Early intervention equals improved outcomes for all: The importance of nurse case management in catastrophic injury and illness claims

Last year (2019), in the state of Massachusetts, a little over 1,600 new workers compensation cases[i] were filed. A number representing a very small percentage of the Massachusetts employment rate which is estimated at over 3.7M individuals. Good job Massachusetts, you’re staying safer at work!

However, we must turn our attention to those who were in fact injured on the job, and more specifically, those catastrophically injured. Employers, Claims Adjusters, insurance companies and third-party administrators are equally devastated at the thought of an individual who’s suffered a catastrophic injury. As industry professionals familiar with catastrophic injury cases, you’re aware that these cases are challenging, emotional, and require a high level of expertise to appropriately manage. The individual’s life is forever impacted, and it’s your job to get them through some of the toughest obstacles on the road to their recovery.

So, what exactly is a catastrophic injury?

The formal definition of a catastrophic injury, as defined by the Commission for Case Manager Certification is “a serious injury that results in severe and long-term effects on the individual who sustains it, including permanent severe functional disability”[ii]. Examples include traumatic brain, spine, or spinal cord injury; multiple trauma; and loss of major body parts. They further define a catastrophic illness as “any medical condition or illness that has heightened medical, social, and financial consequences and responds positively to the control offered through a systematic effort of case management services.

According to the National Institute of General Medical Sciences, there are two main types of trauma first, blunt force trauma – when an object of force strikes the body, often causing concussion, deep cuts or broken bones. The second, a penetrating trauma – when an object pierces the skin or body, usually creating an open wound.

The legal definition of a catastrophic injury, per Title 42, of the U.S. Public Health and Welfare Code § 3796b is “an injury, the direct and proximate consequences of which permanently prevent an individual from performing any gainful work”[iii].

Combining the case management definition, the medical definition of a trauma, the legal definition of a catastrophic injury, and a general understanding of a catastrophe; within workers’ compensation, we define a catastrophic injury as an injury that causes loss or alteration of function that may result in an alteration of the patient’s present life and function permanently.

Varying levels of injury, severity, and corresponding care
Heinrich/Bird Safety Pyramid

Within all injuries, there are varying levels of severity and corresponding care. The Heinrich/Bird safety pyramid, or accident triangle, provides a visual which helps us understand the ratio between fatal occupational accidents, catastrophic or major accidents, accidents, injuries, and minor incidents[i]. For the purpose of this article, we use the accident triangle to provide visual demonstration, and neither fully support nor challenge the theories within the Heinrich/Bird Safety model. From the model, and Heinrich’s theory, catastrophic injuries will happen, and at a rate far less than those of minor injuries, or workplace incidents.

Catastrophic injuries are found in the highest points of the pyramid, and are usually categorized as a physical injury, a spinal cord injury, or a cognitive injury. A study conducted by Aon, of more than 400 companies, found that catastrophic injuries generally account for .5-1 percent of claim frequency yet 20-30 percent of total incurred cost[iv].

Catastrophic cases can be volatile due to the high degree of medical instability during the acute phase of the injury. To manage case volatility and improve outcomes for all, the case should be referred to a seasoned catastrophic nurse case manager immediately. A seasoned catastrophic nurse case manager will have extensive knowledge specific to the injury while also providing significant case insight regarding the diagnosis, treatment, medical complications and recovery trajectory[v].

The role of the worker’s compensation nurse case manager within the catastrophic injury care continuum

When a worker is catastrophically injured anticipate that the number of people and professionals involved in the individuals care and rehabilitation will be significant. Each person will have varying levels of information and understanding about what has happened, what’s going to happen, and how to best support the individual and family through stabilization and rehabilitation.

During the medical stabilization and rehabilitation process, the primary role of the workers’ compensation case manager is to provide ongoing evaluation while becoming the educator, master communicator and trusted advisor to the individual, their family, their employer, and the adjuster managing the case.

Evaluation

Nurse Case Managers utilize the Nursing Process to evaluate the entire person. With a catastrophically injured patient this is an ongoing process throughout the case management relationship and is critical in identifying new diagnoses and facilitating necessary changes to the individual’s care to improve outcomes.  The nursing process includes consistent assessment, diagnosis, outcome identification, planning, implementation and evaluation of the patient’s plan of care. Vital to this process is the nurse’s diagnosis, or clinical judgement concerning a human response to a health condition/life processes, or vulnerability for that response[vi]. Nurses diagnose health problems, risk states and readiness for health promotion.  Once diagnoses have been identified, then outcome identification planning and interventions can be determined.

Education

A critical responsibility of the catastrophic nurse case manager is providing education to the impacted individual, their family, their employer and the workers’ compensation claims adjuster. The likelihood that any of the parties involved, aside from the individual’s medical team, have had experience with the patient’s unique diagnosis is slim to none. What happened? How’s this going to impact the remainder of my life? Who’s available to help me? Why am I being prescribed this treatment? Why do I need to see this doctor? If the patient is not asking these questions, then the family will or should be.

In catastrophic injuries, improving health literacy also improves the patient’s self-efficacy. “One’s sense of self-efficacy plays a major role in how one approaches goals, tasks, and challenges regarding one’s health”.[vii] In a 1999 study ‘Injured Workers’ Perceptions of Case Management Services’, participants shared perceptions of their experience with nurse case managers. One participant shared:

“One of the things that helps a lot in these cases…is having somebody that’s educated and knows what your problems are more than you do or even your doctors, because you’re usually seeing specialist…Somebody has to put all this together”

In the catastrophic injury cases, education is also crucial in the management of the injury. The catastrophic nurse case manager serves as the liaison between the claim adjuster, treating physicians, rehabilitation specialist, patient and family, and others within the patient’s care continuum. Deepening knowledge reduces barriers and time, which improves patient access, and inevitably improves outcomes.

Communication

As an educator the communication role of the catastrophic nurse case manager may seem obvious yet, it’s important to understand the ‘when’ and ‘how’ information is provided has a significant impact on patient outcomes and the case in its entirety. The catastrophic nurse case manager must maintain a continuous communication feedback loop among all parties involved.[ix] Oftentimes there are multiple health care providers involved in treatment of an individual with multiple life-threatening injuries.  Continuous communication between providers can make a significant impact on preventing complications and facilitating timely resolution to health issues.  Once the individual is out of the acute care phase and in the healing and rehabilitation phase of their injury, prevention of complications is the focus of all treatment, as well as promotion of maximum independence which leads to maximum quality of life.

Compassion and Care (Trusted Advisor)

While the catastrophic nurse case manager may present in regular clothes, and much of their work is done outside of the Acute or Rehab hospital, they are still nurses with a duty of compassion. This approach is key to developing a trusting relationship.  In a study published by the Journal of Clinical Nursing, authors share “Compassion unites people in difficult times and is a foundation to building human relationships which can promote both physical and mental health.[x]  Effective interaction with individuals that are critically ill, and their families, in such a stressful time in their lives, is a special skill. There is a fine balance between education and support, and intrusion.  Early interaction with the individual and/or the family of the injured worker can assist in decreasing their anxiety regarding the situation and assist in developing a bond needed to establish a successful relationship.  This is key for long term case management, minimizing and preventing complications, and achieving optimal outcomes.

Case Study – The first steps to a long journey of recovery

A 50-year-old male communications technician high on a ladder, resting against a telephone pole, falls 25 feet to the ground.  He was sent to the closest trauma center via med-flight where his diagnoses included: Fractured left leg, head injury, C4-5 Acute Disc herniation resulting in Tetraplegia, Neurogenic shock. He had no sensation or motion from the shoulders down. This patient was alert…

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References:

[i] Office of Workers’ Compensation Programs (OWCP); EEOICP Program Statistics (Massachusetts)

[ii] Commission for Case Manager Certification: Glossary of Terms, www.ccmcertification.org

[iii] Findlaw:  – 42 U.S.C. § 3796b – U.S. Code – Unannotated Title 42. The Public Health and Welfare § 3796b.

[iv] Heinrich, H.W., Industrial Accident Prevention: A Scientific Approach (1941)

[v] International Risk Management Institute: Managing Volatility in Catastrophic and Medically Complex Cases

[vi] International Risk Management Institute: Managing Volatility in Catastrophic and Medically Complex Cases

[vii] NANDA-I, 2013

[viii] Patrick, Timothy E et al. “Improving health outcomes through patient education and partnerships with patients.” Proceedings (Baylor University. Medical Center) vol. 30,1 (2017): 112-113. doi:10.1080/08998280.2017.11929552

[ix] American Association of Occupational Health Nurses: Workers’ compensation: case management strategies, 1995 May;43(5):245-50.

[x] Bramley, Louise, and Milika Matiti. “How does it really feel to be in my shoes? Patients’ experiences of compassion within nursing care and their perceptions of developing compassionate nurses.” Journal of clinical nursing vol. 23,19-20 (2014): 2790-9. doi:10.1111/jocn.12537

Understanding and preparing an accurate Pediatric Life Care Plan

In 2018, nearly 3.8 million babies were born within the United States. Most of these infants started their lives with no issues at birth and began achieving typical developmental milestones, yet, there were those whose lives were forever impacted by a birth injury. In the United States, it is estimated that nearly 7 birth traumas occur per 1000 live births, with an incidence rate of approximately 1 in 9,714[i]. Nearly one half are potentially avoidable with proper recognition and anticipation of obstetric risk factors. [ii]

Birth injuries can range from minor, temporary, and self-healing to permanent, catastrophic, and having a lasting impact on the morbidity or mortality of the child. Birth injuries are typically divided into two categories, those resulting from hypoxia and ischemia (a lack of or shortage of oxygen) or injuries resulting from mechanical forces during the process of labor and delivery.[iii]

A birth injury likely to result in litigation is hypoxic-ischemic encephalopathy (HIE). HIE is the most common birth injury claim, generally alleging that intrapartum asphyxia led to long-term neurologic sequelae, including cerebral palsy and/or developmental delay.[iv]

Trying to understand the child’s life, determine what their day is like, how they perform in the school system, and how they interact with their families is a key component of evaluation and outlining resources, treatments, and supports needed for the child’s care continuum.

How will the injury impact life expectancy? What will their life look like after K-12 schooling? While schools are mandated to provide the appropriate environment and services needed to facilitate the child’s learning and development – this only continues until the child is twenty-two years old.  Planning and preparation of the child’s care and supports must be made well in advance and outline the child’s care once they are no longer in the school system. Proper planning must also align and support the family’s goals and decisions regarding their child.

In this issue of Insights, we share a sample of a Life Care Plan for a child diagnosed with Hypertonia and Global Development Delay. Hypertonia is a condition in which there is too much muscle tone so that arms or legs, for example, are stiff and difficult to move[v]. The long-term prognosis of a child diagnosed with Hypertonia is dependent on the severity and its cause. Global developmental delay is defined as a child having delays in two or more developmental milestones. At the time of the case, the child was seven years old and is expected to live into their eighties. Delays may include walking, talking, movement skills, and social-emotional development milestones and the delay is continued for at least six months[vi].  Understanding the long-term care and needs of the child requires a complete understanding of the child, the supports provided by family and rehabilitation professionals, and the care needed for the remainder of the child’s life.

When a Nurse Life Care Planner assesses the child, they are also assessing the family functions. Determining the families understanding of the injury, the child’s prognosis for recovery, family dynamics, and understanding the capacity and limits of the primary caregiver. Is the family bilingual? Who works outside of the home and how does that impact care? Is the family a larger extended family with grandparents living in the home, or is it a single parent managing one child or more?  It is also important to take into consideration the living environment when determining the needs of the child.

Pediatric Life Care Plan

Treatment is treatment, whether in a little body or a big body, what’s key is understanding the long-term effects of the diagnosis and treatment on the child’s life. Going to school and being included in the day to day routines and activities of being a child, a son, or a daughter, are important to consider for maximum quality of life.  Reconstructing a day-in-the-life experience is very important in cases with children.

Understanding and planning for the long-term needs of a child who’s experienced a significant birth injury with lasting implications require a deep understanding of their diagnosis, the unique factors surrounding their care, and expertise in the long-term prognosis.

Wondering what you could expect in a Pediatric Life Care Plan? Access the Pediatric Life Care Plan snapshot below. Please keep in mind that the snapshot you access is only a small portion of an actual Life Care Plan.

If you’re an attorney or legal professional managing a birth injury case or any case involving a child, be sure you’re working with a team of professionals who have experience and expertise in the diagnosis, prognosis, and the aligning care needs.

References:

[i] Right Diagnosis from Healthgrades: Statistics about Birth Injury

[ii] Medscape: Birth Traumas

[iii] Clinic in Perinatology: Management of Birth Injuries

[iv] Seminars in Fetal and Neonatal Medicine: Medico-legal implications of hypoxic-ischemic birth injury: https://doi.org/10.1016/j.siny.2014.08.005

[v] National Institute of Neurological Disorders and Stroke: Hypertonia Information Page

[vi] Cerebral Palsy Alliance: Global Development Delay

3 Things attorneys may not know about Medicare Set-Aside allocations

Cynthia Bourbeau, RN, CRRN, CCM, CNLCP®
Founder & President – Medical and Life Care Consulting Services, Inc.

The Centers for Medicare Services defines Medicare Set-Aside (MSA) allocations as financial agreements that allocate a portion of a workers’ compensation, medical malpractice or personal liability settlement to pay for future medical services related to the injury, illness or disease. These funds must be depleted before Medicare will pay for related treatment.

We work with attorneys to evaluate a person’s future medical needs and recommend an amount that should be set aside for future medical care. Once the government approves this amount, the administrator of the MSA fund uses the funds to pay for medical care related to the plaintiff’s injury. For example, if there is a settlement case for $6 million, and $2 million of that was approved for medical and care costs, that amount is put aside for future medical costs.

1. Medicare Set-Aside allocations not required in all states…yet

Medicare requires Medicare Set-Aside allocations in many states. The conditions under which an MSA is required vary by state, and attorneys need to be prepared. While an MSA is not required in all states, the federal government requires that Medicare’s interests are considered in all settlements for those people who are Medicare beneficiaries or likely to become a beneficiary in next 30 months.

MSAs have been used for years in workers’ compensation cases, and the government has extensive reporting and monitoring rules in place. MSA law is complicated and constantly changing, reinforcing the need for an experienced life care planner.

2. Who is responsible to ensure an MSA is completed?

When MSA allocations are mandated, it is the attorney who is responsible to ensure one is completed and the money is put aside. Medicare can collect against insurance carriers, the client, their legal counsel and their advisors—any counsel involved in a settlement—because of workers’ compensation, liability or no-fault settlements when the financial interests of Medicare are not protected with an MSA.

3. We will improve your MSA claims, settlement outcomes and trust arrangements

Our life care plans present concise standards of practice, data analysis, research, clear chronologies and evidence-based plans for current and future costs to maximize wellness throughout the patient’s lifetime.

We work with attorneys across the country to develop life care plans and MSAs, complete the Medicare paperwork, and make the necessary notifications. We offer best practices with a clinical approach for formulating MSA allocations to remain compliant with Medicare.

If you are an attorney specializing in medical malpractice, workers’ compensation or liability claims, contact us today to learn how we can help you plan for your client’s future.

Back to life, back to work: highlighting an invaluable profession during National Case Management Week

National-Case-Management

In the face of serious illness or injury, the idea of ever reclaiming a productive life can feel impossible. Fortunately, there is a set of compassionate professionals whose very role is to help turn that idea around—and make it a healthy and attainable goal.

It’s National Case Management Week (October 7–13), a time to join organizations everywhere in recognizing medical case managers and their invaluable impact. Here at Medical and Life Care Consulting (MLCC), we’ve made “back to life, back to work” a motto of sorts, as helping individuals return to optimal, active living is what we do every day.

“When the unexpected happens, it can be devastating and hard to see the light at the end of the tunnel,” said our president, Cynthia Bourbeau, who founded MLCC in 2001. “Our job is to work with patients, families, health-care providers and employers to develop a plan to reach that brighter place. Our case management professionals bring extensive training, expertise and sensitivity to every situation we encounter. Together, we lay out the smoothest path possible, in terms of the patient’s physical, emotional and social well-being, as well as financial and logistical considerations.”

Because research has shown that patients who stay active recover from their injuries more quickly and with fewer complications, we offer innovative stay-in-work programming as a component of our comprehensive employment-centered services. This allows for job modifications or light-duty job specifications for an individual when possible and indicated.

“We work with patients’ employers to develop customized plans,” Bourbeau said. “When individuals can stay on the job while still protecting their health and safety, it’s often the ideal scenario.”

Beyond our services within the employment realm, which also include workers’ compensation, short-term disability and long-term disability case management, our professionals provide major medical case management services within the community. In these cases, we work directly with patients and families as they navigate the challenges of catastrophic illness or injury, delivering services at a patient’s home or during acute hospitalization.

MLCC is proud of the role that we—and our fellow medical case managers nationwide—play in keeping individuals “in the game.” Learn more about our services, staff and story today. When the goal is getting back to life and work, we’re ready for the job.

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