Vocational rehabilitation in Finland

Introduction

Rehabilitation of disabled persons and persons with impaired functional capacity is pro- vided in Finland by a wide range of sectors such as workplaces/occupational health care, public health care, the Social Insurance Institution, earnings-related employment pension scheme, accident and traffic insurance, and labour administration [1, 2].

Cooperation between these systems on both local and national levels is strengthened by a separate piece of legislation on cooperation between rehabilitation legislation.

Workplaces/occupational health care

In the case of employed persons, the workplace is in a key position in the assessment of rehabilitation needs. The occupational health care system is often the first to see the employees in need of rehabilitation. The need is detected in conjunction with occupa- tional health care services, such as workplace surveys, health examinations and absen- teeism follow-ups. Surveys can also be initiated by occupational safety delegates, col- leagues or superiors who see that an employee is finding it increasingly difficult to per- form his duties.

The duty of occupational health care is to monitor the work performance of an employee who has become disabled on account of illness or some other impairment and, if necessary, to refer him/her for treatment or rehabilitation. That way the occupational health care sector can identify rehabilitation needs at an early phase.

Public health care

Early rehabilitation needs may be identified by child welfare counselling clinics or by

school health care staffs. Guidance is provided for pupils in respect of diseases or other

H. Alaranta

impairments restricting their performance. Secondary schools provide counselling to create the necessary capabilities required by the pupils´ individual study programmes or career plans. Schools and the public health care system work together to design educa- tion, training and rehabilitation plans for individual pupils. Student health care then revises these plans or designs new study and rehabilitation plans together with the stu- dent counsellors and teachers at the educational institution in question.

There are rehabilitation teams at health care centres whose main concern are the chronically sick and those suffering from sequelae of serious diseases or impairments.

Customers requesting occupational rehabilitation surveys are referred to the vocational guidance services provided by employment offices. The process may also be initiated by drawing up a statement concerning vocational rehabilitation needs for the Social Insurance Institution or an insurance institution.

Social Insurance Institution

The duty of the Social Insurance Institution (SII) is to chart a person´s vocational reha- bilitation needs and prospects. This must take place at the latest when a daily allowance has been paid for 60 days under the Sickness Insurance Act. The SII also assesses rehabi- litations needs in conjunction with other social insurance benefits, such as reimburse- ment for medicine costs, disability allowance and unemployment benefits. The initiative can be taken by the person him/herself or cooperation parties such as public health care, social welfare or labour administration authorities. The need for a survey is assessed case by case by each local office of the SII.

In order to identify vocational rehabilitation needs and prospects, the SII arranges for rehabilitation examinations and work and training tryouts to be carried out by rehabili- tation examination institutions and occupational clinics. A rehabilitation need assess- ment is an expert evaluation of rehabilitation prospects and of any need for more exten- sive examination.

The SII carries the cost of examinations, and the person´s subsistence is safeguarded with a rehabilitation allowance during the examination period.

Earnings-related employment pension scheme

Rehabilitation provided under the employment pension scheme is discretionary for all:

the private sector, local authorities and the State. Therefore, the rehabilitation process is always based on the discretion of the pension institution in question.

In the employment pension scheme, vocational rehabilitation needs are identified in

conjunction with pension applications or on the basis of an initiative taken by either the

person involved or an outside party. When a person applies for a pension, it is usually

fairly late with a view to starting a rehabilitation process, since the employee´s health and

weak motivation set restrictions at this stage.

To get the rehabilitation process starting sufficiently early, the employee him/herself should ensure that the rehabilitation need is identified as soon as he/she finds that work performance is endangered by health problems. The need for rehabilitation can also be determined at the workplace, as was pointed out in the section on occupational health care.

Rehabilitation under the employment pension can begin when an employee´s health undergoes a long-term or permanent change weakening his/her work performance. The rehabilitation need can be assessed as soon as symptoms suggesting diminished work performance are detected. Not only health but also, factors such as burnout, stress, aging and “pension risk” must all be taken into account. If full identification of vocational rehabilitation needs and opportunities calls for a more detailed survey, a separate reha- bilitation examination or a work or training try out period can be arranged by either the employment pension institutions or The Insurance Rehabilitation Association in conjunction with the rehabilitation process.

The employment pension institution in question carries the cost of the measures taken and sees to the customer´s subsistence security in the form of a rehabilitation allo- wance.

Accident and traffic insurance

Rehabilitation is provided on the basis of accident or traffic insurance when the need for rehabilitation is caused by an occupational accident entitling compensation, an occupa- tional disease or traffic accident. Such rehabilitation is based on the principle of com- pensation and overrides other rehabilitation systems. As long as the terms laid down in the legislation on rehabilitation based on accident or traffic insurance are met, an injured patient has subjective right to rehabilitation.

If an impairment entitling a person to compensation causes long-term restriction on that person´s working capacity and opportunities for earning his living, the insurance institution is obliged to take immediate action on its own initiative to start the vocatio- nal rehabilitation process and to see to rehabilitation need surveys and the referral for rehabilitation. In assessing the need for a rehabilitation survey, attention must be paid to the nature of the impairment or disease, the restrictions it sets on working capacity and functional ability, loss of earnings, duration or threat of invalidity and handicap, as well as the age of the person concerned.

The initiative to start a vocational rehabilitation process can also be taken by the

injured person, his/her employer, a health care unit, a manpower authority or some other

party involved in evaluating the rehabilitation situation. The suggestion to start voca-

tional rehabilitation is normally sent by the insurance institution to The Insurance

Rehabilitation Association, which plans and implements rehabilitation programmes

(Fig. 1). Insurance institutions must consider setting the assessment process in motion at

the latest when the incapacity for work has lasted 120 days.

Where the identification of vocational rehabilitation needs and opportunities calls for more detailed surveys, separate rehabilitation examinations or work or training try out periods can be arranged by The Insurance Rehabilitation Association, with the insu- rance institutions carrying the cost of the measures and safeguarding the customer´s sub- sistence security in the form of a full-scale loss-of-earnings allowance.

Labour administration

Within the framework of the labour administration, either the customer or an involved official can take the initiative in identifying the rehabilitation need. The necessity to iden- tify rehabilitation needs may emerge in connection with any type of employment ser- vices: the job placement service, vocational guidance, labour market training for adults and vocational information service and vocational rehabilitation services.

Vocational guidance has a central role. Its purpose is to use the interactive relation- ship between the customer and vocational guidance psychologist to help the individual customer to begin systematic, vocational planning and to carry out it. A person may need vocational guidance at any phase of his/her life, but in particular on completing his/her education and training, or when disease or some other impairment changes his/her life situation. The vocational guidance provided for disabled pupils takes place in close cooperation with the school´s health care staff and student counsellor.

Planning and implementation of a vocational rehabilitation programme

rehabilitation measures

”Sufficient recompense for the loss”

Loss of job or profession?

CRITERIA:

Health, limitations by the injury or disease Earlier work experience Education

Age

Employment prospects Annual earnings Living conditions

Workplace programme

Work trial / job coaching

Arrangements at the workplace Acquisition of the necessary aids or protective devices Business support

Vocational education

”Necessary and sufficient education”

Preparatory or remedial education Secondary-level vocational education Polytechnic education University studies

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Fig. 1 – The Insurance Rehabilitation Association.

Rehabilitation staff training

The rehabilitation staff consists of employees with a wide range of basic education, in the course of which each specializes in a certain sector of vocational rehabilitation or employment. The basic education must guarantee sufficient information on various forms of disability and their restrictive effects, as well as the support services available.

Further training will be required as the service systems are elaborated.

The central principles in rehabilitation are cooperation and customer-orientation.

Acquiring skills for these calls for work experience and cross-sectoral complementary training closely linked with the work in question. Cooperation means that the rehabili- tation staff work with the customer to evaluate the situation, set mutually approved goals and take decisions together.

Complementary education should pay particular attention to the following skills:

– communication with the customer and other employees;

– the ability to solve problems in one´s own work and team;

– mastery of the group process and various teamwork models;

– interprofessional cooperation and negotiation skills;

– creation of a favourable and encouraging atmosphere;

– self-evaluation.

The need to include customers on equal terms in multiprofessional teams calls not only for cognitive training and skills on the part of professions but also for attitude trai- ning. Their training must therefore comprise long periods devoted to improving skills in which training events and independent study alternate.

It is particularly important to be able to understand the way other professions repre- sented on work teams think and speak. Customer-oriented approaches require staff to see the customer´s entire life situation through his eyes. Training must provide the means to do this. Complementary training must further provide the skills required for working in multiprofessional teams and for genuinely customer-oriented work.

Complementary training has been provided by various organisations providing reha- bilitation services and by universities and their further education centres. Training has enhanced the professional skills required in rehabilitation and clarified the theoretical foundation and framework of values involved.

Customer-oriented cooperation

Cooperation is often required between various authorities and rehabilitation parties in

devising and implementing an individual rehabilitation programme. The legislation on

rehabilitation creates the framework for local, regional and national cooperation. The

cooperation organs of local authorities and of various rehabilitation organisations dis-

cuss principles related to the division of labour and cooperation and try to solve the pro-

blems of individual rehabilitation customers.

The most important form of cooperation in the view of the person undergoing reha- bilitation and his/her entire rehabilitation process, however, takes place outside official teams in the normal interaction that all the rehabilitation workers experience in their daily work. The development of those cooperation and better customer-orientation call for new work models. In situations where the customer´s problems require simultaneous measures by a number of service systems, cross-sectoral cooperation networks should be established case by case, to establish a better tailored approach. This requires adoption of a new work culture in many organisations, since their basic purpose does not necessarily encourage cross-administrative action. The threshold to active participation in decisions concerning one´s own life should be as low as possible. The lower the threshold, the bet- ter the chances that the rehabilitation programme will succeed. Efficient customer-orien- ted cooperation requires clear rules of the game between the rehabilitation experts and commitment to the solutions agreed on.

Report on rehabilitation of the Council of State to the parliament

In the year of 2002 the Council of State handed in a report on rehabilitation to the parliament. Maintaining working capacity has been an important aim for rehabilitation policy. As employment pension legislation is revised the importance of the occupatio- nally-oriented rehabilitation is emphasised. The occupationally-oriented rehabilitation of handicapped and disabled persons has been taken into account through improve- ments in the rights to rehabilitation allowance and work activity that support employ- ment and by eliminating social security regulations that prevent employment.

Future challenges are to be found in maintaining the working capacity of the ageing workforce, maintaining the functional capacity of the older population, beginning reha- bilitation at an early enough state, developing a multi-professional working group and in increased research on the effect of rehabilitation [3].

Today and tomorrow: Healthy at Work project

Healthy at Work is an extensive cooperation project, the objective of which is to promote such activities in the Finnish society that support employees to continue in the labour market and their ability to cope with their work by means of training and information.

The project provides information about rehabilitation within the statutory earnings- related persons scheme, the rehabilitation reform within in 2004 as well as general infor- mation about the advantages of continuing in working life.

The project Healthy at Work supports widely accepted efforts to raise the average reti-

rement age by 2-3 years. A special object is also that the rehabilitation policies related to

the reform of the statutory earnings-related pensions are put into practice at the work-

places. This presupposes improving cooperation and intensifying the distribution of res- ponsibilities between the parties involved.

The project is backed by the Finnish Pension Alliance TELA and its members. Other central cooperation partners are the labour market organisations, the SII and the Finnish Institute of Occupational Health.

Rehabilitation within the statutory earnings related pension scheme

The rehabilitation which pension institutions in the statutory earnings-related pension schemes provide falls within the scope of vocational rehabilitation, and it applies to employees and self-employed persons who participate permanently in working life. The objective of the rehabilitation within the statutory earnings-related person scheme is that the insured person can remain in working life despite his or her illness.

Rehabilitation within the statutory earnings-related pension scheme is individual and discretionary. In practice, rehabilitation is based on the cooperation between the indivi- dual, the workplace, the occupational health care and the pension institution authorised to operate a statutory earnings-related pension scheme.

Rehabilitation legislation since the beginning of the year 2004

There have been changes in the vocational rehabilitation provided by the pension insti- tutions authorised to operate a statutory earning-related pension scheme and the SII at the beginning of 2004.

The reform approved by the Parliament emphasises the primary nature of the voca- tional rehabilitation in respect to the disability pension. The objective is to support star- ting vocational rehabilitation so early that disability can be prevented or at least postpo- ned.

With the reform, the insured person will receive the right to vocational rehabilitation – if they are duly found to be under the threat of losing their work capacity and to have to retire on a disability pension;

– if this threat can be reduced by means of vocational rehabilitation;

– if rehabilitation contributes to reducing pension expenditure.

In future, the insured person can appeal against the rehabilitation decision stating that there is a threat of incapacity for work and whether this threat can be reduced by means of vocational rehabilitation. The actual rehabilitation measures are discretionary also in future.

The definition of the threat on incapacity for work will be the same in all the diffe-

rent acts on the earnings-related pension as well as in the Act on Rehabilitation Services

according to which the SII provides rehabilitation. The rehabilitation allowance paid by

the SII will be on a level with that provided by the statutory earnings-related pension scheme for all income brackets.

The rehabilitation reform will also increase the flexibility and incentive effect of reha- bilitation within the statutory earnings-related pension scheme. According to the new provisions, the rehabilitated person will have the chance of drawing partial rehabilitation allowance.

Acknowledgement

The author is grateful to Rehabilitation Manager Juha Mikkola, Secretary General Heidi Paatero and Dr. Paavo Rissanen for sharing their valuable expertise in vocational rehabi- litation.

References

1. Bergeskog A (2001) Labour market policies, strategies and statistics for people with disabilities.

A cross-national comparison. IFAU - Office of Labour Market Policy Evaluation. Uppsala 2001:

13

2. Ministry of Social Affairs and Health (1997) From Disability to Ability. National programme of action for vocational rehabilitation and employment of disabled persons. Helsinki, Finland 1997: 5

3. Riipinen M, Hurri H, Alaranta H (1994) Evaluating the outcome of vocational rehabilitation.

Scand J Rehab Med 26: 103-12