By Mariellen Blue, National Director of Case Management at Genex Services
“You only get one chance to make a first impression.” This common phrase is especially true in establishing a positive relationship between an injured employee and the treating physician in a workers’ compensation case.
A thorough initial evaluation sets the course for a successful return-to-work protocol. When individuals are injured on the job, they often don’t know what to expect. They want answers and reassurance and often look to their physician for their medical expertise. Conversely, when important factors are missed in this first meeting, it can significantly delay the injured employee’s progress, resulting in lost productivity and higher claim costs.
Understanding how these errors occur is key in preventing them. So, let’s look at five initial evaluation problems that can lead to delayed return to work.
1. Physician has limited workers’ comp experience
In workers’ compensation, each state has its own unique state regulation requirements such as mandated treatment guidelines, utilization review and drug formularies. For this reason, it’s vital that the treating physician understands these policies to ensure protocols are met.
It’s also important physicians realize regulation differences in conventional health care vs. workers’ compensation policies. Most notable is that workers’ compensation providers are not subject to strict HIPAA regulations. This can be a problem for physicians not experienced in workers’ compensation who are sometimes hesitant to share vital information with claim stakeholders for fear of patient confidentiality violations. Unless there are laws that say otherwise, workers’ comp professionals may share information to help the injured employee safely return to his position. Knowing these factors during the initial evaluation can effectively move a case forward by allowing the rehab team to identify areas of employment the individual is capable of physically performing during various points in his recovery.
2. Communication and engagement problems
Effective communication is extremely important during that first encounter between patient and physician. This is especially true if an individual has a language barrier and needs an interpreter, but also, the complexity of medical terminology and jargon can cause a communication problem of its own. If used when conversing with the injured employee, it’s probable that he or she won’t comprehend it, putting the claimant at risk for not correctly following the protocol or becoming non-compliant.
However, physicians who speak to the health literacy level of their patients and take time to ensure they comprehend the instructions given during the initial evaluation, can make a big difference in improving compliance with the return-to-work plan.
3. Limited adherence to evidence-based treatment guidelines
Effective workers’ compensation programs require physicians to follow evidence-based treatment guidelines and benchmark them against their decisions. These tools are often driven by best practices in treating specific injuries, and offer probable anticipated recovery timelines. Those physicians who are unaware of or don’t regularly incorporate these guidelines into their initial assessment put their cases at risk of delay.
The physician, and even a case manager if assigned to the case, who effectively uses these guidelines can confidently monitor the progress of the injured employee’s recovery. If the individual fails to meet his guideline benchmarks, the provider can then intervene to address factors that are delaying the case and get the injured employee back on track.
4. Failing to include return to work in initial plan
The first priority for workers’ compensation providers is to ensure injured employees receive appropriate treatment in a timely manner. However, treatment must always be focused on meeting the ultimate goal: returning the employee to his or her previous level of function and work ability.
This means addressing return to work from day one by addressing questions such as:
- What types of jobs are available for that individual?
- What are the physical job requirements of the worker’s regular job?
- Is the employer able and willing to accommodate modified or light duty or transitional employment before the employee is released to full duty?
- Is there a structured return-to-work program in place?
Having the answers to these questions allows the physician to establish a progressive return-to-work program allowing the employee to reengage in the workplace and quicken the recovery process. On the contrary, the longer the employee is disengaged from the workplace, the more likely he or she will be delayed in returning to work.
5. Overlooking comorbidities or non-injury related issues
Aside from assessing the employee’s physical injury, physicians often factor in other biological factors that can delay recovery during the initial eval. These include age, gender and comorbid conditions such as diabetes, hypertension, heart disease, obesity, smoking and substance abuse history.
However, case severity scoring can become more complicated when the physician fails to address psychological or social factors, especially those the patient has developed as a result of the injury. This can include fear of pain, financial loss, job security, disability, or failure to meet recovery expectations. When these fears exacerbate, they often manifest into catastrophic thinking where the injured employee gets trapped in a worst-case scenario mindset that halts recovery.
In addition, social factors such as job satisfaction or personal issues can also impact return to work. Is the employee unmotivated to return to a job he or she doesn’t like? If the employee is the sole working parent, how will he or she pay for daycare while in recovery? These are all concerns that need to be considered when developing a successful return-to-work plan.
Help From Case Management
While there are several factors the physician must consider during the initial evaluation, a case manager can be essential in working with the provider to ensure the injured employee’s needs are met. The role of the case manager is to serve as the injured worker’s advocate, educator, and the overall liaison between all the parties in the case, throughout the recovery and return-to-work process.
About Mariellen Blue
Mariellen Blue, RN, CCM, is national director of case management at Genex Services where she is responsible for overall product management and development, as well as regulatory compliance, accreditation, and quality assurance initiatives related to utilization management, telephonic and field case management, IME, and MCO services. A graduate of the Helene Fuld School of Nursing, Ms. Blue has an extensive background in nursing, case management and utilization review.
About Genex Services, LLC
Genex Services provides best-in-class clinical solutions that enable customers to transform their bottom lines while enhancing the lives of injured and disabled workers. Genex, a clinical management leader throughout North America, serves the top underwriters of workers’ compensation, automobile, disability insurance, third-party administrators and a significant number of Fortune 500 employers. In addition, Genex clinical services are enhanced by intelligent systems and 360-degree data analysis. Its clinical expertise 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. Genex Services and Mitchell International merged recently to create the broadest continuum of technology and products servicing the auto, workers’ compensation, and disability markets.
Genex Services is a WorkCompWire ad partner.
This is not a paid placement.