Rehabilitation guarantee: Evaluation of the initiation of the national rehabilitation guarantee for common mental disorders and backpain

In 2008 the rehabilitation guarantee was initiated as a response to the high rates of sickness absence for common mental ill disorders and backpain. The aim of the guarantee was to increase the exposure to evidence-based method in order to increase return to work or prevent sickness absence for individuals with mild or moderate anxiety, depression and stress in addition to individuals with back- and neck pain.

Since 2008 our unit has had the assignment of the Ministry of Health and Social Welfare to conduct several evaluations of the guarantee and associated reforms. The treatments that are included within the guarantee for individuals with mild to moderate anxiety, depression and stress are cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) and for individuals with back- and neck and multimodal rehabilitation (MMR). All treatments should have a clear focus on work and return to work.

A nationwide evaluation of the implementation of the rehabilitation guarantee, and effects on sickness absence and health

The first part of the assignment concerned 1) the evaluation of the implementation of the guarantee within the regions and 2) the evaluation of the effects of the guarantee. In summary, the results showed initial difficulties getting practitioners within rehabilitation to perform the treatments that were included in the guarantee, especially regarding multimodal rehabilitation for individuals with back- and neck pain. Only a minority of the practitioners, report that workplace interventions are included in the treatments of mental ill health or neck- and backpain. This could partly be due to the fact that the rehabilitation guarantee does not include a clear description of what workplace interventions are, in addition to practitioners prioritizing traditional treatment above return to work. Previous studies have however shown that importance of including rehabilitation practitioners in the process of return to work in order to establish sustainable return to work.

In 2015, a change was made to the rehabilitation guarantee. The updated guarantee now contained the requirement of including workplace interventions in the recommended treatments. Our results showed that this led to a positive development regarding the implementation of workplace interventions at region- and MMR practitioner-level. Practitioners reported that they were motivated to perform the interventions and discuss return to work with their patients. Practitioners within MMR to a higher degree established contacts with other partners, including employers than practitioners within CBT/IPT. However, half of the practitioners included in the evaluation reported that the content of the workplace interventions and how they should be implemented was unclear. Access to support, for example through education, routines and/or guidelines was scare at the clinics.

The effects of the guarantee showed improved health and workability after rehabilitation; however, sickness absence did not decrease more among individuals who participated in the rehabilitation compared to those who did not participate. The evidence-base for return to work and the prevention of sickness absence for mental ill health has strengthen since the initiation of the guarantee. The knowledge base to date supports that rehabilitation should be conducted in close collaboration with the employer and in relation to the current employment.

Publications

Busch H., Bonnevier H., Hagberg J., Lohela Karlsson M., Bodin L., Norlund A., Jensen I. En nationell utvärdering av rehabiliteringsgarantins effekter på sjukfrånvaro och hälsa. Slutrapport, del I. Enheten för interventions- och implementeringsforskning, Institutet för miljömedicin (IMM). Karolinska Institutet. Stockholm 2011.

Bakshi, A., Hansson, J.L., Brommels, M., Klinga, C., Bonnevier, H., Jensen, I.B. En processutvärdering av implementeringen av den nationella rehabiliteringsgarantin. Slutrapport del II. Enheten för implementerings- och interventionsforskning, Institutet för miljömedicin samt Medical Management Centrum, Institutionen för lärande, information och etik, Karolinska Institutet. Stockholm 2011.

Hellman T., Bonnevier H., Jensen I., Hagberg J., Busch H., Björk Brämberg E., Bergström G. En processutvärdering av multimodala team inom ramen för rehabiliteringsgarantin. Slutrapport. Enheten för interventions- och implementeringsforskning, Institutet för miljömedicin (IMM). Karolinska Institutet. Stockholm 2014

Björk Brämberg E., Jensen I.B., Hagberg J., Bonnevier H., Kwak L. En kartläggning av förutsättningar för arbetsplatsnära insatser inom ramen för rehabiliteringsgarantin. Slutrapport. Enheten för interventions- och implementeringsforskning, Institutet för miljömedicin (IMM), Karolinska Institutet, 2015.

Björk Brämberg, E., Klinga, C., Jensen, I., Busch, H., Bergström, G., Brommels, M., & Hansson, J. (2015). Implementation of evidence-based rehabilitation for non-specific back pain and common mental health problems: a process evaluation of a nationwide initiative. BMC Health Serv Res, 15(79). doi:DOI 10.1186/s12913-015-0740-4 https://www.ncbi.nlm.nih.gov/pubmed/25889958

Hellman, T., Jensen, I., Bergström, G., & Busch, H. (2015). Returning to work - a long-term process reaching beyond the time frames of multimodal non-specific back pain rehabilitation. Disability and Rehabilitation, 37(6), 499-505. doi:10.3109/09638288.2014.923531 https://www-tandfonline-com.proxy.kib.ki.se/doi/abs/10.3109/09638288.20…

Hellman, T., Jensen, I., Bergström, G., & Björk Brämberg, E. (2016). Essential features influencing collaboration in team-based non-specific back pain rehabilitation: Findings from a mixed methods study. J Interprof Care, 30(3), 309-315. doi:10.3109/13561820.2016.1143457 https://www.ncbi.nlm.nih.gov/pubmed/27152534

Hellman, T., Irene Jensen, Carole Orchard & Gunnar Bergström (2016). Preliminary testing of the Swedish version of the Assessment of Interprofessional Team Collaboration Scale (AITCS-S), Journal of Interprofessional Care, 30:4, 499-504, DOI: 10.3109/13561820.2016.1159184 https://www.tandfonline.com/doi/full/10.3109/13561820.2016.1159184

Busch, H., Björk Brämberg, E., Hagberg, J., Bodin, L., & Jensen, I. (2017). The effects of multimodal rehabilitation on pain-related sickness absence - an observational study. Disability and Rehabilitation, 1-8. doi:10.1080/09638288.2017.1305456 https://www.ncbi.nlm.nih.gov/pubmed/28345360

Björk Brämberg, E., Jensen, I. & Kwak, L. (2018). Nationwide implementation of a national policy for evidence-based rehabilitation with focus on facilitating return to work: a survey of perceived use, facilitators, and barriers. Disability and Rehabilitation: 1-9. Doi: 10.1080/09638288.2018.1496151 https://www.tandfonline.com/doi/full/10.1080/09638288.2018.1496151