Obesity within workers’ compensation case management

Strategies to help patients along the road to recovery and improve rehabilitation outcomes

The battle of the bulge has been a losing battle for many as the obesity rate for Americans has steadily increased to over 40%.[i] More and more of the population, as indicated, have problems with weight management due to a sedentary lifestyle and job duties. With increased weight, we also see an increase in related health issues, including diabetes and cardiovascular disease, which are among the leading causes of death in the United States. When we consider the impact of obesity on recovery and rehabilitation within workers’ compensation case management, the effect is even more significant. In this INSIGHT article, we explore obesity within workers’ compensation case management, and strategies nurse case managers can use to help their patients along the road to recovery and improve rehabilitation outcomes.

Medical and Life Care Consulting

In 2016, the Journal of Occupational and Environmental Medicine, an official publication of the American College of Occupational and Environmental Medicine (ACOEM), published a study comparing workers’ compensation costs and outcomes for obese, overweight, and normal-weight workers. The study found that for workers with major injuries, costs averaged about $470,000 for obese and $270,000 for overweight workers, compared to $180,000 for normal-weight workers.[ii] Now, as nurse case managers, our work is purely focused on the recovery and rehabilitation of the injured individual, but the financial data clearly demonstrates that weight can have a profound impact on the time and resources needed for the injured worker’s recovery. 

As nurse case managers, our approach to evaluating patients is very holistic, and we review all their diagnoses and comorbidities at the initial evaluation (meeting). In the patient’s initial meeting, comorbidities regarding weight are evaluated when taking the patient’s height, weight, and assessing their BMI. Obesity occurs when a BMI is over 30. When a nurse case manager is first meeting a patient addressing comorbidities is a very delicate discussion. Often, the conversation regarding their weight status is approached throughout the patient’s treatment plan as the treatment plan is an ever-evolving process, and evaluation of their response to the treatment is also evolving. With today’s typical lifestyles, patients’ weight can vary from being within normal BMI ranges to overweight, or the patient can be obese. Visual evaluation of the patient is usually sufficient to identify the patient’s BMI.

The diagnosis of obesity is a significant diagnosis in which we often do not see the ramifications until it’s become the standard in our life. While many people are obese but do not have any other health issues, the extra weight will eventually take a toll on their bodies and deteriorate other systems. For case management of work-related injuries, chronic illness, congenital or developmental issues, the diagnosis of obesity further complicates existing diagnoses – recoveries are delayed, and complications can occur.

Because the nurse case manager’s work is holistic, we cannot ignore the diagnosis of obesity, regardless of the work injury. We need to address it and assist in determining ways the patient can resolve this issue while we are also working on treating the primary diagnosis. 

Identify and Inform

As the patient’s advocate and trusted partner in their rehabilitation and recovery, the nurse case manager plays a crucial role in helping them improve their overall health. While the injury or illness of the claim is the number one concern, the patient’s weight can affect their recovery and should be identified in a respectful and nonjudgmental way. The National Institute of Diabetes and Digestive and Kidney Diseases suggest asking patients if you can talk with them about their general health, including their weight. Studies also show that patients prefer terms like “weight,” and “BMI” when talking about obesity, and dislike terms such as “fatness,” “excess fat,” and “obesity.” Don’t forget to be sensitive to medications that may contribute to their weight gain or challenges losing weight.

Inform the patient of not only the health risk and negative impacts of their weight, but more importantly, highlight the positive effects of losing weight during their recovery and their overall health. Working towards a positive outcome may be more motivating for the patient than trying to avoid a negative consequence of being overweight.

Spend some time learning about the patient beyond their medical records and charts to understand better their eating and drinking patterns and what they may enjoy doing for physical activity. The 2015-2020 Dietary Guidelines for Americans suggest questions like “What’s your family’s favorite dinner” “When you’re thirsty, what kind of drink do you reach for?” or “Does eating healthier seem hard or unrealistic?”.[iii]

Here are some additional resources:

  • Just Enough for You: About Food Portions– This resource is published by the National Institute of Diabetes and Digestive and Kidney Diseases and provides information on portions and servings, how much someone should eat, how to manage portions and eat well when money is tight and much more.
  • USDA’s ChooseMyPlate– This is a great resource to help with creating toolkits and integrating additional resources into the patient’s recovery and rehabilitation plan, including the MyPlate Plan which can be personalized based upon age, sex, height, weight, and physical activity level, and shows the patient’s food group targets – what and how much to eat within their calorie allowance.
  • Physical Activity Guidelines for Americans– Published by the U.S. Department of Health and Human Services, this guide is an essential resource for health professionals when designing physical activity programs. 

Set & Facilitate Goals

The goal for good health and wellbeing is for all to be within the appropriate weight scale for their body type. While helping a patient execute their recovery and rehabilitation treatment plan, help them integrate goals for achieving a healthy weight. The Mayo Clinic recommends focusing on process goals instead of outcomes goals. An outcome goal is the target result – lose X number of pounds. A process goal is how you will reach that outcome, for example, walking 30 minutes per day, or drinking water at every meal.[iv] 

References

[i]Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018, retrieved fromhttps://www.cdc.gov/nchs/products/databriefs/db360.htm

[ii]Study Links Obesity to Higher Workers’ Compensation Cost, retrieved fromhttps://www.insurancejournal.com/news/national/2016/09/30/427876.htm

[iii]Dietary Guidelines for Americans 2015-2020, Eighth Edition , For Professionals: Talk to Your Patients & Clients About Health Eating Patterns, retrieved fromhttps://health.gov/sites/default/files/2019-10/DGA_Conversation-Starters.pdf

[iv]Weight-loss goals: Set yourself up for success, retrieved fromhttps://www.mayoclinic.org/healthy-lifestyle/weight-loss/in-depth/weight-loss/art-20048224

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.

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

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