case management during coronavirus

Caring in the midst of a crisis: Re-examining workers’ compensation case management during COVID-19

In the wake of COVID-19 healthcare professionals worldwide are experiencing drastic changes in how they work and care for their patients – changes which not only impact hospital and acute care professionals,  but changes with rippling impacts to health care providers in varying fields including nurse case management. Whether facing a global pandemic, or an equally significant crisis, the ability to adapt is critical for patient recovery and care. After more than a month of shelter-in-place protocols, MLCC takes a moment to re-examine workers’ compensation nurse case management and how we’re ensuring our patients continue to receive the attention and care they need for recovery.

As workers’ compensation, or field nurse case managers, our primary role is not direct care. Instead we are commissioned to assess, plan, facilitate, coordinate care, evaluate and advocate options and services to meet an individual’s and family’s comprehensive health needs.[i] During a crisis, our mission does not change yet, how we deliver and manage our cases just might. Within workers’ compensation, we’re often treating individuals with emergent injuries or illnesses, and elective treatments may not appear critical in the face of those directly affected by the crisis. However, our goals remain focused on the improvement and healing of our patients, and here’s how we’re doing it:

1. Finding alternative methods of treatment

Our patients and the care they need is our priority. When customary modes of treatment are not available, nurse case managers must find alternative solutions such as replacing in-office provider visits with telehealth visits and video appointments. Physicians, physical and occupational therapist are still able to provide orders, update treatment plans, provide treatment, and more through video conferencing features of telehealth software platforms.

2. Finding alternative care providers and alternative methods of care delivery

As nurse case managers within workers’ compensation, finding alternative care providers and alternative methods of care delivery is something we do every day in practice.  When one door is closed there is always another that is open. At MLCC, once regional shelter-in-place and stay at home orders were executed we immediately developed an evolving list of providers that were open and confirmed the level of services they had available. If certain caregivers were closed and unavailable, alternative treatment sites and treatment providers were identified.

telehealth in workers' compensation case management

For our existing patients, we immediately reassessed diagnosis and whether any new complications or risk for complications were identified while continuing treatments put in place by their care providers through video appointments and telehealth conference calls.

When new patients were referred, with new or evolving injuries/illnesses, physicians were identified, and visits facilitated as needed. As with all patient visits during this time of crisis, appointments were completed in person with appropriate personal protective equipment (PPE) or through telehealth platforms and video conferencing until the pandemic is under control.

3. Exploring varying options for testing

During times of crisis usual and customary standards of care and case management may not be available. In the Northeast region we found that provider offices may be closed for patients, but open for specific services, or even transformed into COVID-19 testing centers. As case managers we rely on our relationships with our providers and are consistently exploring the varying options available to our patients.

Let’s consider an example case where a patient who has been diagnosed with a fracture and needs an evaluation of the injury. The evaluation has been delayed due to the shutdown of offices but can no longer be postponed. Even though the physician’s office is closed, their x-ray office may be open, and their treating physician is requesting an x-ray.

However, amid the current crisis the x-ray department is now a known COVID-19 evaluation and treatment center. That patient, who is severely compromised, may be put at risk in that center. An alternate site would be found, orders facilitated, and the treatment scheduled by the nurse case manager to decrease risk of the patient contracting COVID-19.

Having the ability to continue managing our cases and securing varying options is the responsibility of the nurse and by doing so decreases the anxiety the patient may have around their treatments and care.

4. Connecting patients with the appropriate resources

As health care professionals, our focus always includes the prevention of further complications, or contamination in the case of COVID-19, of patients and their families while getting them resources and services they need for recovery. In the wake of the current pandemic this includes nurses wearing appropriate PPE’s and taking precautions during patient visits, at therapy appointments, or out in the community.

personal protective equipment

It also means connecting our patients with protective equipment, masks and gloves, when attending appointments in their physician’s or provider’s office. Continuing to educate and provide supplies goes a long way in minimizing risk of possible contamination.

Managing hypertension as a co-morbidity in workers compensation

Hypertension and workers’ compensation case management: Three strategies for improving patient and claim outcomes

In January 2018, the American Heart Association published an estimate that 103 million U.S. adults have high blood pressure, which accounts for nearly half of all adults in the United States[i]. High blood pressure, also known as hypertension, can lead to severe health complications and increase the risk of heart disease, stroke and sometimes death. With such a high occurrence of U.S. adults having high blood pressure, it is not surprising that hypertension is the most prevalent comorbidity within workers’ compensation claims[ii]. In this issue of INSIGHT, we explore hypertension within workers’ compensation, and three nurse case management strategies to improve patient and claim outcomes.

When managing any type of diagnosis, a preexisting health condition has the potential to impede upon the individual’s recovery. Comorbidities can prolong the claim and have been known to increase the risk of complications. In a study by Harbor Health Systems it was found that “claims associated with comorbid conditions experienced longer claims duration, higher medical costs, more temporary total disability (TTD) days and increased litigation and surgery rates.[iii]

Given the prevalence of high blood pressure, it is important for nurse case managers to understand the underlying effect the condition has had on the individual’s body and develop a plan to reduce complications on the present injury or illness being treated. An effective approach to managing workers’ compensation patients with hypertension requires early identification, education to mitigate further complications, and consistent management.

Indentification

Hypertension in workers compensation

High blood pressure usually has no symptoms, and many adults are unaware they have the condition. The Centers for Disease Control reported that over 46% of adults worldwide don’t know they have hypertension[iv]. In workers’ compensation case management, it is critical that the nurse is skilled in identifying underlying comorbidities or other conditions which may interfere with the individual’s recovery.

When a patient presents with pain don’t assume the source of the pain is only the injury. Oftentimes symptoms of untreated or substandard treatment of high blood pressure produces symptoms which can mimic other conditions, such as headaches and migraines, pain, anxiety, and more. It is important that the nurse case manager includes an assessment of blood pressure to rule out high blood pressure as the underlying cause.

It’s is also important to consider the impact an individual’s emotions can have on their blood pressure. We frequently observe a patient’s blood pressure elevated by simply attending their doctor’s appointments.  The claimant may also have anxieties surrounding missed work or other life stressors resulting in higher than normal blood pressure. Appropriate identification and follow-up with the patient’s primary care provider is critical. Sometimes, something as simple as recommending the patient keep a blood pressure log to review and share with the primary care provider.

Mitigation through education

High blood pressure can quietly damage an individual’s body for years before being diagnosed. If the claimant was unaware that they had high blood pressure or don’t understand the impact high blood pressure can have on their injury or illness, proper treatment and patient education is key to mitigating further complications.

Education helps patients better understand their condition, the role of medication and lifestyle changes as well as increasing awareness about the progression of high blood pressure and complications.[v] Comorbidities such as hypertension are not compensable, yet poor treatment regimens, and out of control blood pressure can affect the compensable injury or illness of the claim.

References: 

[i] More than 100 million Americans have high blood pressure, AHA says. (2018). Www.Heart.Org. https://www.heart.org/en/news/2018/05/01/more-than-100-million-americans-have-high-blood-pressure-aha-says

[ii] Laws, C., & Colon, D. (2012). Comorbidities in Workers Compensation. https://www.ncci.com/Articles/Pages/II_research-brief-comorbidities-in-workers-compensation-2012.pdf

[iii] New Research Shows Impact of Underlying Conditions on Workers’ Compensation Claims. (2011). Harborhealthsystems.Com. https://harborhealthsystems.com/new-research-shows-impact-of-underlying-conditions-on-workers-compensation-claims/

[iv] Carey, R. M., Muntner, P., Bosworth, H. B., & Whelton, P. K. (2018). Prevention and Control of Hypertension. Journal of the American College of Cardiology72(11), 1278–1293. https://doi.org/10.1016/j.jacc.2018.07.008

[v] Ribeiro, C. D., Resqueti, V. R., Lima, I., Dias, F. A. L., Glynn, L., & Fregonezi, G. A. F. (2015). Educational interventions for improving control of blood pressure in patients with hypertension: a systematic review protocol. BMJ Open5(3), e006583–e006583. https://doi.org/10.1136/bmjopen-2014-006583

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…

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

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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