CONDITION CHRONIC: How Improving Workplace Wellness Helps Canadians and the Economy

The Public Policy Forum (PPF) shortlisted an initial list of key stakeholders to be interviewed for a project on chronic pain in Canada. The interviews lasted for 30–45 minutes and were conducted over the phone. Each stakeholder was asked recurring policy questions, ongoing initiatives in the workplace to include people with health challenges and best practices for disability management.

This report provides a broad overview of the issues concerning chronic conditions in the workplace and supports the development of public policy and interventions to assist those with chronic conditions.

Key findings:

• Create more accurate definitions of disability within policy discussions
• Ensure Canadians have access to flexible work programs
• Base legislation on best practices in disability management
• Developing national strategies to promote best practices for employers
• Collecting and analyzing data on chronic conditions.

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Summary

Canada must do more to both reduce the incidence of chronic disease and to appropriately accommodate those already living with chronic disease. While governments, employers and advocacy organizations have good intentions and are undertaking helpful initiatives, the challenge is immense and it requires a well-informed, broad, integrated response.

• Primary prevention: Interventions aimed at preventing injury or illness before they occur. For example, workplace health programs and incentives to keep staff active, immunizations or legislation on safety standards.[10]
• Secondary prevention: Interventions focused on minimizing the impact of an injury, disease or condition to slow the progress of a condition or to prevent further harm or reinjury, for example, screening for early detection of a disease or condition, adapting workplace conditions to avoid known safety concerns or offering medical benefits to slow the progress of a condition.[11]
• Tertiary prevention: Interventions aimed at functionally minimizing the impact of an ongoing condition like a chronic disease or permanent impairment, for example, return-to-work programs, rehabilitation programs or other initiatives that assist a person to improve their ability to function.[12]

This report is based on two main sources of data: interviews with key stakeholders and a review of the related literature.

The Public Policy Forum (PPF) shortlisted an initial list of key stakeholders to be interviewed for this project. These individuals, in turn, provided recommendations for additional stakeholder interviews. The interviews lasted for 30–45 minutes and were conducted over the phone. Each stakeholder was asked questions about the policy context, ongoing initiatives in the workplace and best practices for disability management.

Additionally, a thorough literature review was undertaken to understand the broad context of workplace health and chronic conditions. The research team reviewed statistics, key theoretical and context-specific documents and reports.

This report provides a broad overview of the issues concerning chronic conditions in the workplace and supports the development of public policy and interventions to assist those with chronic conditions.

Half of Canadians over the age of 20 have a chronic disease, and 15 percent have two or more.(13) The annual cost to Canada’s economy of lost productivity due to chronic disease is around $122 billion, equivalent to about six percent of Canada’s gross domestic product (GDP).[14]

Canada must do more to both reduce the incidence of chronic disease and to appropriately accommodate those already living with chronic disease. While governments, employers and advocacy organizations have good intentions and are undertaking helpful initiatives, the challenge is immense and it requires a well-informed, broad, integrated response. At the same time, most Canadians need to do more to reduce the risk of chronic disease by maintaining a healthy and active lifestyle — for example, only one in five adults meet national guidelines for physical activity.[15]

Canadians with chronic conditions should not have to choose between working without supports or leaving the labour force. Instead, a continuum of supports and accommodations should be made available to all. Several ongoing initiatives by individual provinces and employers can be scaled for impact. They include:

• developing disability management plans;
• fostering organizational cultures of health and openness;
• encouraging individual responsibility towards one’s health;
• providing supports that are consistent and accommodate all types of chronic conditions; and
• creating individualized return-to-work plans and applying principles of universal design to workplace wellness.

Policymakers and employers are challenged by:

• the restrictive definitions and lack of understanding of chronic conditions in the policy realm;
• supports and benefits systems that are difficult to navigate;
• the lack of recognition of episodic and invisible disabilities;
• the critical gap between short- and long-term disability benefits; and • the stigmatization and discrimination following the disclosure of a chronic condition.

Crucial policy interventions include:

• Creating more accurate definitions of disability within policy discussions: For example, British Columbia has developed two designations: Persons with Multiple Barriers (PPMB) and Persons with Disabilities (PWD). These definitions demonstrate how governments can account for periodic and episodic impairments in their definitions of disability.
• Ensuring Canadians have access to flexible work programs. For example, part-time work and access to flexible employment insurance sickness benefits.
• Basing legislation on best practices in disability management: For example, New Brunswick is redesigning its disability supports through the Employment Action Plan for Persons with a Disability; the Health Employers Association of British Columbia has an Enhanced Disability Management Program, which brings together unions, employers, government and private insurance to enshrine and systematize responses to disability; and the prospective Canadian Accessibility Act could draw on similar legislation in Germany to require employers to have disability management plans and access to professionals in this field.
• Developing national strategies to promote best practices for employers: For example, the European Network for Workplace Health Promotion’s 10-point Brussels Declaration focuses on establishing partnerships between the public and private health sectors.
• Collecting and analyzing data on chronic conditions.

More than half of Canadians over the age of 20 (51.6 percent) live with a chronic disease and 14.8 percent have two or more chronic conditions. [16] From the 28-year-old IT technician suffering from arthritis to the 54-year-old social worker who has epilepsy, Canadians of all ages are affected by chronic conditions. In fact, more than 30 percent of Canadians aged 12 and older report their activities are sometimes or often limited due to disease or illness.[17]

For many of these Canadians, managing their chronic condition in the workplace is a critical issue. It is also a critical issue for Canada’s economy: The annual cost of lost productivity due to chronic disease is around $122 billion, or about six percent of Canada’s GDP.[18]

Having a job, especially a “decent” one,[19] promotes health and wellbeing.[20] Healthy, committed and engaged workers stay in their organizations longer and are more productive. Workplace health promotion programs save from two to 10 times their cost in reduced workplace absences and medical costs.[21] Conversely, unemployment, underemployment or precarious work can harm a person’s health and can result in lost productivity for organizations. It is estimated that sick days cost the Canadian economy $16.6 billion in 2012.[22]

Despite these concerning statistics, workplaces rarely do enough to support those living with chronic conditions. Now is an opportune time for this to change as policymakers and employers are preparing for fundamental shifts in the nature of the workplace. Flexibility and agility are now seen as key for productivity. Mobile work styles, focus on work-life balance, collaboration, innovation and diversity are hallmarks of the “new” workplace.[23] In such fluid work environments, there is a growing emphasis on improving work conditions and employee experience. This is a window of opportunity to ensure work environments are more inclusive and respectful of those with chronic conditions.

Workplace support of chronic conditions is a complex policy issue. It affects public health, the economy, productivity, insurance and human rights. To develop a policy path forward, it is critical to understand how these overlap and shape workplace health and how to improve stakeholder involvement.

This report addresses four elements:

• It provides a broad overview of chronic disease and disability and its impact on the workplace;
• It addresses insurance and workplace benefits, including a discussion on human rights;
• It highlights key workplace interventions and promising disability management practices; and
• It explores policy opportunities.

Chronic conditions and risks

Chronic conditions are many and varied; some are preventable while others are not. Four chronic conditions — cardiovascular diseases, cancer, chronic respiratory diseases and diabetes — are the cause of 65 percent of Canadian deaths each year.[24] Other major chronic conditions include arthritis, multiple sclerosis (MS), mood and anxiety disorders and different forms of dementia.[25]

Many of these chronic conditions share risk factors such as physical inactivity, unhealthy diet, tobacco use and excessive alcohol use.[26] Prevention strategies and policies that support a healthy lifestyle can play a key role in reducing the impact of these conditions and mitigating their risks.

Historically, chronic conditions had their onset in later adult years. However, in Canada, as in other Organisation for Economic Co-operation and Development (OECD) countries, rates of childhood obesity and inactivity have increased, potentially leading to earlier onset of these conditions.[27] The Public Health Agency of Canada (PHAC) estimates that more than 90 percent of Canadian children do not meet physical activity guidelines, presenting a significant challenge for public health.[28] These findings underscore that we must address chronic conditions holistically across all age groups.

Workplace and wellness

The world’s population spends an average of one-third of their adult lives at work[29] meaning that chronic disease prevention and management in the workplace is critical.[30][31] Although participation in the workforce promotes both health and well-being,[32] those with chronic conditions may struggle to enter or remain in the workforce. As one example, The Arthritis Society found that only 40 percent of those suffering from arthritis reported being employed in the previous month, substantially below the national labour participation rate of almost two-thirds.[33]

From its physical design to recruitment practices[34] and promotion of accommodation and support,[35] the workplace can either promote inclusion or create barriers.

Social determinants of health and social supports influence a person’s ability to be present and perform well at work.[36] An interview with the MS Society highlighted the importance of adequate housing, transportation and home care; holistic supports and interventions are necessary beyond the workplace.[37]

Episodic and invisible impairments

Whether or not the cause of an impairment occurred at work determines the support a person will receive and from whom. If the impairment occurs in the workplace, an employee is more likely to receive supports.[38] Whether the disability is episodic or permanent and whether the resulting impairments are visible or invisible also determines how the disability is perceived and addressed.[39]

Under the current Canadian disability system, benefits are designed for short-term or permanent leaves, excluding people requiring episodic leave.[40] According to the Episodic Disabilities Network (EDN), episodic conditions are unique because “… unlike permanent or progressive disabling conditions, they result in episodes of disability … The periods of disability can vary in severity and duration. There may be some advance warning or the episode may come on unexpectedly.”[41]

INTERSECTIONAL EQUITY

Women are three times more likely than men to have MS and they are more likely to be precariously employed and therefore have fewer benefits. MS is also an episodic disability, with many invisible impairments. These compounded conditions make equity in the labour market a serious challenge.

Consider a condition such as anxiety; a person’s anxiety levels may vary greatly from day to day. At times, they may be unimpaired and able to work without any accommodation. At other times, they may be severely impaired, requiring accommodation or even a total absence from the workplace for an unpredictable length of time.

Many episodic conditions, such as mental illness, arthritis, multiple sclerosis and Crohn’s disease, result in impairments that go undisclosed[42] and unrecognized because they are invisible. This can cause added hardship and marginalization for those who suffer from episodic chronic illness. According to Dr. Michael Prince from the University of Victoria, invisibility occurs when an impairment is:

• Not recognized by the individual: People with mental health conditions may not have the capacity to identify their condition or may not consider their condition to be an impairment.
• Not recognized by others: Society may not recognize those with chronic conditions, or may choose to ignore them. In the workplace, managers or colleagues may be less likely to accept decreased productivity from a colleague whose impairment they do not see or recognize.
• Not recognized by the medical community: Medical professionals may not recognize a condition (symptom etiology), especially if it is new or rare.
• Not recognized by policymakers and service providers: Policymakers and service providers may not recognize the condition as a disability, leading to exclusionary policies.

These aspects of invisibility affect employees’ sense of safety and ability to disclose their conditions, as well as the employer’s responses to such disclosure. Yet without disclosure, the employer has no duty to accommodate.[43][44]

In a 2016 study, Dr. Prince highlights how individuals can “pass” or continue to work without disclosing their conditions to supervisors or colleagues. “Passing” places the burden of coping and adapting solely on the employee, compounding stress linked to the management of the condition.[45] For example, many people with arthritis work with colleagues who are unaware of their condition.

This can make them socially isolated, stigmatized and penalized if their work suffers and they are unable to explain why. Ultimately, they may experience less workplace success.

TAKEAWAYS: Why support people with chronic conditions?

Human rights and workplace health

The 2008 United Nations Convention on the Rights of Persons with Disabilities stipulates that having to leave work prematurely or not having access to work due to a disability is a human rights violation. Despite Canada’s commitment to the convention, many people with disabilities, including those with chronic diseases, are forced to leave the labour market prematurely.[46]

A recent consultation on a proposed federal Accessibility Act found employment and job retention to be a top priority among Canadians.[47] The report highlights the necessity of engaging employers to shift the framing of disability from burden and obligation to an opportunity to find simple solutions that open up an untapped labour force. For instance, The Arthritis Society emphasizes that although arthritis can affect a person’s ability to work, many people with chronic conditions are productive members of the workforce who require few or no accommodative measures.[48]

Government policy and role of public health

The Canadian Government pledge to increase spending on mental health is intimately tied to chronic illness. People who report symptoms of depression also report three times as many chronic physical conditions as the general population.[49] The federal government’s pursuit of policies on inclusive growth cannot afford to neglect those with chronic health challenges.

In its 2015 strategic plan, PHAC, the federal agency responsible for the prevention and management of chronic illness, identified the need for stronger coordination amongst stakeholders, including the sharing of knowledge and the engagement of partners outside the health sector.[50] The plan also discusses piloting behavioural approaches to improve unhealthy lifestyles.

PHAC has an important role to play in deepening the surveillance of chronic conditions to improve understanding of their prevalence and impact. According to interviewees, exclusionary definitions of disablement have also had repercussions on the availability of sound data on episodic conditions.[51] PHAC must also ensure better aggregation of its data with provincially collected data. The collection of data and its analysis provide the grounding to identify gaps and inequities in prevention, treatment and management of chronic conditions.

Supporting the spectrum of chronic conditions

The Canadian benefit system is characterized by a lack of coordination between federal and provincial governments, insurance companies and employers.[52][53] Even if eligible for a disability benefit under provincial or territorial governments or from private insurers, individuals may not qualify for a Canada Pension Plan Disability Benefit (CPP-D).[54] It is difficult to navigate the different systems to receive support,[55] and eligibility criteria are not inclusive of the “fluidity of disablement.”[56] In other words, supports are designed assuming people fit into a binary of either disabled and unable to work or able-bodied and able to work.

This system does not reflect the experience of most people living with chronic conditions; 84 percent of people who live with a disability experience it episodically and are able to work during periods of remission.[57]

Canadian jurisdictions do not have a common definition of “disability.” To be eligible for the Government of Canada Disability Tax Credit, applicants must have an impairment that is prolonged, that has lasted or is expected to last for a continuous period of at least 12 months, and that is present at least 90 percent of the time.[58] Similarly, to qualify for the Canada Pension Plan Disability Benefit, individuals must have a disability that is “severe and prolonged” and that prevents the applicant from working any job on a regular basis. Both the “severe” and “prolonged”[59] criteria must be met at the time of application; therefore, people with episodic disabilities are excluded from this benefit.[60]

There are at least seven different disability benefit providers in Canada, including the CPP-D, EI Sickness Benefit, Workers’ Compensation, veterans benefits, tax measures and provincial income support programs.[61] Despite the number of disability benefit providers, one-third of people who require support receive it through general provincial income support programs rather than through disability-specific supports.[62] As people with episodic conditions are not eligible for disability benefits, they access greater support at the provincial level.[63]

Public benefit programs often have conflicting eligibility criteria and guidelines on allowable earnings, rendering systems difficult to navigate.[64,65] This lack of coordination regarding disability and wellness benefits is also noted across Europe by the European Network of Workplace Health Promotion.[66]

It is difficult to navigate a complex benefits system at any time; it is worse when living with cancer or depression. When people succeed at being accepted into a benefit program, they are often forced to leave work for fear of losing their eligibility status; leaving work can be the most certain way to secure a benefit program income.[67]

Gaps between government benefits and private insurance

To care for themselves, people need benefits that enable them to take a leave of absence without losing their income. Paid sick leave is not available to everyone, and if a person doesn’t have access to private insurance or government benefits to supplement their income, they are unlikely to be able to afford taking a leave of absence.

In a 2015 report for the Institute for Research on Public Policy, Meredith and Chia describe this as the “medium-term” gap, where individuals exhaust their short-term disability leave or support but do not qualify for long-term disability programs.[68] This is a priority concern for people with episodic conditions. Although the medium-term gap can be mitigated through private insurance, not all workers have access to this type of insurance, it is not regulated by governments in Canada and it remains at the discretion of the employer.[69]

Individuals living with chronic conditions can also find it difficult to get the medication they need. Without employer coverage, the financial burden of medication falls on the patient. Access to medication has a direct impact on a person’s ability to return to and remain in the labour force.[70] Since the capacity of employers to accommodate varies greatly, it is necessary to explore how public and private benefits might fill these gaps and ensure individuals stay in the labour market.

DEFINITIONS OF DISABILITY: THE MS EXAMPLE

MS is a chronic disease that occurs episodically and with unpredictably varying severity: it has cycles of relapse and remission. Existing definitions of disability, which emphasize continuity of impairment, exclude people with MS from important benefits (Meredith & Chia, 2016, p.2). As a result, people with MS can be too disabled to work and not disabled enough to receive the necessary benefits.

In Alberta, the MS Society offers a workshop on how to apply for the provincial benefit Assured Income for the Severely Handicapped. One of the tips offered to clients is to fill out the form with their worst day or most severe experience of impairment in mind.

‘JILL’ SHOULD NOT HAVE TO QUIT HER JOB

An example from the Episodic Disabilities Network (EDN).

“Jill is not a real woman, but her story captures the reality of thousands of Canadians. The Arthritis Society regularly heard these stories and used the details to create ‘Jill’. Jill is a 50-year-old woman who has been working for over 25 years. Seven years ago, she was diagnosed with rheumatoid arthritis. As a result of prompt diagnosis and good management, Jill was symptom-free until last year.

Over the past year, Jill has begun to experience flare-ups of her arthritis that are unpredictable and last from a few days to, more recently, a month. Sometimes Jill can work for a few months or more without an episode. Jill gets 10 sick days a year from her employer, but one arthritis episode can use up all of her allotted sick days. Jill’s doctor cannot promise that her arthritis could be more consistently managed.

Last month, Jill decided she had no choice but to quit her job and go on disability income support. Her employer had offered her a part-time position, but Jill is a single woman and would not be able to live on that level of income, especially as her medications are costly. Now Jill is out of the workforce on disability income support and not paying employment-related taxes. She does not have as much money to contribute to the Canadian economy. However, if Jill were able to use Employment Insurance Sickness Benefit in a more flexible way and over a longer period, instead of the current 15 consecutive weeks or 75 full days, she would be able to stay engaged in the workforce, have access to her employer’s benefits plan and continue to pay income tax and Employment Insurance premiums.”

PRINCIPLES OF PROGRESS

Investment in workplace health

As people live longer, many of them are extending their careers. As a result, it is more likely that people will develop a chronic condition while in the workforce. Regardless of age, employees with chronic conditions may present several challenges for their employers such as attendance, temporary transfer of workloads, loss in productivity and costs related to staff replacement. As employers manage the demographic shifts in the workplace, they will need to accommodate growing numbers of employees with disabilities and chronic illness. If they are successful, they will retain experienced workers, building a knowledgeable and skilled workforce.[71] Employers need to both understand and support their employees with chronic conditions to create work cultures that are flexible and adaptable to their health needs. Ultimately, this increases employee productivity.

Prevention and accommodation

Disability management recommends that employers have universal response protocols in place to support and accommodate people with workplace impairments, regardless of how the impairment occurred or began.[72][73][74][75] When an employee discloses a disability, employers should always respond in a systematized, evidence-based and supportive manner. There are two broad categories of actions that employers, governments and individuals can take in response to chronic disease in the workplace. They are:

• Primary prevention: Actions to maintain productivity by decreasing incidence of chronic conditions and associated absences and workforce exits. Workplace wellness initiatives that address risk factors and conditions with the aim of preventing chronic disease are considered primary prevention.
• Accommodation: Actions to maintain workforce productivity and social inclusion by keeping skilled people in the labour market or helping them return to it. Accommodation initiatives aim to decrease the impact of a condition, to prevent its worsening and to prevent relapse and comorbidity when possible.

Workforce participation in these efforts promotes health and well-being and aims to prevent workplace accidents.[76] While primary prevention is universally beneficial, it is not always part of a systemic workplace wellness plan; neither is it adequate for all conditions and impairments. Rather, primary prevention needs to be one part of coordinated workplace wellness plans that include high-quality disability management programs.

Disclosure

Legally, employers have a duty to accommodate a disability only if the disability or condition is disclosed.[77][78] A 2015 Sun Life report reveals a disconnect between the number of Canadians who report living with a chronic condition (59 percent) and the number estimated by employers (32 percent), suggesting many employees choose not to disclose.[79]

According to Dr. Monique Gignac, from the Institute for Work and Health, fear of disclosure can push people to exhaust all other supports or wait until a crisis, or both, before telling their employer about their condition.[80] Regardless of whether an organization has the proper disability management protocol in place, if the culture is such that a person will be stigmatized and penalized, they are unlikely to disclose their condition. Under these circumstances, they may feel their disclosure is an obligation, rather than a choice. Further, at this point, early intervention practices are no longer sufficient to address the crisis or condition.

Disclosure requires open and trusting relationships with staff. Experts agree employers and disability management professionals should address accommodative needs proactively.

UNPREDICTABLE RESPONSES TO DISCLOSURE

This story from the MS Society shows how employer responses to disclosure can be challenging:

“I was diagnosed with multiple sclerosis in 2002. I never displayed a single MS symptom at work, ever. I was let go shortly after confiding in one of my coworkers about my diagnosis. I understood it to be a downsizing issue relating to a recent merger, but I was later told that my vice-president had told my coworkers: ‘I had to fire Catherine a few weeks ago because she has MS.’ Coulda, shoulda fought it, but at the same time, you’re 26 years old, you’re new to your career and you don’t want to be blacklisted! Since then, I’ve worked for much more compassionate organizations.”

PROMISING PRACTICES

Employers can adopt several strategies to address chronic conditions in the workplace.

• Ensure a disability management plan or protocol is in place: When a disability or need for accommodation is disclosed, a systematic and predictable protocol should be followed.[81][82] This removes the guesswork and ensures that accommodations are provided equitably. However, the plan should allow accommodations to be adaptable to each individual and situation.
• Foster an organizational culture of health and openness: Disclosing a disability is the first step in the accommodation process. It is essential that the workplace environment minimizes fear and stigma around disclosure.[83][84] Employers must take responsibility for workplace health and safety and communicate this clearly to their employees. This also requires examining the current workplace culture and ensuring the senior leadership is involved in creating an environment where trust and support are prioritized. Leadership, boards and senior management must be engaged and supportive to effect change. Greater awareness and understanding of the capacities of coworkers living with chronic conditions must be encouraged. Finally, it is necessary to develop supports and accommodations that enable and empower people to live well and work better.
• Develop a clear and coherent strategic approach: Organizations must understand the objectives and goals of wellness programs and involve all staff in their planning and implementation. This may require both education and training about workplace health and chronic conditions. It may also require reviewing human resources policies (including hiring, firing, absences, work-from-home options, holidays and disability support), working conditions and supervision. Rather than simply responding to individual concerns, employers can develop and execute measures for all.
• Identify good measurement tools: To track progress and quantify success, it is important to develop strong indicators that can be measured. A successful corporate wellness strategy should consider return on investment, including the financial, social, psychological and societal benefits of the strategy. Measurements can include a health risk assessment of employees’ current health, the current cost of illness to the organization, the levels of abstenteeism and presenteeism, health insurance costs, retention rates, productivity and employee satisfaction. Individual health tracking devices, such as Fitbit, can be integrated into wellness or health data of the company to broaden the notion of self-directed wellness. This information can be compiled at an aggregate level to establish a baseline and design wellness interventions that target common employee health issues.
• Provide employment support interventions early during illness and leave: Employers should set guidelines for when an employee on leave is to be contacted to begin the return-to-work process.[85][86][87] Engaging with employees during their absence improves their physical and mental health and makes it less likely they will lose their job.[88]
• Designate personnel to address workplace health: Employers should identify a person with disability management expertise, either a staff member or an external consultant, to assist employees who are returning to the workplace after an absence due to disability.[89][90] Human resources personnel should provide effective support for workplace health initiatives,[91] including helping employees with documentation, assessing health and safety risks and creating a systematic approach to coordinating interventions to retain workers with chronic illness or to facilitate their return to work.[92]
• Ensure accommodations address both visible and invisible aspects of a disability: Both visible impairments such as mobility issues and invisible impairments such as fatigue and pain should be accommodated.[93][94] It is necessary to consider all aspects of a disability, not simply those that are most visible.
• Involve the person with chronic illness in the assessment and in planning their return to work: Individual return-to-work plans must be embedded in the broader disability management strategy — chronic diseases cannot be treated in isolation, and any model of care should offer a comprehensive solution for associated symptoms.[95] It is also critical to understand a person’s home environment and together identify factors that could affect work. Disability management programs need to be flexible and monitored for continuous quality improvement and efficacy.
• Engage all stakeholders in the return-to-work process: Employers, employees, health-care providers, benefit and welfare authorities, and public employment services must all be involved. Effective delivery of programs and services requires clarity of roles and responsibilities, transparency of the process and strong communication. Effective support requires a long-term and sustained effort rather than a single, one-off intervention.[96]
• Apply principles of universal design: Many workplace processes and structures can be adapted to better suit the needs of workers. The employer can ensure, for example, that the workplace is physically accessible or provide flexible working arrangements that include options for job sharing, working from home and opportunities for modified work schedules.[97][98][99] Workplaces and policies should take such needs into account from the outset. It is also important that episodic disability be considered when conceptualizing universal designs.

GOOD IDEAS FROM CANADA AND THE WORLD

Policy interventions that show promise in Canadian and international jurisdictions include:

Creating more useful and accurate definitions of disability within policy discussions: British Columbia has responded to the need for a more nuanced definition of disability by developing two different designations. The Persons with Persistent Multiple Barriers (PPMB) designation includes anyone who has been on assistance and unable to achieve financial independence for 12 out of the past 15 months. The Persons with Disabilities (PWD) designation includes anyone with an impairment that “directly and significantly restricts the person’s ability to perform daily living activities either continuously or periodically for extended periods….”[100] The British Columbian definitions recognize how impairment can occur periodically and episodically, which creates a more inclusive and supportive policy environment for those with chronic conditions

Crafting legislation for best practices in disability management:

• The province of New Brunswick is redesigning its disability supports programming and legislation to improve employment outcomes for people with disabilities [101][102] through the Employment Action Plan for Persons with a Disability. This provincial government is supporting people living with chronic conditions or a disability in several ways: by connecting people with disabilities to appropriate employment support services; by increasing access and awareness of available employment supports; by educating employers about benefits and disability; by updating the provincial benefit programs to allow people to maintain access to health benefits while working, and; by offering more wage exemptions for people who are currently receiving assistance.
• The Enhanced Disability Management Program of the Health Employers Association of B.C. brings together unions, employers, government and private insurance to enshrine and systematize responses to disability.
• Germany’s legislation on Rehabilitation and Participation of Disabled Persons[103][104]: Germany has enacted federal legislation on how employers respond to disability in the workplace regardless of whether the disability is the result of a workplace injury. Companies with 20 or more staff are required to have a disability management plan and to either hire or have access to a disability management professional.
• The proposed Canadian Accessibility Act [105] could incorporate components of the German law, including obliging employers to have disability management plans and access to professionals in this field. However, jurisdictional issues related to employment standards and benefits between the federal government, provinces and territories may pose challenges to such an initiative.

DISABILITY MANAGEMENT:FROM PIECEMEAL TO STANDARDIZED

• Like disability management policies, workplace health and safety standards used to be piecemeal. Interviewees stressed that workplace health and safety measures were voluntarily adopted by employers before being legislated.

•Disability management policies may follow a similar trajectory to become legislation and accepted workplace practices. For instance, the Canadian Standards Association has an initiative on accommodation standards that seeks to normalize accommodation practices in workplace culture and involve employers in developing such standards.

Developing national strategies and promoting best practices for employers:

• The European Network for Workplace Health Promotion has developed a campaign called Promoting Healthy Work for Employees with Chronic Illness — Public Health and Work (PH Work) that aims to achieve sustainable employment for all.[106] With the slogan “Work. Adapted for all. Move Europe”, it focuses on “coordination, communication and collaboration between health-care professionals and the workplace, and puts more focus on work-related issues (including adaptation of the workplace, reorganization of tasks, matching jobs to abilities, supportive management).” The strategy focuses on establishing partnerships between the public and private sectors to invest in health.
• The members of the European Network for Workplace Health Promotion signed the Brussels Declaration,[107] including the following 10 recommendations for the European Union and its members:

1. Focus on the prevention of chronic diseases at the workplace.
2. Detect chronic diseases at an early stage.
3. The paradigm should shift from reduced performance to retaining current and future working ability.
4. Focus on the abilities and resources of the individual rather than on limitations or restrictions.
5. Address discrimination against people with chronic diseases.
6. Raise the importance and priority of return-to-work (RTW) on the policy agenda.
7. Increase the opportunities for employment of persons with chronic illness.
8. Work must reward: work must include a positive cost-benefit ratio.
9. Close and systematic cooperation of all relevant players and stakeholders involved.
10. Fill the gaps in existing knowledge, and extend and maintain evidence and experience-based interventions.

CALLS TO ACTION

Creating more accurate definitions of disability within policy discussions.

Current disability legislation is too restrictive and exclusionary. The definitions, which vary across Canadian jurisdictions, create a binary system that assumes a person can or cannot participate in the workforce, with no middle ground. Such definitions exclude the millions of Canadians suffering from episodic conditions. Moreover, these definitions restrict access to public benefits and supports, compelling people to prematurely exit the workforce. It is essential to begin providing a continuum of supports and accommodations for all.

Such definitions must also be consistent, or at least coherent, across jurisdictions. A person should not access supports at one level while being denied at another due to conflicting definitions and eligibility criteria.

Example: British Columbia has developed two designations: Persons with Persistent Multiple Barriers (PPMB) and Persons with Disabilities (PWD). These definitions demonstrate how governments can account for periodic and episodic impairments in their definitions of disability.[108]

Ensure Canadians have access to flexible work programs and benefits.

More accurate definitions of disability should result in the adaptation of Canadian support benefits. For instance, employment insurance sickness benefits should be more flexible and adaptable to the realities of episodic conditions while the eligibility criteria must reflect the “fluidity of disablement”.[109]

Base legislation on best practices in disability management and ensure coordination of benefits.

Employer benefits and supports are largely voluntary in Canada, which creates piecemeal access for people with chronic conditions. Developing clearly defined employer obligations and coordinating benefits through the proposed Canadian Accessibility Act is an opportunity to establish universal and equal access to supports. Access to these benefits should be coordinated across public and private systems to ensure individuals are covered consistently, regardless of the nature of their chronic condition and their employer’s ability to provide private insurance. Potentially, employers could be required to provide a minimum benefit level for employees, with additional coverage provided by governments.

Examples: New Brunswick is redesigning its disability supports through the Employment Action Plan for Persons with a Disability; the Health Employers Association of British Columbia has an Enhanced Disability Management Program, which brings together unions, employers, government and private insurance to enshrine and systematize responses to disability; and the anticipated Canadian Accessibility Act could draw on similar legislation in Germany to require employers to have disability management plans and access to professionals in this field.

Develop a national strategy to promote best practices for employers.

Governments must work with others, including insurance providers, health professionals and non-profits, to develop and implement a national workplace wellness strategy and agenda. This strategy must include a set of measurable indicators to evaluate its implementation and its efficacy. Developing such indicators, sharing evidence and building a knowledge base will inform best practices and enable more systematic management of chronic conditions.

Stronger partnerships and coordination between these stakeholders can support benefit provision and improve workplace wellness. Coordinated and collective action can boost employer engagement, increase incentives for workplace wellness, identify promising practices, share measurement tools, build collaborative models of care and scale evidence-based interventions.

Canada has several ongoing promising practices, initiatives and collaborations. Applying key principles to local needs is a crucial next step for managing chronic conditions in the workplace.

Example: The European Network for Workplace Health Promotion’s 10-point Brussels Declaration focuses on establishing partnerships between public and private health sectors.

Collect and analyze surveillance data on chronic conditions.

PHAC has an important role to play in deepening the surveillance of chronic conditions to improve understanding of their prevalence and impact. Exclusionary definitions of disablement have also had repercussions on the availability of sound data on episodic conditions. The collection of data and its analysis provide the grounding to identify gaps and inequities in prevention, treatment and management of chronic conditions.

CONCLUSION

Half of Canadians over the age of 20 have a chronic condition. This number continue to rise as Canada’s population ages and diseases that were once considered fatal are better managed.[110] Additionally, chronic conditions are now more likely to afflict people earlier in life due to sedentary lifestyles. As a result, workplace accommodation of chronic conditions is more important than ever. The success of our economy depends on an engaged and healthy workforce.

The economic and social costs of chronic disease and an aging population are immense.[111] Together with the rapid change in the nature of work and the workplace, this opens a window of opportunity to ensure that every Canadian can be a productive member of the labour force. Creating workplaces that support people living with chronic conditions will foster a workforce that is more inclusive of all. Canadians require more fluidity in employment because of aging, pregnancy, health conditions and caregiving, and workplaces of the future need to include accommodations in their employment practices. Such accommodations also have the potential to reduce the stigma surrounding chronic conditions and to support those returning to work.

Employers and government can spearhead a cultural shift that supports disclosure, creates channels of open communication, establishes inclusive workplaces and supports employees for the long term. To create effective change, it is crucial to address the issue holistically and with strong stakeholder coordination. By adopting or replicating evidence-based or promising practices at scale, employers can reduce costs, increase reach and strengthen impact. Consolidation of services can also help to optimize resources and achieve holistic wellness.

Countries are starting to grapple with the immense challenge of chronic illness. Governments are leading initiatives to encourage healthier living, but they must also do the hard work of examining public policy to provide greater regulatory flexibility for workers with chronic illnesses. Employers are providing more workplace accommodation, but need guidance on how to turn good intentions into good practices. Advocacy organizations have advised on best practices and lobbied successfully for increased research funding, but have largely done this on an individual basis rather than working together to put chronic illness front and centre in the public consciousness. And, at least in Canada, government, business and advocacy groups have not banded together to examine new rules and processes that would ensure greater workplace fairness for the millions of Canadians living with chronic illnesses.

With better disability legislation, coordination among employers, government and non-profits, and comprehensive disability management in the workplace, Canadians with chronic conditions can lead healthier, more productive lives, for the benefit of them as individuals and for Canadian society as a whole.

END NOTES

[1] Treasury Board of Canada. 2011. Accommodation.

[2] Employment and Social Development Canada. 2017. Accessible Canada, p.10

[3][4] Government of Newfoundland and Labrador. 2017. Chronic Disease.

[5] Government of Canada, n.d. Managing for Wellness — Disability Management Handbook for Managers in the Federal Public Service.

[6] Prince, M. 2016. Policies and Practices in the Accommodation of Persons with Invisible Disabilities in Workplaces: A Review of Canadian and International Literature. Employment and Social Development Canada, Office for Disability Issues, p.7

[7] Bernhard, D. Niehaus, M., & Marfels, B. Changes in Managing Disability in the Workplace in Germany: Chances of Professionalization. pp.59–75 In Disability Management and Workplace Integration: International Findings. H. Harder (Ed.). 2016. Routledge.

[8] Shrey, D. 2011. Disability Management at the Workplace: Overview and Future Trends. International Labour Organization Encyclopedia.

[9] United Nations. n.d. Convention on the Rights of Persons with Disabilities and Optional Protocol. p.4

[10][11][12] Institute for Work & Health. What researchers mean by… primary, secondary and tertiary prevention.

[13] Centre for Chronic Disease Prevention. 2015. Improving Health Outcomes A Paradigm Shift: Strategic Plan 2016–2019. Ottawa: Public Health Agency of Canada, p.6

[14] Sun Life Financial. 2015. Chronic Disease in the Workplace: Focus on Prevention and Support, p.3, citing the Centre for Chronic Disease Prevention.

[15] Centre for Chronic Disease Prevention. 2015. Improving Health Outcomes A Paradigm Shift, p.6–7

[16] Public Health Agency of Canada. 2013. Preventing Chronic Disease Strategic Plan 2013–2016.

[17] Centre for Chronic Disease Prevention. 2015. Improving Health Outcomes A Paradigm Shift.

[18] Sun Life Financial. 2015. Chronic Disease in the Workplace: Focus on Prevention and Support, p.3, citing the Public Health Agency of Canada Strategic Plan

[19] The International Labour Organization defines decent work as “work that respects the fundamental rights of the human person as well as the rights of workers in terms of conditions of work safety and remuneration. It also provides an income allowing workers to support themselves and their families (…). These fundamental rights also include respect for the physical and mental integrity of the worker in the exercise of his/her employment.”

[20] Waddell, G. & Burton, A.K. 2006. Is Work Good For Your Health and Well-Being? United Kingdom Department of Work and Pensions.

[21][22] European Network for Workplace Health Promotion. 2012. Promoting healthy work for workers with chronic illness: A guide to good practice., p.3

[23] Conference Board of Canada. 2013. Absent workers cost the Canadian economy billions.

[24] Citrix. 2012. Workplace of the future: A global market research report.

[25] Public Health Agency of Canada. 2016. Chronic Disease and Injury Indicator Framework. Quick Stats, 2016 Edition.

[26] Sun Life Financial. 2015. Chronic Disease in the Workplace.

[27] Public Health Agency of Canada. 2016. Chronic Disease and Injury Indicator Framework. Quick Stats, 2016 Edition.

[27][28] Centre for Chronic Disease Prevention. 2015.

[29] World Health Organization. 1994. Global strategy on occupational health for all: The way to health at work.

[30] European Network for Workplace Health Promotion. 2012. Promoting healthy work for workers with chronic illness: A guide to good practice.

[31] Sun Life Financial. 2015. Chronic Disease in the Workplace.

[32] Waddell, G. & Burton, A.K. 2006. Is Work Good For Your Health and Well-Being? United Kingdom Department of Work and Pensions.

[33] The Arthritis Society of Canada. 2013. “Fit for Work” Study — Findings, challenges for the future and implications for action, p. 7

[34] Employment and Social Development Canada. 2017. Accessible Canada.

[35] Institute for Work & Health. What researchers mean by… primary, secondary and tertiary prevention.

[36] The World Health Organization (WHO) identifies several social and economic factors that shape health, called the social determinants of health. They include: income, employment, housing, food, social exclusion, social support, gender, race and disability. See: Wilkinson, R., Marmot, M. eds. (2003). The Social Determinants of Health: The Solid Facts (2nd ed.). World Health Organization.

[37] Interview Julie Kelndorfer, MS Society of Canada, August 15, 2017

[38] Furrie, A., Gewurtz, R., Porch, W., Crawford, C., Haan, M., & Stapleton, J. 2016. People with Episodic Disabilities in Canada: Who are they and what supports do they need to obtain and retain employment? Centre for Research on Work Disability Policy.

[39] Prince, M. 2016. Policies and Practices in the Accommodation of Persons with Invisible Disabilities in Workplaces.

[40] Furrie et al. 2016. People with Episodic Disabilities in Canada.

[41][42] Episodic Disabilities Network. What are episodic disabilities?

[43] Furrie et al. 2016. People with Episodic Disabilities in Canada.

[44][45] Prince, M. 2016. Policies and Practices in the Accommodation of Persons with Invisible Disabilities in Workplaces.

[46] Sun Life Financial. 2015. Chronic Disease in the Workplace.

[47] Employment and Social Development Canada. 2017. Accessible Canada.

[48] The Arthritis Community Research and Evaluation Unit. 2013. The Arthritis Society “Fit for Work” Study: Findings, Challenges, and Future Implications for Action.

[49] Sun Life Financial. 2015. Chronic Disease in the Workplace, p. 7

[50] Centre for Chronic Disease Prevention. 2015. Improving Health Outcomes A Paradigm Shift.

[51] Janet Yale, interview August 18, 2017

[52] Organisation for Economic Cooperation and Development. 2010. Sickness, Disability and Work: Breaking Barriers: Canada.

[53] Torjman, S., & Makhoul, A. 2016. Disability Supports and Employment Policy. Caledon Institute of Social Policy.

[54] Government of Canada. 2017. Canada Pension Plan Disability Benefit — Overview.

[55] Tompa, E., Buettgen, A., Mahood, Q., Padkapayeva, K., Posen, A., & Yazdani, A. 2015. Evidence Synthesis of Workplace Accommodation Policies and Practices for Persons with Visible Disabilities. Employment and Social Development Canada Office for Disability Issues.

[56][57] Furrie et al. 2016. People with Episodic Disabilities in Canada, p.5

[58] Government of Canada, 2017b. Eligibility criteria for the disability tax credit.

[59] A “severe” disability is defined as a disability that regularly stops a person from doing any type of substantially gainful work. “Prolonged” means a disability is long term and of indefinite duration or is likely to result in death

[60][61][62][63] Furrie et al. 2016. People with Episodic Disabilities in Canada.

[64] Meredith, T., & Chia, C. 2015. Leaving Some Behind: What Happens When Workers Get Sick. Toronto: Institute for Research on Public Policy.

[65] Alberta Health Services. 2015. Workplace Health Improvement Pilot Project: Follow-up Evaluation Report.

[66] European Network for Workplace Health Promotion. 2012. Promoting healthy work for workers with chronic illness: A guide to good practice.

[67] Furrie et al. 2016. People with Episodic Disabilities in Canada, p.4

[68][69] Meredith, T., & Chia, C. 2015. Leaving Some Behind.

[70] The Arthritis Community Research and Evaluation Unit. 2013. The Arthritis Society “Fit for Work” Study.

[71] European Network for Workplace Health Promotion. 2012. Promoting healthy work for workers with chronic illness: A guide to good practice.

[72] Furrie et al. 2016. People with Episodic Disabilities in Canada.

[73] Prince, M. 2016. Policies and Practices in the Accommodation of Persons with Invisible Disabilities in Workplaces.

[74] Tompa, E., Buettgen, A., Mahood, Q., Padkapayeva, K., Posen, A., & Yazdani, A. 2015. Evidence Synthesis of Workplace Accommodation Policies and Practices.

[75] Torjman, S., & Makhoul, A. 2016. Disability Supports and Employment Policy. Caledon Institute of Social Policy.

[76] Waddell, G. & Burton, A.K. 2006. Is Work Good For Your Health and Well-Being? United Kingdom Department of Work and Pensions.

[77] Prince, M. 2016. Policies and Practices in the Accommodation of Persons with Invisible Disabilities in Workplaces.

[78] Torjman, S., & Makhoul, A. 2016. Disability Supports and Employment Policy. Caledon Institute of Social Policy.

[79] Sun Life Financial. 2015. Chronic Disease in the Workplace.

[80] Interview with Dr. Monique Gignac, August 24, 2017

[81] Prince, M. 2016. Policies and Practices in the Accommodation of Persons with Invisible Disabilities in Workplaces.

[82] Tompa, E. et al. 2015. Evidence Synthesis of Workplace Accommodation Policies and Practices.

[83] Astles, P., Dinh, T., & Turpin, K., 2016. Supporting Successful Employment Experiences. Ottawa: The Conference Board of Canada.

[84] European Network for Workplace Health Promotion. 2012. Promoting healthy work for workers with chronic illness: A guide to good practice.

[85] Meredith, T., & Chia, C. 2015. Leaving Some Behind.

[86] Astles, P., Dinh, T. & Turpin, K., 2016. Multiple Sclerosis in the Workplace.

[87][88] European Network for Workplace Health Promotion. 2012. Promoting healthy work for workers with chronic illness: A guide to good practice.

[89] Astles, P., Dinh, T. & Turpin, K., 2016. Multiple Sclerosis in the Workplace.

[90] Prince, M. 2016. Policies and Practices in the Accommodation of Persons with Invisible Disabilities in Workplaces.

[91][92] European Network for Workplace Health Promotion. 2012. Promoting healthy work for workers with chronic illness: A guide to good practice.

[93] Astles, P., Dinh, T. & Turpin, K., 2016. Multiple Sclerosis in the Workplace.

[94] Prince, M. 2016. Policies and Practices in the Accommodation of Persons with Invisible Disabilities in Workplaces.

[95][96] European Network for Workplace Health Promotion. 2012. Promoting healthy work for workers with chronic illness: A guide to good practice.

[97] Astles, P., Dinh, T. & Turpin, K., 2016. Multiple Sclerosis in the Workplace.

[98] Prince, M. 2016. Policies and Practices in the Accommodation of Persons with Invisible Disabilities in Workplaces.

[99] Tompa, E. et al. 2015. Evidence Synthesis of Workplace Accommodation Policies and Practices.

[100] Government of British Columbia. 2017b. Designation Application.

[101] Torjman, S., & Makhoul, A. 2016. Disability Supports and Employment Policy. Caledon Institute of Social Policy.

[102] Government of New Brunswick. 2017. New Brunswick’s Employment Action Plan for Persons with a Disability: Progress Report.

[103] Bernhard, D. Niehaus, M., & Marfels, B. Changes in Managing Disability in the Workplace in Germany.

[104] Interview with Wolfgang Zimmermann, July 31, 2017.

[105] Employment and Social Development Canada. 2017. Accessible Canada.

[106] A European conference (Brussels, 22–23 October) on “Workplace Health Practices for Employees with Chronic Illness” concluded the Europe-wide campaign. Both conference and campaign are co-funded by the Health Programme of the European Commission.

[107] European Network for Workplace Health Promotion. 2013c. The Brussels Declaration on Workplace Health Practices for Employees with Chronic Illness.

[108][109] Furrie et al. 2016. People with Episodic Disabilities in Canada.

[110][111] Sun Life Financial. 2015. Chronic Disease in the Workplace.