By Delainne Bond, BSN, BS, RN, CCM, National Catastrophic Program Manager, National Crisis Intervention Coordinator, Genex Services
Catastrophic workplace injuries present far-reaching complexities that go beyond severity of injury, making these cases at-risk for claim derailment. These are among the most serious and complicated workers’ comp cases involving diagnoses such as traumatic brain injury, spinal cord injury, crush injuries and amputation, burns (2nd and 3rd degree) and multiple trauma.
When a critical injury occurs, the impact often has a domino effect on daily operations. Employers, payers and providers are charged with making quick decisions that could dictate the injured worker’s return-to-work capability.
With so many players involved, keeping everyone on the same page is crucial. However, too often, unnecessary problems arise due to poor or obstructed communication. This often occurs when professionals work in silos, resulting in lack of communication between the various parties, including the injured worker and the family, doctors, hospital staff, employers, carriers, TPA and attorneys.
When any one of the key players involved in a claim disengages from the communication, the claim instantly comes to a slow grind, ultimately impacting the timeliness of the injured worker’s recovery and return to gainful employment.
Enter the Case Manager
In these instances, a case manager with experience in catastrophic injuries can make a significant difference. Statistics show that the two optimal outcomes — return to work and maximum medical improvement — are best achieved when catastrophic case management is assigned within the first 30 days following a catastrophic injury, and these outcomes decline dramatically when there’s a lag time of 60 days.
Late case management intervention often results in delayed or inappropriate medical care due to certain barriers that are created by lack of communication. This may include delayed approval for treatments, a lack of resources in geographic areas or something as simple as transportation to an MD or physical therapy appointment. Catastrophic case managers are specially trained to identify these barriers proactively and assertively address them in a timely fashion.
Catastrophic case managers are also in the unique position to facilitate opening and ongoing communication. Their clinical background provides them with keen assessment and analytical skills necessary to provide early intervention on complications. This also leads to a familiarity regarding the chain of communication in hospital settings to access essential medical information and records.
These skills are critical, since catastrophic claims often have up to 30 diagnoses, including medical sequelae and comorbidities, leaving the injured worker at high risk of complications. These injuries often require multiple medical specialists in the acute and chronic phases of the injury. Good catastrophic case managers tie all these factors together to present a comprehensive overview of the injured worker’s condition and treatment plan, identifying and removing the barriers to recovery.
Case managers are also responsible for reporting to multiple key parties. High-profile cases are often monitored by attorneys, CPAs, insurance brokers, insurance executives, employer executives and others. Catastrophic case managers are knowledgeable at presenting comprehensive and professional medical information in a manner that is understandable to those with and without a medical knowledge base.
When the injured worker is ready for hospital discharge, the case manager offers a communication bridge between the hospital and rehab staff, ensuring the ensuring appropriate care is being administered throughout the life of the claim.
Casing the Case Manager
For all of these reasons, selecting the right case management organization is imperative. The best programs require their staff to receive specialized training and certification in catastrophic case management, use evidence-based research to achieve best outcomes, and offer dedicated resources such as critical pathways to return-to-work. To promote early intervention, these organizations also offer 24/7 access so a catastrophic case manager can be quickly assigned and working on the case with 24 hours.
With the right case manager in place, a catastrophic injury can evolve from a high-cost, litigated claim, to a success story in which the injured employee returns to work or highest level of functioning.
About Delainne Bond
Delainne Bond, BSN, BS, RN, CCM, is National Catastrophic Program Manager, National Crisis Intervention Coordinator at Genex Services, Wayne, PA.
About Genex Services, LLC
Genex Services is the trusted provider of managed care services enabling clients to transform their bottom lines while enhancing the lives of injured and disabled workers. Genex is a managed care leader with more than 2,900 employees and 41 service locations throughout North America. The company serves the top underwriters of workers’ compensation, automobile, disability insurance, third-party administrators and a significant number of Fortune 500 employers. In addition, Genex is the only company that delivers high-quality clinical services enhanced by intelligent systems and 360-degree data analysis. The company consistently drives superior results related to medical, wage loss, and productivity costs associated with claims in the workers’ compensation, disability, automobile, and health care systems.
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This is not a paid placement.