The Latest Trends in Work Hardening

Five tips for proving your value in a competitive field.

Is work hardening dead? What is the difference between work hardening and work conditioning? I have heard someone refer to it as advanced work rehab lately. What is that, and where did it come from? Do insurance companies even pay for any of these programs anymore?

The heydays of work hardening programs for the most part are gone. Many rehab practices said they performed work hardening, but they did not provide the value of getting the injured workers back to full-duty work. Too many rehab clinics said they performed work hardening, billed the work hardening codes, but kept patients in their program for weeks on end without progressing them to return-to-work levels.

Thus came the advent of work conditioning. This was more general strength and conditioning exercises in an effort to get the injured worker conditioned for return to work. The clinics that said they offered work hardening just switched, and said they did work conditioning. Their program format and whether they got the patient back to work did not change. The CPT code they billed out, 97545 and 97546, remained the same, since it is the same code for both work hardening and work conditioning in most states.

Advanced Work Rehabilitation

More recently, the Occupational Health Physical Therapy Advanced Work Rehabilitation Guidelines were published and adopted in 2011. One of the goals of this guideline was, "Each person has individualized needs and it is not appropriate to separate physical and behavioral aspects of care through artificial program distinctions."

Since work hardening programs are becoming less prevalent, work conditioning programs by definition tend to be the trend; however, it does not matter what you call your program, since the goal is getting the injured worker back to work. Thus the Occupational Health Special Interest Group of the American Physical Therapy Association has termed advanced work rehabilitation as a combined work hardening/conditioning approach.

Some of the program elements associated with advanced work rehabilitation include: 

    -- Addressing physical, functional, behavioral, and vocational needs within a multidisciplinary model that includes medical and workplace stakeholders; 

    -- Requiring examination and evaluation with functional testing and communicating/coordinating with all stakeholders; 

    -- Utilizing various therapeutic interventions with a functional emphasis, emphasizing the role of the worker/work activities; 

    -- Hours required in the program are to be determined by situational analysis, and may extend from hour to multi-hour sessions depending on evaluation plan of care and options/availability for work reintegration.

The program elements as a whole are a combination of the previous program elements of work hardening and work conditioning. Interestingly, you do not see any rehab practices changing the signage on the front of their practice saying they have an advanced work rehab program.

This is, however, exactly what a work hardening or work conditioning clinic should be doing from a program perspective. It does not matter what you call your program. Your primary goal should be to provide rehabilitation, strengthening, conditioning and functional testing that gets a person back to full-duty work.

The other important trend is that your work conditioning or hardening program should not just be a dumping ground for the most difficult return-to-work patients. Many times, physicians run out of options with the challenging workers' compensation patient. Their final attempt in regard to return-to-work is to have the patient enter a work hardening or conditioning program. Your program then becomes the dumping ground for the most challenging patients, and in a sense you become a pain management program.

Role of the Therapist

There is no better medical professional who knows whether a workers' compensation patient needs work hardening/conditioning/advanced work rehab than a therapist. The therapist treats them three times per week for weeks, and each therapist should have documentation at discharge that defines whether that patient can perform the physical demands associated with the essential functions of a job.

When an outpatient therapist discharges a workers' compensation patient, there are programs, calculations, and algorithms on the market that could help a therapist document the following: "Mr. Smith demonstrated the ability to perform 72.6% of the physical demands of their job as a police officer at discharge from outpatient therapy." This objective and evidence-based documentation approach specifically suggests the workers' compensation patient requires advanced work rehab.

Documenting function with our Medicare patients in today's medical climate is required to get paid. Documenting function is not required in workers' compensation presently but there is buzz within the industry that workers' compensation may go the route of Medicare and require rehabilitation professionals, during outpatient rehab, to document function so more efficient return-to-work decisions can be made.

Documentation of function in outpatient rehab, as well as defining the exact percentage of the job a workers' compensation patient can perform, assists in providing objective documentation in regard to which of your patients need work conditioning/hardening/advanced work rehab, and which are able to perform 100% of their job's physical demands.

Proving your Value

Claims managers tend to be very picky in regard to verbal authorization when a physician has ordered work hardening/conditioning. I would scrutinize a request as well when someone wants me to pay them $5,000 to $10,000 for a rehabilitation program! A rehab practice has to provide value when the expense to the insurance company is so high. Here are some value-based strategies you can use to be considered the best work hardening/conditioning program in your market:

1. Your initial evaluation in a work hardening/work conditioning/advanced work rehab program should never be a full functional capacity evaluation. It should be a baseline evaluation focusing on return-to-work function, used to determine the most appropriate strength and conditioning starting points.

2. Make sure you document functional improvement on a weekly basis and communicate this with the case manager, claims adjustor, physician, patient, and employer.

3. During your initial evaluation, determine an exact length of stay in your program, and stick to that. If you get to the end of your initial decision and the worker is not ready to go back to work, only ask for more visits if the worker continues to make functional improvement.

4. If, after one week, the worker is not progressing specifically in regard to return-to-work function, call the insurance company and the physician to communicate that the worker has not progressed functionally. If after two weeks there is no progress, discharge that patient, as you are wasting the insurance carrier's money.

5. Determine and promote your clinic's full-duty return-to-work percentage for workers that have successfully completed your advanced work rehab program.

Strategy #5 is your primary marketing tool. Every work hardening/conditioning program should know what their full-duty return-to-work percentage is. What percentage of your work hardening/conditioning/advanced work rehab patients who completed your treatment plan returned to full-duty work?

Once you know this percentage, and if it is 60% or higher, promote it to the world. Mention it in every piece of marketing collateral and every conversation you have about your clinic's program. If you are lower than 60% you need to figure out how to improve it.

Work hardening is not dead. It has just evolved. No matter what you call your program, make sure that your focus is on full-duty return to work by showing the exact improvement a worker makes weekly in your program, and communicate with all the stakeholders involved in that workers' compensation patient.

Jim Mecham is continuing education director and primary developer of OccuPro's Work Hardening/Work Conditioning software and continuing education courses. He teaches medical providers how to implement or enhance these programs within their medical practice. Visit Contact Jim at 866-470-4440 or

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This might help.

Tyler May 21, 2014

Ellen, I have taught clinicians how to come up with this calculation in 15 to 30 minute functional tests for the past 11 years. Give me a call at 866-470-4440 and I will show you exactly how it is done by hand. The organization I work for also has a software system that does this calculation automatically for you.


Jim Mecham,  Continuning Education Director,  OccuProOctober 10, 2013
Kenosha, WI

Could you inform me where i can find the below mentioned programs, without completing a FCE? Many thanks, Ellen

Quote "there are programs, calculations, and algorithms on the market that could help a therapist document the following: "Mr. Smith demonstrated the ability to perform 72.6% of the physical demands of their job as a police officer at discharge from outpatient therapy."

Ellen de JongOctober 05, 2013


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