Worker`s Compensation Case Management

advertisement
Running Head: WORKER’S COMPENSATION CASE MANAGEMENT
1
Worker’s Compensation Case Management: Case Manager’s Responsibilities While Managing
Workers with Work-related Injuries to Successfully Return to Work
Nadzeya Lazarev, RN, ASN
Case Management
Professor Emma Kontzamanis
November 28, 2012
WORKER’S COMPENSATION CASE MANAGEMENT
2
Worker’s Compensation Case Management: Case Manager’s Responsibilities While Managing
Workers with Work-related Injuries to Successfully Return to Work
Concept: A case manager’s job responsibilities
A case manager’s job responsibilities are extensive and continue to evolve because of
incessant changes in the healthcare system. The responsibilities are not seen as “a set of distinct
job actions; rather… a tapestry of many aspects of life woven together” (Powell & Tahan, 2010,
p. 41). A case manager’s responsibilities are so complex that no national standard exists for
them. Based on scientific evidence, experiences, and opinions of case management experts, the
Case Management Society of America defines all possible case managers’ job responsibilities;
however, not all the responsibilities may be relevant to one’s clinical area of case management
practice. At the same time, some of the responsibilities are incorporated in every form of case
management. These primary responsibilities are classified into five broad categories: clinical
care management, management and leadership, financial and resource management, information
management, and professional responsibilities (Powell & Tahan, 2010).
In the healthcare environment, wherein costs are skyrocketing, the reimbursement
process is undergoing many changes, and human resources are limited, a case manager still has
the most essential responsibility to act in patients’ best interests. Patients – not insurance payers,
nor other providers of care, nor institutions – are at the center of case management practice. A
case manager is obligated to maximize patients’ opportunities for available services and for
optimal desired outcomes. While being a patient advocate, a case manager communicates,
collaborates, and, if necessary, negotiates with other healthcare providers and insurance
companies regarding optimal services and scarce resources.
WORKER’S COMPENSATION CASE MANAGEMENT
3
It is necessary to carefully study a case manager’s job responsibilities, consider what
responsibilities are required for a specific care setting, and be clear about the responsibilities
since the responsibilities which are stated unclearly and misunderstood may interfere with
accomplishing case management goals. In turn, unmet case management goals may lead to
inadequately met desired outcomes, including poor quality of care and poor allocation of
healthcare resources (Powell & Tahan, 2010).
Cultural Competence
A case manager’s responsibilities are modified based on the client population served and
its needs, the context of the care setting, the reimbursement method applied, and the case
management perspective. The workers with work-related injuries who want to successfully
return to work have their own unique healthcare needs. To address these workers’ needs, the case
manager takes on the responsibility of looking at the workers’ compensation cases with a whole
person approach. With a broader perspective in the whole person approach, the case manager not
only assists the workers with physical restoration of health but also provides them with access to
the financial, social, and emotional services required for leading healthier lives (Langstaff,
2011).
For the case manager in a workers’ compensation practice setting, the primary ethical
responsibility is to advocate for the injured workers receiving services and as well for their
families. The case manager balances the needs of the clients and the constraints of a statemandated benefit system. While meeting what the clients wants, the case manager may come
into conflict with the workers’ compensation insurance carriers since the carriers do not allow or
are not responsible for certain services. Moreover, the situation even worsens when there is a cap
imposed by the workers’ compensation statute (Carter, 2011).
WORKER’S COMPENSATION CASE MANAGEMENT
4
In the following example, the case manager is an advocate for an employee John who
breaks his ankle at work and requires surgery. Nonetheless, the complexity of his treatment and
prognosis for recovery is impacted by preexisting medical conditions including obesity, diabetes,
and cardiovascular disease. In this case, the case manager finds out what is covered and not
covered by the workers’ compensation carrier, and what other benefits the employee may be
entitled to. The case manager explores all available resources, and communicates and educates
all stakeholders thoroughly about the options available. The case manager explains to all parties
involved the benefit to the employee -- as regards successfully returning to work -- of both
having surgery and at the same time managing other health conditions. “Advocating for the
injured worker in this setting means clarifying what services can be obtained through workers’
compensation and which services require other resources, and then working with the injured
worker to make informed choices regarding his or her care” (Carter, 2011, p. 95).
Being a manager and leader in workers’ compensation cases, the case manager takes the
responsibility to facilitate consistent communication and collaboration among all healthcare team
members, employers, insurance adjusters, and injured workers. To achieve a successful return to
work, the case manager assures that all members of the team understand one another’s roles and
responsibilities in the process of the return and are aware of how they can help and assist one
another. For instance, when the injured worker is not compliant with the physical therapy, the
physical therapist should, upon previous counsel from the case manager, immediately notify the
case manager so that he/she may work directly with the worker to explore and address his/her
concerns. The case manager also reminds the worker that nonparticipation and noncompliance
can affect his/her compensation benefits (Watson, 2011). Furthermore, the case manager keeps
all lines of communication open and mutual regarding current rehabilitation goals and provides
WORKER’S COMPENSATION CASE MANAGEMENT
5
frequent updates of any changes on the file to all involved parties. The case manager does not
hide the information about expected disabilities from either employers or employees. It is
imperative to relay such data to employers and to involve their human resources departments in
reviewing return-to-work options and exploring possible positions that can accommodate
workers' abilities (Ferris, 2007).
Before determining a possibility of a return to work at an old, modified or new job, the
case manager assumes the responsibility for clarifying medical restrictions and physical abilities
of the injured workers and then making sure all parties, including physicians, employees and
employers, understand. The case manager communicates and collaborates with all parties
involved to provide as safe and quick as possible a return to work from an initial transition stage
to actual employment. During this process, the development of a transitional employment
program is one of the case manager’s primary responsibilities because the well-designed
program promotes both physical and psychological recovery of the workers and the timely return
to productive employment. The case manager communicates to the injured workers that they are
valuable to their employers and the transitional employment program should not be seen as
threatening to the employees (Strickland, 2011).
Prior to initiating the transitional employment program, the case manager contacts
employers, obtains a written job description, and completes a job analysis that can be helpful for
physicians in understanding work environment and specific job duties and requirements, so
physicians may more clearly set ranges for certain physical job aspects. The case manager
identifies potential and actual problems before the program of return-to-work is started, during
the implementation of the program, and after the realization of the program. Hence follows
another of the case manager’s responsibilities – problem resolution. For instance, during the
WORKER’S COMPENSATION CASE MANAGEMENT
6
transitional employment program, if the employee reports a problem in accomplishing assigned
actions, the case manager assesses the problem, contacts a physician and employer, and
determines with them if it is necessary to postpone the program until additional medical
treatment is provided (Strickland, 2011).
Case Management
Successful return to work is a complex outcome for case management. When all
responsibilities of the case manager in workers’ compensation setting have been clearly defined
and consequently carried out, case management facilitates safe, timely, and successful return to
work for the workers with work-related injuries. Successfully returning the workers to their
employers is a win-win strategy for all involved parties:
…the employer who reduces lost time days and regains a skilled employee; the claims
rep who moves closer to file closure; the physician who sees restored productivity from
his or her treatment; and the injured worker who returns to a job in familiar surroundings
and, in most cases, retains seniority and a salary level he or she has worked to attain.
(Strickland, 2011, p. 43)
When the case manager utilizes a multifaceted approach, intervenes early in the course,
manages the process proactively, and supports injured workers, all stakeholders benefit in the
return process. An effective case management leads to substantial financial gains to employers
and insurance companies since employers and insurance companies have significant reduction in
the number of days of compensation and the overall costs associated with workers’
compensation claims (Iles, Wyatt, & Pransky, 2012).
An effective case management also causes considerable physical, psychosocial,
emotional, and financial gains to employees. When the case manager assumes the designated job
WORKER’S COMPENSATION CASE MANAGEMENT
7
responsibilities of assessing, planning, implementing, coordinating, communicating, monitoring,
and evaluating options and services available to the injured employees, he/she will be able to
meet their health needs (Lai & Chan, 2007). The case manager who involves the employees in
the planning at an early stage and accommodates suitable employment for them will more likely
achieve optimal return-to-work outcomes (Schultz, Stowell, Feuerstein, & Gatchel, 2007).
There is no doubt that when the case manager fulfills the job responsibilities of returning
the injured workers to work, he/she helps control costs as well as improves outcomes for both
employers and employees.
WORKER’S COMPENSATION CASE MANAGEMENT
8
References
Carter, J. (2011). Workers’ compensation case management: Being an advocate amid
complexity. Professional Case Management, 16(2), 95-97.
Ferris, K.A. (2007). Communication is the key to a successful return to work. Professional Case
Management, 12(2), 116-117.
Iles, R.A., Wyatt, M., & Pransky, G. (2012). Multi-faceted case management: Reducing
compensation costs of musculoskeletal work injuries in Australia. Journal of
Occupational Rehabilitation, 22, 478-488. doi:10.1007/s10926-012-9364-2
Lai, H.S., & Chan, C.C.H. (2007). Implementing a pilot work injury management program in
Hong Kong. Journal of Occupational Rehabilitation, 17, 712-726. doi:10.1007/s10926007-9110-3
Langstaff, M.A. (2011). Case managers take “whole person” approach to workers’ compensation
cases. Professional Case Management, 16(5), 267-269.
doi:10.1097/NCM.0b013e318225d47e
Powell, S. K., & Tahan, H.A. (2010). Case management: A practical guide for education and
practice. Philadelphia, PA: Wolters Kluwer/ Lippincott Williams & Wilkins.
Schultz, I.Z., Stowell, A.W., Feuerstein, M., & Gatchel, R.J. (2007). Models of return to work
for musculoskeletal disorders. Journal of Occupational Rehabilitation, 17, 327-352.
doi:10.1007/s10926-007-9071-6
Strickland, T. (2011). Workers’ vs. worker’s. Professional Case Management, 16(1), 43-45.
Watson, E.M. (2011). Vocational case managers and therapists working together. Professional
Case Management, 16(1), 45-47.
Download