Work hardening programs refer to physical conditioning programs for injured workers who are out of work, or who are working at less than full capacity. Work hardening is a highly specialized rehabilitation program that transitions the patient from standard rehabilitation to return to work by simulating workplace activities and surroundings in a monitored environment. A wide range of programs conducted by a number of different health disciplines have been reported in the professional and scientific literature. In general, work hardening programs include a systematic program of gradually progressive, work-related activities performed with proper body mechanics, with the goal of physically and psychologically reconditioning the patient in order to facilitate return to full employment.

Cognitive Work Hardening for Return-to-Work Following Depression

Wisenthal (2021) noted that the growing number of mental health disability claims and related work absences are associated with a magnitude of human, economic and social costs with profound impact on the workplace. In particular, absences due to depression are prevalent and escalating. There is a need for treatments that address the unique challenges of individuals returning-to-work following an episode of depression. Occupational functioning often lags depression symptom improvement that necessitates targeted treatment. Cognitive work hardening (CWH) is a multi-element, work-oriented intervention with empirical research supporting its role in return-to-work following a depressive episode. In a case report, these researchers described the use of CWH to prepare an individual to return to work following a disability leave due to depression. It showed how CWH bridges the functional gap between being home on disability and returning to competitive employment. The patient presented was a 50-year-old divorced woman who had been off work for approximately 2 years for depression precipitated by the terminal illness of her mother. She participated in a 4-week CWH program that addressed fatigue and decreased stamina, reduced cognitive abilities, outdated computer skills, and heightened anxiety. Work simulations enabled the rebuilding of cognitive abilities with concomitant work stamina; task mastery bolstered self-confidence and feelings of self-efficacy; and coping skill development addressed the need for stress management and assertive communication strategies. By program completion, the patient's self-reported work ability had increased and both fatigue and depression symptom severity had decreased. Clinical markers of work performance indicated that the patient was ready to return to her pre-disability job. Three months after completion of CWH, the patient reported that she was at work, doing well and working full days with good stamina and concentration. The authors concluded that this study provided insight into how CWH could be used to return-to-work preparation following depression with positive outcomes.

The authors stated that as is often the case with single-case studies, limitations of this report included the lack of generalizability, inability to show cause and effect, and the danger of over interpretation of a single case. That said, the case report is a strong vehicle to present the novel (CWH) approach, offer a valuable in-depth lens into CWH, and complement the empirical research. With respect to the intervention itself, incorporating targeted standardized cognitive tests may be a useful complement to the current measures and tools already in place. These researchers stated that future studies on other CWH interventions would enhance the understanding of this intervention and further establish its role in RTW; moreover, longer follow up is needed to determine the more long-term effects of CWH.

Scope of Policy

This Clinical Policy Bulletin addresses work hardening programs.

Policy Limitations and Exclusions

Aetna does not cover back school for occupational purposes and other return to work/reintegration or vocational programs including work hardening programs as they are considered vocational training, and not treatment of illness or injury.

Aetna medical benefit plans provide coverage only for treatment of illness or injury. Please check benefit plan descriptions for details.