must be obtained before a referral can be accepted.
- When a Visiting Specialist Clinic doctor requests a worker they are seeing in their public practice be transferred to the care of the Visiting Specialist Clinic, the decision maker is responsible for determining entitlement, providing approval and completing the referral.
In both cases, before making any changes to a worker’s treatment plan, ensure the worker agrees to the change in appointment and/or specialist. Also, inform the worker they may be able to get an earlier appointment if they would be willing to travel to another location. If reporting from the Visiting Specialist Clinic is unclear, or if a case conference with a surgeon and decision maker is needed, complete an Assistance Request (AR) form. To confirm diagnosis or procedure, discuss concerns with the clinical or medical consultant. Confirm if surgery is authorized and send the appropriate letter. A worker requires a new referral and recent injury diagnostics for all follow-ups six months after they have seen the surgeon and/or have been discharged from the surgeon's care.
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Administrative tasks
Complete the Surgical Coordinator VSC Referral (FM235D) form from the eCO Create Referral screen. Ensure the release of care confirmation is received before sending the referral, if required. Release of care:
Send the letter obtaining approval to release a worker from care with their treating general practitioner or specialist. - VSC - Release of Care (SP235F)
- VSC - GP Approval (SP235G)
Contact the Visiting Specialist Clinic coordinator for all questions related to release of care. Send the Surgery Authorization (SP235B) letter when the results of a consult confirm that surgery is recommended. Notify the worker of the appointment details and ensure they have a responsible adult to accompany them and discuss post-surgical needs. Contact the facility when a worker cannot attend an appointment. Follow up to address any issues with the worker. Send a Surgical-Claim Denial (SP235C) letter or a Surgical Denial (SP235D) letter to the worker with rationale for any changes when the referral is inappropriate. Complete a new referral for any transfer of care to the Visiting Special Clinic. Complete an VSC Assistance Request (FM235E) form before contacting a Visiting Specialist Clinic surgeon. Contact the Healthcare Strategy (HCS) team when there are concerns with the surgeon care provided.
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