A lot has changed since the 1990s when I started as a telephonic case manager (TCM) in workers’ compensation (WC). Intracorp was my training ground as it was for many “old timers” in this industry. I came from a surgical nursing background which gave me a good foundation for the challenging interactions I would face in dealing with treating physicians when managing the case of a WC claim. Surgery could be a volatile environment, so I quickly learned to stand my ground on decisions driven by medical necessity and patient safety.

And just like in surgery, sometimes difficult conversations must be initiated in order to impact a WC case. Just because an injured worker doesn’t want to return to work does not mean that he/she is incapable of doing so. And just because a treating physician decides to order more physical therapy or chiro care, even after a patient reaches a plateaued state, doesn’t mean that an aggressive treatment such as surgery is the right course of action. Collaboration, well-supported clinical judgement, and negotiation are key skills for a case manager to possess.

What is Case Management in Workers’ Compensation?

Case Management in workers’ compensation involves clinicians evaluating the cause of a workers’ comp claim (i.e. the injured worker) and developing a treatment plan for the injured worker. This involves coordination with the injured workers, providers, employers, and sometimes family members.

What are the goals of Case Management?

The goals of case management are two-fold.

  1. Medical Management ensures the injured worker is getting the right treatment at the right time in the right setting. Discussions incorporating evidence-based guidelines emphasizing best treatment practices for the injured worker and agreed upon by the treating physician are key to optimize treatment outcomes.
  2. Return to Work assists and encourages the injured worker to return to work in a full or light duty capacity. This requires collaboration with the treating physician and employer and setting expectations early on with the injured worker about return to work and the personal gains associated with this goal.

 

When I started at Intracorp, I had a large caseload of 120 cases – 120 injured workers that I navigated through a difficult WC system. It was quite a daunting challenge and difficult to meet case management goals when every case required targeted attention and a strategy that fits an individual and personal clinical picture. These are people and not just case numbers.

The good news is that TCM caseloads have changed dramatically over the years. Most companies now feel the best practice caseload for their TCMs is in the 60-70 range. Even so, there are many non-clinical aspects of case management that can cloud the real focus of what a case manager is trying to accomplish.

Tasks such as calling for updated medical/RTW status, calling to confirm an appointment, and calling to obtain medical/diagnostic records. These are just a few of the responsibilities that do not require a nursing degree to perform yet in many organizations the case manager does all of this and more.

What is your organization doing to ensure your case managers have the capacity to have those difficult yet meaningful clinical interactions? Strategic interactions that breed positive financial – and more importantly – clinical results for all stakeholders involved. Interactions that do more than document collection, appointment scheduling and care coordination.

Shearwater Health’s Case Management Support program may be something for you to consider. Contact us for more information about how we can help.

 

Marcia Headley, RN BSN CCM
Workers’ Comp Practice Leader