New York State Occupational Health Clinic Network Report 1988 - 2003
Chapter 7. Future Challenges Chapter
- Chapter 7 is also available as an individual Adobe Portable Document (PDF, 58.6 KB, 4pgs)
The overall mission of the NYS OHCN is to contribute to maintaining a healthy workforce. The NYS OHCN has contributed to occupational medicine by publishing in peer-reviewed journals, developing the clinical practice reviews, issuing industrial hygiene guidelines that are used nationally, diagnosing emerging diseases, and defining new examples of work-related diseases. Information from the Clinic Network has been submitted to OSHA to assist with formulating regulations. By utilizing a public health approach of treating the worker, conducting preventive medicine and improving the work environment, the Clinic Network has been able to work towards this goal. As previously discussed in Chapter 1, the Clinics are in a unique position to provide immediate response to exposure episodes or disease clusters. The NYS OHCN has successfully provided education and training tools to workers, employers, and medical care providers within their communities. The NYS OHCN efforts go beyond the individual worker and their employer, and have benefited entire communities.
Since the establishment of the NYS OHCN, the nature of workplace hazards has changed rather significantly. There remains a pressing public health need to diagnose, treat and prevent work-related illness. There is still a profound shortage of trained occupational medicine practitioners. Few other practitioners provide comprehensive preventive services; thus, the NYS OHCN remains uniquely qualified to provide this care.1
The challenges to address these needs have intensified. Since the Network was established, the nature of the delivery of health care services has been dramatically altered. The impact of health maintenance organizations on access to health care services and the significant changes in Workers' Compensation law and administrative procedures have created increasingly difficult challenges to the OHCN's ability to provide service to workers with occupational disease. Flat funding of the NYS OHCN since 1997 has inhibited the ability of the Clinics to continue to address their mission due to rising costs and newly emerging occupational health needs. Satellite Clinics that were started have had to close, thus limiting access to the Clinics. Hours have been cut, staff has been reduced, and services such as physical, occupational and medical massage therapy have been cut. New initiatives have had to be cancelled and the Clinics have had to reduce the number of patients seen in order to identify other funding sources. The patient load on the Clinics continues to increase, but many Clinics have found it difficult to offer both continued care to their existing patient population and to identify and assist new patients.
Delays in processing claims by Workers' Compensation insurance carriers continues to create hardships for the patients and the Clinics. Clinics have had to develop techniques to allow for communicating insurance issues with their patients, addressing needs not being met by the delay of payments, and advocating for the patients with lawyers and within the Workers' Compensation system. The limited reimbursement offered to medical practices from Workers' Compensation in NYS has also created a financial strain on the Clinics, requiring them to supplement the cost of the patient visits with the funding from NYS.
Analysis of the data provided by the Clinics along with information on New York States's changing workforce reveals specific areas upon which the Clinics should consider as they continue to provide high quality diagnostic, treatment and preventive occupational health services in New York State.
The ability of the OHCN to diagnose occupational diseases and understand toxic exposures from the work environment allows the Network to be available throughout the state for consultations or referrals from other medical providers. Therefore, the clinicians need to be aware of newly identified workplace hazards and provide appropriate care based on the current knowledge of occupational health issues. Since they are sometimes the only resource available to workers, they should continue to expand their services to identify co-morbid conditions, and sociological stressors.
- The Clinics should ensure that they continue their focus on the diagnosis of occupational disease. Activities such as pre-employment physical examinations or periodic evaluations, treating acute occupational injuries, and delivering general medical care in an occupational setting are necessary, but do not constitute a practice which focuses on the diagnosis and treatment of occupational diseases.
- The Clinics should continue to be able to identify new associations between workplace exposures and diseases. They should also be aware of and focus on emerging risks such as work organization, cardiovascular disease related to the work environment, and psychological outcomes.
- Clinics need to plan accordingly to handle the patient load expected due to repetitive stress disorders. The number of patients seen with these disorders continues to increase and the chronic nature of these conditions necessitate multiple patient visits (Figures 3.12 and 3.23).
- The Clinics should continue to screen for co-morbid conditions, such as diabetes, hypertension and hypercholesterolemia, during patient visits. This will help ensure the total health and safety of the working population in NYS.
- Mechanisms need to remain in place to assist the patients and their families with psychological and sociological issues. The Clinics need to continue to be aware of the multiple stressors inflicted by being unable to work or from continuing to work with chronic illness or chronic pain, and be able and willing to assist them (Figure 3.7).
The major demographic factors expected to influence the workforce over the next 15 years are the aging population and the expected increase in international immigration. Therefore, the Clinic Network needs to be prepared to continue and possibly expand their work to reach these populations and address occupational health issues relevant to them.
- Further focus needs to be placed upon low-income and immigrant populations. The NYS OHCN should continue to use their skills to reach these populations. Joint partnerships with community groups, including community health centers and migrant clinics should be forged wherever possible.
- Efforts should continue to reach high-risk female workers, particularly those of Hispanic ethnicities and African American race, and those of low-income. These populations appear to be at higher risk for occupational diseases (Figure 2.6).
- Outreach should be conducted to aging workers providing prevention information. While these workers currently experience a lower rate of work-related injuries and illnesses, these rates are anticipated to increase as the working population ages.
- Education regarding physical and ergonomic factors and avoidance of needlestick injuries should be offered, particularly to low-income workers in the medical fields. As the need for assistants in the medical fields continues to increase, there will be an increase in the need for this information.
<High Risk Exposures
Because occupational medicine must link clinical care of individuals to preventive efforts in the workplace, it is often critical that the healthcare provider identifies workplace hazards and assists in facilitating workplace prevention efforts. The Clinic Network needs to continue screening their patient populations for health effects from specific exposures.
- The Clinics need to continue to screen high-risk workers for toxic effects of lead exposure. Even though cases of lead poisoning have decreased over time, certain populations are still at increased risk. High-risk workers include bridge rehabilitation workers, residential remodelers, and shooting range employees (Figure 3.27).
- Screenings for asbestos-related diseases should continue. Clinics should consider expanding their screenings of construction workers, particularly masons and road maintenance workers, to include screening for silica-related diseases.
- Clinics encountering patients who reside in NYC should consider conducting audiometric exams for high-risk populations (Figure 3.11).
- Clinics should consider conducting audiometric exams among their female populations (Figure 3.11).
- Clinics need to offer screenings, prophylaxis, education, and/or treatment to people who work outdoors for insect-borne diseases. Clinics need to recognize the risks for tick and mosquito-borne diseases within their catchment areas, particularly as Lyme Disease continues to spread throughout NYS (Figure 3.3). Recent experiences with West Nile Virus show that new infectious diseases can rapidly appear and immediate public health interventions, particularly to outside workers, should be conducted.
- Skin cancer screenings should be included in the list of services provided to workers who spend long periods in the sun. This would include farmers, loggers, construction workers, and public works employees (Figure 3.5).
- The Clinics should utilize research being conducted regarding health conditions associated with World Trade Center disaster-related exposure to assist in treating and managing patients with WTC disaster-related exposures. It is anticipated that diagnosis of these health conditions will continue to increase for a period of time.
The continuing challenges speak to the need for the network to expand its outreach efforts to raise the level of awareness about the prevalence, cost, and preventable human suffering which result from occupationally-related disease.1 Core groups, which should know about the NYS OHCN and should be utilizing their services, are still too often unaware of what the network has to offer. Policy makers often have only minimal familiarity with common occupational diseases, and the effects these conditions can have on workers. While the overwhelming majority of outreach work will continue to be carried out by individual Clinics, increased collaboration between the Clinics and the development of network-wide resources to promote greater utilization of their services needs to be developed. These resources can include:
- Standardized public service announcements (PSAs)
- Statewide list of media resources
- Boilerplate newsletter articles
- Camera read print ads
- Display materials for statewide meetings of health professionals, legal, labor and employer groups
- Presentation materials (e.g., slides, lecture outlines) for health professional grand rounds or seminars. Although the number of unionized employees has been declining, the Clinics should continue to reach out to the unions. Unions have access to unique worker populations and can also assist with access to worksites. Because of this decline, the NYS OHCN should also focus upon reaching out to employers.
There needs to be enhanced collaboration between the Clinics, to allow them to utilize their individual skills to address larger occupational health issues. Materials developed for select populations should be available to all network members, as should translations for immigrant populations.
Balance needs to be maintained between the primary clinical missions and the benefits of occupational disease prevention to be obtained through research. Research can include further database analyses for use in prevention including developing accurate methods to conduct ongoing surveillance of occupational diseases and exposures of public health importance in New York State. Research may also include conducting pilot clinical research projects for diagnosis, management, and final health and work outcomes.
Each Clinic should be involved in internal research evaluating the most effective use of industrial hygiene and other nonmedical interventions; and what are the most effective worker training methods to accomplish preventive goals.
Network research activities may include health survey research and publication of clinical case reports and case series; pilot clinical research projects to improve the accuracy of recognition and diagnosis of occupational diseases, the effectiveness of clinical management, and the final health and work outcomes of occupational diseases of public health importance in NYS.
Supply of Occupational Health Professionals in NYS
Another goal established for the NYS OHCN was to strengthen and expand training programs in occupational health for professionals at all levels. In order to continue working towards this goal, the Clinics should work on integrating occupational medicine into mainstream medical care. Awareness of the NYS OHCN should be increased through fellowships and residencies with as many medical centers as possible.
The number of board-certified occupational medicine physicians in NYS has increased from 73 in 1985 to 97 in 2003 for a rate of 1.1 per 100,000 workers in the state. There are currently 290 members of the American College of Occupational and Environmental Medicine (ACOEM). The majority of these physicians are not board-certified in occupational medicine. It is unlikely that this larger group of self-designated occupational medicine physicians significantly increases the availability of services established specific to diagnosis and treatment of occupational disease since they often spend their time delivering general medical care in an occupational setting or to identified occupational groups. Meanwhile, the number of board-certified industrial hygienists has increased from 91 in 1985 to 316 in 2003. There are also currently 306 board-certified occupational health nurses in NYS.
- NYS Clinics Network Report and Recommendations of the Network Outreach Committee. March 16, 2000.
- NYS Clinics Network Prevention/Intervention/Research Committee notes. December 1, 1999.
- Council of State and Territorial Epidemiologists. Putting Data to Work: Occupational Health Indicators from Thirteen Pilot States for 2000. October 2005.
- Mt Sinai. Report to the New York State Legislature. Occupational Disease in New York State. Proposal for a Statewide Network of Occupational Disease Diagnosis and Prevention Centers. Environmental and Occupational Medicine Department of Community Medicine, Mount Sinai School of Medicine of the City University of New York. February 1987.