Jean Chambers, MSN, RN, CCM, Vice President of Clinical Services, Bunch CareSolutions
In Part 1 of this Leaders Speak series, “Helping Patients Choose,” Dr. Rischitelli discussed shared decision-making (SDM) and its impact on health outcomes for injured workers. Nurse case management can enhance patient education and shared decision-making through an assortment of clinical best practices, including collaborative communication, biopsychosocial assessments, clinical specialization and injury management tools.
In the past, many health care providers have taken a paternalistic approach to patient treatment1. This approach, however, is giving way to a more autonomous style of informed decision-making as individuals become better educated health care consumers. SDM has gained prominence in recent years “as the value placed on patient engagement has grown and as research has found that well-informed patients tend to choose less invasive—and less costly—treatment alternatives.”2
SDM is also one of the guiding principles of case management practice. It is the case manager’s responsibility to help patients “facilitate self-determination and self-care through the tenets of advocacy, shared decision-making, and education.”3 Counseling a patient on all treatment options available for a specific diagnosis empowers the patient and encourages active participation in decisions regarding medical care. Studies show that providing patients with a more active role in their medical treatment can lower medical costs and improve health outcomes.4
Best Practices for Obtaining Patient Engagement
Telephonic nurse case management is an effective way to obtain patient engagement in workers’ compensation. To successfully facilitate care coordination, ensure patient safety and achieve quality health outcomes, nurses must be aware of individual factors affecting treatment choices. Educating a patient on treatment options involves enhanced communication skills and an awareness of leading medical technology. It also requires tailored planning and an evaluation of care that respects patient diversity and takes into account cultural, religious, psychological, social and economic factors.
Nurse case managers are experts in assessment, planning and coordination of patient treatment across all settings of care. Employers count on them to anticipate, monitor and respond to fluctuating conditions, including those that may require a modification to a patient’s care or treatment plan. For example, when an injured worker is diagnosed with a lumbar strain/sprain (a common workers’ comp injury resulting in low back pain), treatment recommendations are generally conservative and include work restrictions, medications and physical therapy. However, in our hyperconnected world, patients expect immediate results. When pain from a lumbar strain/sprain does not resolve quickly, patients may become easily frustrated and willing to seek other unnecessary and expensive treatments, including advanced imaging (MRI), spinal injections and surgical intervention. Instructing the patient on the prescribed course of treatment, its progression and how this progression may vary from patient to patient with the same diagnosis is an important part of the patient engagement process.
Effective communication is a key principle in patient engagement and a critical function in the case manager’s role to enhance SDM. When a patient suffers a work-related injury and seeks treatment, information regarding diagnosis and care recommendations can be overwhelming. While the patient receives information and education from the treating provider, medical terminology often leaves the patient confused. Meanwhile, well-meaning neighbors, family members and friends provide anecdotal information, and the Internet offers a host of medical resources with differing treatment data and protocols. So, the question becomes: How does the patient make sense of this information to determine the treatment best suited to individual preferences and personal lifestyle choices?
Nurse case managers are skilled communicators vital to the exchange of information between health care providers, patients and family members. As a member of the patient’s health care team, the nurse case manager acts as the filter, interpreter, educator and advocate, providing objective information on recommended treatments—all without losing sight of the biological, psychological and sociocultural factors influencing the patient and potential outcomes.
Strategies for Improved Patient Engagement
Performing a comprehensive assessment of the biopsychosocial status of a patient gives the nurse case manager insight into the patient’s subjective experience as a significant contributor to accurate diagnosis, individualized care and quality health outcomes. Besides injury specifics, these evaluations should include information on co-morbid conditions, medications (both prescription and over the counter), family dynamics and personal interests, as well as an assessment of pain tolerance and fear avoidance characteristics. These personalized assessments allow the nurse case manager to identify at-risk patients at the onset of the claim based on psychosocial factors, which may potentially prevent a normal recovery process.
In some cases, clinical specialization, such as pharmacy or surgery-focused nurse case managers, provides an additional level of clinical oversight and expertise to support patients undergoing surgical procedures or medication management issues5. Nurses in these specialty roles have extensive experience in managing high-cost and complicated medical treatments. Utilizing a nurse resource with surgical competencies, for example, enhances SDM and cost containment opportunities by making the most of pre-op and post-op education events and coaching the patient on the proper use of prescription medications and drug interactions. Shared communication between the patient and members of the health care team ensures the patient has a secure understanding of the treatment plan and realistic recovery and return-to-work expectations throughout the progression of care management. Moreover, the use of a nurse specialist can optimize claim outcomes through shortened recovery time and disability duration.
Nurse case managers should utilize comprehensive, system-integrated tools and applications to enhance patient involvement and promote SDM between the patient and treating physician. Some of these clinical aids include:
- Biopsychosocial assessments, functional assessments, pain assessments and pain diagrams
- Online and print resources for patient education on the work-related injury and co-morbid conditions (e.g., smoking cessation information)
- Injury management tools (e.g., core treatment plans, pre- and post-op surgery planning checklists, patient letters, pre-operative and psychological surgery education, etc.)
Ongoing and collaborative communication between the nurse case manager and the patient builds mutual trust, respect and confidence—each one an essential component in the nurse-patient relationship. Cooperative communication encourages the patient to be a more proactive participant in treatment choices and the decision-making process. This supportive relationship fosters patient satisfaction, compliance with the plan of care, shortens recovery time and disability duration, and results in improved health outcomes.
Is telephonic nurse case management needed on every claim? No, but by employing a predictive workflow management tool, claims professionals can use analytical output to identify the level of nursing resource required (such as a clinical nurse specialist) and advance resolution with clinical involvement that supports patient education and informed decision-making. Clinical interventions triggered at critical stages in the care process allow a case to move more expeditiously to final resolution, resulting in lower medical costs for the claim.
About Jean Chambers, MSN, RN, CCM
Chambers, a registered nurse, began her career at Bunch in 1999. She has held several pivotal roles within the organization. Chambers’ responsibilities include providing strategic direction to the entire clinical services team for the successful delivery of quality medical management programs. Operating units under her direct supervision include telephonic nurse case management, utilization management, field case management, NFR® (Nurse First Response) 24/7 injury triage and the firm’s Quality Management Committee.
Along with her clinical duties, Chambers actively participates in the research and development of new products and services. She has been instrumental in the development and deployment of several new capabilities, including the company’s patent-pending biopsychosocial assessment tool and 24/7 telephonic injury triage services, as well as the implementation of clinical specialization roles focused on pharmacy, surgery and legacy claims. Chambers earned her Master of Science degree in nursing from Jacksonville University and her bachelor’s in nursing from Florida Southern College.
About Bunch CareSolutions, A Xerox Company
Bunch CareSolutions is a national medical management company based in Lakeland, Florida. The company operates exclusively in the workers’ compensation industry as a full-service, managed care firm offering injury triage, case management, utilization review, peer review and medical bill review. Since its founding in 1988, Bunch CareSolutions has consistently grown in size, scope of services and standards of excellence. It has done so without compromising its clinical focus or mission of “making the world a better place—one life at time.” To learn more, visit www.bunchcare.com.
Notes
1 Tracy George, MSN, APRN-BC, “How nurses can encourage shared decision making,” Nursing 2013; 43(8): 65-66, http://journals.lww.com/nursing/Fulltext/2013/08000/How_nurses_can_encourage_shared_decision_making.19.aspx, accessed July 2015.
2 American Institutes for Research, “Shared Decision-Making and Benefit Design: Engaging Employees and Reducing Costs for Preference-Sensitive Conditions,” Robert Wood Johnson Foundation, April 2013, http://www.rwjf.org/en/library/research/2013/04/shared-decision-making-and-benefit-design.html, accessed July 2015.
3Case Management Society of America (CMSA), “Standards of Practice for Case Management,” p. 9 (PDF file) downloaded from the CMSA website, http://www.cmsa.org/portals/0/pdf/memberonly/StandardsOfPractice.pdf, accessed July 2015.
4George, 2013
5Lief G. Goodson, “Providing the Framework for Clinical Specialization in Medical Case Management,” WorkCompWire, February 16, 2015, https://www.workcompwire.com/2015/02/lief-goodson-providing-the-framework-for-clinical-specialization-in-medical-case-management/, accessed July 2015.