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.

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

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