CASE EXAMPLES - CHRONIC PAIN CASE

APPENDIX A - VOCATIONAL WORKSHEET

ANTICIPATED LENGTH OF REHABILITATION PROGRAM

VOCATIONAL HANDICAPS

IMPACT ON PLACEMENT

IMPACT ON RANGE OF JOB ALTERNATIVES

REHABILITATION PLAN

I. Allied Health Evaluations and Treatment:

II. Medical Follow-up to include:

III. Acute Intervention to include the following:

IV. Medications:

V. Home Furnishings/Medical Equipment/Supplies:

VI. Home Maintenance (Interior Cleaning):

VOCATIONAL DEVELOPMENT OPTIONS - PRE-ONSET

VOCATIONAL DEVELOPMENT OPTIONS - POST-ONSET

PRE-ACCIDENT VOCATIONAL ALTERNATIVES - BY OPTION

POST-ACCIDENT VOCATIONAL ALTERNATIVES - BY OPTION

APPENDIX A

VOCATIONAL WORKSHEET

February 1, 2005

NAME: Gwendolyn Drawdy
AGE: 52
DOB: 4/3/52
DOA: 9/8/02

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ANTICIPATED LENGTH OF REHABILITATION PROGRAM

Ms. Drawdy will require some supportive intervention for the remainder of her life expectancy.

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VOCATIONAL HANDICAPS

Restrictions, limitations, and/or deficits are consistent with cervical and lumbar injuries, as well as other orthopedic complaints, and include:

Additionally, the following are described:

IMPACT ON PLACEMENT

Moderate to Severe. This individual's vocational handicaps present a moderate to severe impact on her ability to be placed in the competitive labor market based on her level of subjective pain complaints and significant psychological overlay.

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IMPACT ON RANGE OF JOB ALTERNATIVES

Moderate to Severe. Ms. Drawdy’s vocational handicaps, restrictions and physical limitations place a moderate to severe impact on her ability to participate in a range of job alternatives. This includes her chosen career (Loan Officer) and careers related to her past work groups, on a full-time basis.

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REHABILITATION PLAN

I. Allied Health Evaluations and Treatment:

A. Psychological Evaluation to establish base-lines for individual therapeutic intervention. Anticipate once only @$ based on $ / hour for 2-4 hours. (Paul M. Deutsch, Ph.D., CRC, CCM, CLCP, FIALCP)

B. Pain Management Program: Inpatient Program of four weeks including a three-day evaluation costing $. This inpatient program to be followed by outpatient pain program for four additional weeks, costing $. These costs do not include any lab work, pharmacy or X-rays, which might be required. (See below for follow-up Individual Counseling). (Recommended By: Paul M. Deutsch, Ph.D., CRC, CCM, CLCP, FIALCP, F. Hisgen, MD, Treating Neurosurgeon, 12/16/04 and Andrea Zotovas, MD, Consulting Physiatrist)

The role of psychological factors in chronic pain is quite complex. Chronic pain constitutes a complex mixture of pathophysiologic factors interacting with numerous psychological, social and cultural factors, including the following:

A comprehensive chronic pain treatment model includes the clinical health psychologist consulting with the patient, family and treatment team. The target of intervention is the interaction of psychological and physiologic factors that cause and perpetuate chronic pain. Patients with complex chronic pain present with multiple risk factors for poor outcomes, however. Psychological factors are usually significant and numerous in patients with complex chronic pain, and may exhibit depression, anxiety or personality disorders than can interfere with treatment if not addressed. In some, the underlying pathophysiologic state may be exacerbated by emotional distress, which presents as intensified pain symptoms. (Source: Why is chronic pain so difficult to treat? Psychological considerations from simple to complex care. Mark B. Weisberg, Ph.D., Alfred L. Clavel, Jr., MD. Chronic Pain, Vol. 106, No. 6, November 1999, Postgraduate Medicine).

C. Intensive period of individual counseling to assist in pain management, coping skills, progressive relaxation, behavior therapy to focus on residual personal strength and disability management. This is to follow the Chronic Pain Management Program (see above entry). Frequency: Weekly for 13-26 weeks ($ / session), then 3-4 X / year to life for supportive, $ / year. (Paul M. Deutsch, Ph.D., CRC, CCM, CLCP, FIALCP).

D. Family Counseling/Education. To teach disability management techniques and a method for reinforcing coping mechanisms. Anticipate 1X/week for 6 weeks [6 visits]. Costs: $ total, Based on $ / session. (Paul M. Deutsch, Ph.D., CRC, CCM, CLCP, FIALCP).

E. Therapeutic Evaluations: Physical Therapy evaluations are recommended, yearly, for proper exercise instruction, maintenance and education purposes: $ / session X 2 hours = $ each evaluation, 1 X / Year.(F. Kilborn, MD, Treating PCP, 12/10/04 response to questionnaire & F. Hisgen, MD, Treating Neurosurgeon, 12/16/04).

F. Physical Therapy: In the future, she is likely to experience flare-ups with very little provocation. When this occurs she will benefit from PT, 3 X / week for 6-8 weeks (18-24 sessions); anticipate one episode every 1-2 years on average. Costs: $ / hour, or average of $ / hour X 3/week = $ / week X 6 weeks = $; $ / week X 8 weeks = $. Therefore, $ every 1-2 years. (Recommended by: Andrea Zotovas, MD, Consulting Physiatrist).

G. Massage Therapy: To manage acute flare-ups of muscle spasms. Anticipate 3 X / week for 4 weeks every 1-2 years. $ / session X 3 times per week X 4 weeks = $ every 1-2 years. (Dr. F. Kilborn, Treating PCP recommended Massage Therapy & Andrea Zotovas, MD, Consulting Physiatrist).

II. Medical Follow-up to include:

A. Neurosurgical Follow-Up: Three times per year as stated in F. Hisgen, MD deposition of 11/18/04; One to two times per year throughout life (Recommended by F. Hisgen, MD, treating Neurosurgeon, response to questionnaire of 12/16/04) to follow her, regarding status of completed back surgery, monitor deterioration as aging combines with the disability, and assess the need for additional or acute intervention. $ per evaluation, 1-3 X / year. (Andrea Zotovas, MD, consulting physiatrist).

B. Physiatrist: Routine follow-up to monitor status and recommend physical restoration activities. 1 X / year:$(Recommended by F. Hisgen, MD, Treating Neurosurgeon, 12/16/04 & Andrea Zotovas, MD, consulting physiatrist).

C. Psychiatrist: Follow-up for medication management due to anxiety and depression. 2-3 X / year; $ each visit, or $ / year. (Recommended by Dr. Mohler’s office, I. Hull, RN, ARNP, 12/10/04, F. Hisgen, MD, Treating Neurosurgeon, 12/16/04 and Andrea Zotovas, MD, consulting physiatrist).

III. Acute Intervention to include the following:

A. Cervical Spine MRI: $, 2-3 additional times over life (Recommended by F. Hisgen, MD, Treating Neurosurgeon, 12/16/04; and F. Kilborn, MD 12/10/04, and Andrea Zotovas, MD, consulting physiatrist).

B. Thoracic Spine MRI: $, 2-3 additional times over life. (Recommended by F. Hisgen, MD, Treating Neurosurgeon, 12/16/04; F. Kilborn, MD 12/10/04, and Andrea Zotovas, MD, consulting physiatrist).

C. Lumbar Spine MRI: $ , 2-3 additional times over life. (Recommended by F. Hisgen, MD, Treating Neurosurgeon, 12/16/04; F. Kilborn, MD 12/10/04, and Andrea Zotovas, MD, consulting physiatrist).

D. X-Rays: (Recommended by F. Hisgen, MD, Treating Neurosurgeon, 12/16/04, and Andrea Zotovas, MD, consulting physiatrist). Five (5) sets over her lifetime recommended.

E. Coccygeal Nerve Blocks: $ (Facility); $ (Physician) [Series of three, 3-5 times over life] (Recommended by F. Hisgen, MD, treating Neurosurgeon, 10/5/04 report).

F. EMG/NCV Studies of the cervical and lumbar spine, once only: $ total. (Andrea Zotovas, MD, consulting physiatrist).

G. Epidural Nerve Blocks: $ each, (Physician), $ (Facility) – total of $ each, limited to a series of three, done 3-5 times over her life for a total of 9-15 blocks over her life. (Recommended by F. Hisgen, MD, Treating Neurosurgeon, 12/16/04 and Andrea Zotovas, MD, consulting physiatrist)

H. C5-C6 cervical fusion (Recommended by F. Hisgen, MD, Treating Neurosurgeon, in his deposition of 11/18/04)

I. Radiofrequency Rhizotomy of Coccygeal Nerve (Recommended by F. Hisgen, MD, in his 10/5/04 office notes)

IV. Medications:

A. It is likely she will continue to require anti-inflammatory and/or pain medications periodically into the future, as well as anti-depressants. At the present time, her medications include: Norvasc for High Blood Pressure, 0.5 mg 1/day: $ / month; Levoxil, Thyroid medication, .05 mg 1/day (not related to this injury); Effexor: 150 mg 1/day for anxiety: $ / month and Darvocet $ / month for pain.

V. Home Furnishings/Medical Equipment/Supplies:

A. Power Home Bed beginning at age 60: $; 1 X / 10 years.
B. Moist Heating Pad: $, 1 X / 3-4 years.
C. Raised Toilet Seat/Frame, beginning at age 70: $, 1 X / 5-6 years.
D. Tub/Toilet Safety Rails: $, installed.
E. Shower Chair (Bench), beginning at age 60 for safety purposes, $

VI. Home Maintenance (Interior Cleaning):

A. Housecleaning:$ / week, $ / year.

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VOCATIONAL DEVELOPMENT OPTIONS
PRE-ONSET

Continued direct placement in the labor market as a Loan Officer with no additional training.

Continued direct placement in the labor market with additional coursework taken to become a Mortgage Broker.

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VOCATIONAL DEVELOPMENT OPTIONS
POST-ONSET

Placement in the labor market on a restricted basis, with no additional training. Work is therapeutic; therefore, Ms. Drawdy is encouraged to participate in at least part time employment, although at a level much reduced in terms of hours worked, and responsibilities as compared to prior to the injury.

Placement in the labor market on a restricted basis, with additional training as a Mortgage Broker. Ms. Drawdy is encouraged to participate in at least part time employment, although at a level much reduced in terms of hours worked, and responsibilities as compared to prior to the injury.

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PRE-ACCIDENT VOCATIONAL ALTERNATIVES
BY OPTION

I. Continued employment as a loan officer. Her earnings as reflected by W-2 records for the previous several years included:

Ms. Drawdy had been employed in the Home Mortgage/Loan Officer market for seven years. Prior to her work within this market, she worked for Burdines as a Sales Associate (Appliances) from September 1987 through September 2001 (she continued working part time at Burdines while she was working as a Loan Officer).

She is a highly motivated, extremely articulate person with an outgoing personality, which are all characteristics required to excel in a sales oriented position. She clearly demonstrated an increased earnings stream up through the time of her injury (September 2002). At about this time, the home mortgage market was booming with the lowering of mortgage interest rates resulting in a rush of new housing and re-financing of existing homes. Her territory included the Cape Coral to Naples area. By the time Ms. Drawdy returned to work (First United) on a part-time basis in September 2003, after having been off work for a year, her ability to work had been reduced to only six hours per day, and she had been unable to maintain her contacts, resulting in a lowered market share of available contracts. She was also physically limited in her territory to just the immediate Cape Coral/Fort Myers area due to her injuries. This restriction in territory made it quite difficult to bring in new contracts. The plus side of her employment with First United was that she could work from her home as she needed to, so if she was having a particularly bad pain day, she could at least be a bit more comfortable. She indicated she was able to begin bringing in new business again between September 2003 and January 2004 after working diligently to reconnect with her realtor contacts. She continued employment with First United through to June 2004 at which time she was terminated.

Immediately after her termination from First United, she went to work with Brooms Mortgage and went into the office every afternoon. She described this experience “like being a pioneer for a new company, as all my contacts with First United were out of the area”. She noted she was able to maintain approximately six hours per day with Brooms and felt she could have continued at this rate if it had not been for Hurricane Charley, which devastated her area, destroyed the Brooms Mortgage building, and severely damaged Ms. Drawdy’s home as well (8/13/04). She notes the mortgage industry really suffered after the storms in that area, resulting in decreased activity and earnings for the industry in general. Had she not had her injury, she indicated she would have “picked up and moved to Tampa, Orlando or Ft. Lauderdale area, as the Mortgage industry has maintained its business levels”. (A telephone conference with Ms. Drawdy on 1/26/05 indicated she is working a few hours a day at the new, temporary Brooms Mortgage Company offices.)

Edgar Rios, her former supervisor at First United, indicated Ms. Drawdy was a superb employee, with much energy, enthusiasm and intelligence. He noted she made friends and contacts easily. He described Ms. Drawdy as very hard working, disciplined, well liked by her clients. He indicated her earnings were on the up-swing at the time of her injury, and he had no doubt she would have been able to earn in excess of $100,000/year had she not been injured. (He felt $100,000/year was entirely reasonable). He indicated the best years in recent history for the mortgage industry were in the 2002-2004 timeframe and most loan officers doubled or tripled their income during that three year time period. He anticipates in the foreseeable future, business will continue on the upward swing, at least at the same rate as the 2002-2004 period. The business plan for First United Mortgage, up to 2008, calls for an increase of 4% of market share in terms of volumes of business and the industry does not foresee any increase in interest rates or a slowdown in the housing industry in the near future*. There has been no change in the immigration flow of people into Florida, with 1,300-1,400 people moving into Florida on a daily basis.

*(A January 2005 article by Stephen Corsi in the National Mortgage Broker Magazine, (The Official Publication of the National Association of Mortgage Brokers) indicated: “2004 was a banner year for the mortgage industry”).

Hurricane Charley did not really negatively effect the area in which Ms. Drawdy did most of her business pre injury and thus, the storm would not have affected her earnings. Post injury, however, she was only able to work in the immediate Fort Myers area, which was significantly damaged by the storm and thus the mortgage business has suffered significantly. Mr. Rios indicated that over the last few months, home sales have improved in the Fort Myers area and it is projected that within one to two years post hurricane, the business will recover and spike upward as it had been prior to the hurricane.

II. Mortgage Broker licensing was discussed. (This was certainly an option for Ms. Drawdy to consider pre injury, but it was not necessary or advantageous for her to consider a move to this position). Mr. Rios had several comments regarding a Broker position. Generally, a broker receives a higher percentage of commission on sales, but the loan officer has many benefits the Brokers do not have (such as 401 K, Pensions, Health Plans, etc.). [A broker is a real estate financing professional acting as an independent contractor]. The loan officer is able to establish many contacts through realtors and obtain leads from many sources, and thus, is able to obtain a high number of loans with which to work. The Broker receives a higher percentage of the loan, but works on a lower number of loans per Broker. A Mortgage Broker is licensed by the state and can only work in one Mortgage Company (one shop), a loan officer can work with many different clients in bringing the accounts into the Broker.

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POST-ACCIDENT VOCATIONAL ALTERNATIVES
BY OPTION

I. Due to the length of time off a full time work basis with chronic pain, it is not within reasonable rehabilitation probability to anticipate a return to full-time employment. The percentage of patients resuming a career after being in pain for 6 months is 50%; one year is 25% and two years is only 2%. (Turk, D., & Stacey, B. (1997). Multidisciplinary pain centers in the treatment of chronic back pain. In J. W. Frymoyer (Ed.). The adult spine: Principles and practice. New York, NY: Raven Press. Cited in: Spinal column, produced by the Shepherd Center, Fall 2001).

Part time work is certainly reasonable given success in a rehabilitation program as outlined above.Ms. Drawdy has just returned to work with Brooms Mortgage (1/26/05) in a temporary location in the mall. She is only able to work in the afternoons due to her back limitations. She is unsure how long she will be able to work in terms of hours per day, but states she will likely be limited to three to four hours per day. Since the hurricane hit, she has only closed on two mortgages, and this is attributed to the lack of house sales since the hurricane. It is not within reasonable probability to anticipate her having the opportunity to work to the level she enjoyed pre-injury and as such, will have a significant impact regarding a loss of capacity to work and earn. It is not anticipated she can achieve a pre-injury level of earnings. There is also a high risk for a shortened work life expectancy, (to age 60-65). It is entirely possible she could only earn about a third of what she enjoyed pre-injury, or approximately $19,289 to $24,038 at a maximum (based on the pay statistics from the Occupational Employment and Wages, 2004 wages estimated). This is based on the number of hours per week she is able to work. With success from surgery and a chronic pain management program she may be able to move up to a consistent 20-25 hours per week. This still will not, however, allow her the opportunity to get out of the office to do the marketing she was doing pre-morbidly to develop her customer base.

II. The option does exist for her to achieve her Mortgage Broker’s License post injury, but once licensed, she would still need to do a significant amount of sales activities to build up a clientele. I am concerned she has been out of the business at the peak, and therefore would not be able to earn near the levels at which she had earned in the past as a Loan Officer, especially considering her physical limitations. According to The National Association of Mortgage Brokers Magazine, today, over two-thirds of the nation’s mortgages are originated by Mortgage Brokers. A January 2005 article by Stephen Corsi in the National Mortgage Broker Magazine, (The Official Publication of the National Association of Mortgage Brokers) New Marketing Opportunities for a New Year: “It is safe to assume that everyone will have to work harder and smarter to maintain the levels of success that came quite easily to some in 2004”.

However, given the above, it is felt a move to a Mortgage Broker would represent the best opportunity for her to work and earn. A Broker’s position would require less in the amount of pressure to perform regarding the minimum number of loans [closings] required, and less travel.

Therefore, funding should be allotted for completion of the Broker’s license, and the time to pursue this training and licensing and then certification. To do so, she must complete 24 hours of classroom instruction and receive a passing score on the Mortgage Broker Examination within 90 days of the date the license application was reviewed by the Department of Licensing and Registration (State of Florida). A Broker’s license is only valid for a two-year period of time before re-licensing is required. The classroom instruction (24-Hour Mortgage Broker Pre-License Course) costs $249-$399 (depending on the vendor), and the One-Day Cram Review Course is $75. The Mortgage Loan Processing Study is $399 for 3-days, Application is $200 and Fingerprint Processing fee is $15. The Mortgage Class Interactive CD-ROM is $40.

The National Association of Mortgage Brokers awards its designation of Certified Mortgage Consultant (CMC) through its National Certification Committee. Certification for a CMC requires a minimum of 30 continuing education training hours. Application fee is $350. Recertification is $250.

According to the Occupational Outlook Handbook, 2004-2005 Edition, U.S. Department of Labor, employment (Securities, Commodities, and Financial Services Sales Agents) was expected to grow as fast as the average for all occupations through 2012. Median annual earnings of securities, commodities and financial services sales agent were $60,990 in 2002; with the middle half earning between $36,180 and $117,050. Median annual earnings in the industries employing the largest numbers of securities and financial services sale agents in 2002 included:

“Securities and Commodity Contracts Intermediation and Brokerage”: $78,140 (Median). 2002 Dollars.

Earnings from commissions are likely to be high when there is much buying and selling, and low when there is a slump in market activity.

Again, it is not anticipated she will be able to return to full time hours, and at best, could earn perhaps one-third of the projected median earnings for a Broker, of $26,047/year (2002 Dollars).

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