By: Tammy Bradly, VP Clinical Product Development, Coventry Workers’ Comp Services
Before the Thanksgiving holiday Anne Levins left her readers with some hearty food for thought: Empower your people to act using decision support tools that include a well-calibrated risk model to bring about meaningful change in workers compensation. However, she also stressed that claim and clinical professionals must combine the intelligence gained from the data with the expert judgment earned through their experience. Pairing what they know with what the risk model identifies enables these professionals to take strategic action as soon as risk is evident on every claim.
Collaboration is Key
We rely on the claims professional, the case manager, the provider, the employer, and the injured worker to keep recovery on firm ground to avoid adverse outcomes and runaway costs. However, there are times when a claim veers off track because of problems not necessarily captured within the claim data. These problems often impede an injured worker’s recovery and only an experienced claim professional or case manager can detect and understand their significance. We know with certainty that hard-to-capture attitudinal factors can drive or undermine recovery. Claim data alone — even with claim notes — may not reveal whether a worker places trust in her employer or whether a worker dislikes his boss or colleagues.
Intangible elements such as these can be powerful rudders in the direction a claim takes. By dealing with all challenges, including attitudes, beliefs and fears we can earn injured worker trust and have the credibility to support their return to health and function at work.
Advocacy, Trust and Engagement
Case managers are at the hub of a complex workers’ compensation claim. Typically, they know the doctors and other treating providers. They know the employer. They are familiar with the patient’s medical history. And they often know the patient’s family and can be uniquely positioned to identify the more subjective factors that could affect progress.
Case managers have clinical knowledge, and the claim-specific knowledge to most effectively advocate on behalf of each injured worker.
Increasingly, their professional knowledge and training encompasses not only medical content, but also the behavioral factors that can help bring about change. This behavioral training can help them understand the individual as a whole person, instead of simply focusing on the injury. This means case managers can help injured workers deal with not only medical but also psychosocial barriers to return-to-work.
Individualized patient education is essential. Health and behavioral coaching should address the compensable injury, comorbid conditions as well as any psychological and psychosocial concerns. For education to foster injured worker engagement, the source must be credible and empathic. Positive outcomes occur when the injured worker trusts that all those engaged in his or her claim—not only the doctors, but the employer, insurer, adjuster, case management nurses, etc.—have his or her best interest at heart.
Even a simple accident can result in a complex course of treatment. Let’s say an injured worker hurt her back when she fell from a tall ladder in a warehouse. The evidence-based medical guidelines indicate that the optimal treatment for her diagnosis is physical therapy and a course of NSAIDs (non-steroidal anti-inflammatory drugs). However, the case manager learns that the worker has a co-morbid condition for which she is being treated with medication and that the prescribed medications may be contraindicated. Digging further, the case manager discovers that the injured worker’s financial situation is such that she can’t afford to live on reduced wages while she recovers. Now she is grappling with anxiety over her ability to pay her mortgage, credit cards and other bills. Through communication with the provider, the case manager can ensure the provider prescribes alternative medication that is not contraindicated. The case manager also can work with the injured worker, provider, and the employer to create a transitional return-to-work plan that lessens her time on reduced benefits. That can ease her anxiety.
Insight Emerges from Experience
The indispensable human element plays a key role in the recovery of the injured worker. This is true not just because the injured worker needs to feel safe, comfortable, and engaged but because experienced case managers become adept at guiding injured workers to manage the obstacles that can hinder or even prevent successful return-to-work. That experience accumulates to engender insight. Data analytic tools work much the same way. And as algorithms churn through ever more structured and unstructured data they can render more precise and nuanced analyses. A useful risk model delivers crucial information to claim professionals and clinicians when they need it most. In doing so, the model enables claim professionals and clinicians to make the right decisions at the right time. Experienced clinicians and claims professionals are a requisite to the return-to-work process.
Robust data and human experience are both necessary for real insight to emerge.
About Tammy Bradly
Tammy Bradly is vice president of clinical product development for Coventry Workers’ Comp Services. Bradly is a certified case manager with more than 25 years of comprehensive industry experience through service delivery, operations management and product development. She holds several national certifications, including certified case manager (CCM), certified rehabilitation counselor (CRC) and certified program disability manager (CPDM).
About Coventry Workers’ Comp Services
Coventry offers workers’ compensation cost and care management solutions for employers, insurance carriers and third-party administrators. With roots in both clinical and network services, Coventry leverages more than 30 years of industry experience, knowledge and data analytics. The company offers an integrated suite of solutions, powered by technology to enhance network development, clinical integration and operational efficiencies at the client desktop, with a focus on total claims cost.
Coventry is a WorkCompWire Ad Partner.
This is not a paid placement.