By Zack Craft, ATP, VP of Rehab Solutions and Complex Care Education, One Call Care Management
It’s easy to understand how claims continuing for five, ten, twenty or more years, can involve changes in the status of the injured worker, in the home environment and in the family. These evolving changes require a consistent and holistic approach to identify appropriate modifications and emerging needs that can result in deterioration of the injured worker’s condition and unnecessary costs if not addressed.
While these types of catastrophic cases only represent 10 percent of the total claims, they result in 90 percent of costs. These seriously injured individuals are one of the most vulnerable groups covered by workers’ compensation. It is essential that the care teams work together to actively remain vigilant and exercise leadership in managing these cases – performing diligent evaluation of the injured worker’s overall life issues, care plan, and at-home situation from the onset of their injury and throughout the life of the claim.
Over time, conditions of an injured worker may change and the course of care agreed upon at the onset of a claim may no longer be the best fit for an injured worker. For example, a worker that has been injured on the job and is now bed-ridden may have gained weight and now needs different considerations than at the onset of the claim when he or she may have been mobile and exercised regularly.
As workers’ compensation professionals managing catastrophic claims, we can take a page out of the healthcare industry’s “team care” playbook and make a greater effort this year to collaborate, review, monitor and reassess long-term claims in order to provide the most appropriate type of care for seriously injured workers. By implementing a consistent, programmatic assessment over the lifespan of these “large loss” claims, workers’ compensation professionals can reduce skyrocketing healthcare costs and poor outcomes, leading to a better quality of life for these injured workers.
Strategies for Successfully Managing Catastrophic Claims
Once a serious injury is treated, the patient is stabilized and the care team and plan are put in place, there may be a tendency to follow the original care plan throughout the life of the claim. However, neglecting to account for changes in an injured worker’s condition over time could have a serious impact not only on claims costs, but on the injured worker’s condition and lifestyle.
Key strategies to consider when managing catastrophic claims include:
-Reevaluate care plans regularly. The Care Team Can’t See What’s Happening at Home 24/7. Even the most dedicated physicians, nurses, clinicians and case managers do not see what goes on in the home twenty-four hours a day, seven days a week. Because the care team cannot always see the full picture of the home environment, it can be challenging to detect changes in circumstances and the patient’s condition.
While family members may be conscientiously dedicated to providing their relative’s care in the beginning, over time the demands of their jobs and lives intensify and they are not able to be as attentive. Precise directions may be forgotten or short cuts taken in an effort to save time. For example, a patient may need to be tilting exactly 45 degrees to avoid pressure sores. It’s hard to remember what 45 degrees looks like over a ten-year period of time. As we know, pressure sores become wounds that can be extraordinarily difficult and costly to treat, illustrating the need for careful monitoring and review of an injured worker’s care plan and how it is consistently followed in the home.
As a claimant’s condition changes over time, the situation may warrant a recommendation to switch to different equipment or services. Care teams across the country managing catastrophic claims can use “smart” technology or more modern equipment which has the potential to reduce costly hours of care and well as give a patient more independence. Unless there are periodic re-assessments of the patient’s situation, these opportunities could be overlooked.
-Examine all of the symptoms, even if unrelated to the injury. Just one small oversight could result in complications that lead to more treatment and increased costs. By taking a closer look at an itchy, blistery skin rash for example, the injured worker can be correctly diagnosed as having celiac disease. Because of the attention spent on all symptoms, the care team is then able to properly modify the injured worker’s diet so he or she can adhere to a gluten-free diet. If all symptoms, even if unrelated to injury, are not taken into consideration, the injured worker might otherwise have faced the serious outcomes of celiac disease, which can be cancer or osteoporosis – unnecessary complications which of course lead to higher claims costs.
-Take into consideration that injured workers may require different treatments as they age. Over time, many factors influence the health of an injured worker and cause conditions that may require changes in the course of treatment. When people age, they may gain weight or develop other health problems such as diabetes or heart conditions. The treatment plan itself may even impact their health, as medication often produces side effects. All these factors require regular re-evaluation and a holistic assessment.
-Reinforce the fact that decisions made in the early stages of a treatment plan can have unexpected consequences in the years to come. For example, an injured worker may be prescribed a medication that causes dry mouth. Over the years, dry mouth contributes to tooth decay which may be overlooked or not seen as related to the medication. Eventually, the patient must have his or her teeth replaced – an uncomfortable and unnecessary complication that is also compensable since it is related to the original injury.
To effectively manage and contain costs, the workers’ compensation industry can develop better strategies to positively guide the outcomes of complex or long-term catastrophic claims. Cross-functional teams of clinical experts and rehabilitation specialists should collaborate to go deep into the patient’s environment and evaluate the lifestyle, independence, functionality and environment from a broad versus narrow perspective. These evaluations should be made a regular part of the treatment plan.
Reporting on the in-home support systems and existing care conditions, the care team can provide recommendations, inventory and review equipment and suppliers, conduct side-by-side cost comparisons, and implement new strategies when appropriate. This integrated, long-term care approach has the ability to reduce the administrative burden by streamlining and managing communication with ongoing project updates. Such a program could produce substantial savings to the carrier while at the same time enhancing the quality of care for the patient and even improving the safety of the patient and his or her caretakers.
What may be missing from long-term claim management approach currently is a more holistic view of the care plan, the injured worker’s condition and the at-home situation that affects their well-being – a tool for those 10 percent of claims that make up 90 percent of costs. With a healthier claimant, better care, better quality of life and lower costs, the result will be a happier outcome for all.
About Zack Craft
Zack Craft is VP of Rehab Solutions and Complex Care Education at One Call Care Management. Zack directs the rehabilitation technology and complex care services for One Call, specializing in assistive technology for severely injured employees. Zack and his cross-functional team of rehabilitation specialists, technicians serve patients who have suffered complex and/or catastrophic injuries, such as brain injuries, severe wounds, amputations and other similar life-altering conditions. He and his team travel the country, evaluating patients in rehabilitation centers and visiting their homes to determine the best home-based treatment approach. For more information about how wearable technology can lower claims costs while improving the quality of life for injured workers, contact Zack Craft at: 800-848-1989.
About One Call Care Management
One Call is the nation’s leading provider of specialized solutions to the workers’ compensation industry. One Call’s solutions enable faster, more efficient and more cost-effective claims resolution with a focus on injured workers’ needs across the continuum of care. One Call provides reliable, consistent connections to care with expertise in high end diagnostics, physical therapy and transportation services, post-discharge home care and durable medical equipment, dental and doctor specialty services, complex care management, and the language services required for today’s multicultural workforce. For more information, visit www.onecallcm.com.