By Mariellen Blue, National Director of Case Management and Tim Howard, Senior Vice President, Field Case Management at Genex Services
Today, payers will often leverage the clinical expertise of case managers to ensure their catastrophic cases get the specialized care and attention they require, as well as any other services the injured employee may need to cope with a life-altering injury.
Last week, our colleague – Carlos Cordova, Director of Operations at PCS – discussed the statistics surrounding catastrophic claims and how to streamline the provision of ancillary services for these cases. In our follow-up column, we continue to examine catastrophic injuries – this time from a medical management perspective. We’ll look at important criteria for selecting a sophisticated case management firm, as well as the vital role catastrophic case managers play in helping to manage these claims.
Catastrophic Case Management: What’s Needed in a Service Provider?
To help ensure optimal outcomes, it’s important to work with a case management firm that has a depth of expertise and coverage in this area. As such, it’s important to look for the following criteria:
A sophisticated case management firm must have highly experienced case managers. This starts with recruiting professionals who have the right background, education, experience, and a track record of success in this field. From there, the firm must further invest in their expertise by providing training. This includes initial training when case managers are first brought on board, as well as continuing education (CE) throughout their career.
Training must advance their skills. As such, an educational program must be reviewed on an ongoing basis for opportunities to update or expand the program with emerging trends, latest developments and new medical advancements. A competitive program will include at least 10 continuing education units (CEUs) a year, enabling case managers to keep their knowledge on the cutting edge.
Broad Geographic Coverage
For employers, catastrophic injuries may occur anywhere in the U.S. – in both metro and rural areas. As such, it’s important to select a firm with broad geographic coverage and access to hundreds of catastrophic case managers across the country. In this way, the firm can assign an experienced case manager to a catastrophic injury as soon as possible. Oftentimes, these case managers also have the benefit of deep regional expertise, as they’ve already been working with the critical care centers in that area and can act as a seamless extension of those teams.
A case management firm should have supervisors specifically dedicated to providing guidance and oversight on catastrophic cases. These supervisors have a singular focus 24/7, 365 days a year, which is to advise catastrophic case managers and provide a second set of clinically-trained eyes on these tough cases.
A Sophisticated Technology Platform
A sophisticated case management system is pivotal to ensuring timeliness in clinical management, which in turn fosters successful outcomes. For example, a system might use analytics to assign a catastrophic injury to a case manager with the right experience and in a particular geographic region. In this way, the case manager can intervene as soon as possible in terms of coordinating patient needs and helping to bring about a positive outcome. In addition, the platform can be programmed to deliver automated alerts to keep case managers abreast of new developments. The system also provides remote access to the most up-to-date clinical guidelines, which case managers can reference during patient appointments and discuss with treating physicians.
Catastrophic case managers should also be provided with secure mobile devices to access the case management system from the field. With such devices, they can enter notes for thorough documentation, communicate with claims adjusters and coordinate ancillary services.
Managing Catastrophic Injuries: The Role of the Catastrophic Case Manager
Catastrophic claims are the most challenging of cases to manage. They often involve horrific accidents, debilitating injuries, multiple traumas and are at risk of complications. For example, an employee may have sustained a traumatic brain injury, a spinal cord injury that left the person paralyzed, severe burns or an amputation. Going forward, the injury will have a dramatic impact on every aspect of that person’s life.
As a result, these cases require the most experienced of care management professionals – the catastrophic case manager. These professionals bring the right blend of clinical expertise and compassionate heart, dedicated to helping employees navigate the complexities of the workers’ compensation and health care systems in order to get the treatment and services they need to recover.
In this role, catastrophic case managers track both small, seemingly insignificant details, which could alert them to potential red flags, as well as the overall big picture on a case. They’re not just looking at a specific diagnosis, but all factors that could interact with the patient’s injury. Preexisting medical conditions, such as diabetes or high blood pressure, are on their watch list. They’re also on the lookout for signs of delayed recovery, for which they’ll investigate further to find out what’s causing this trend. Their ability to simultaneously observe the small details and big picture keeps them alert to potential risks or roadblocks to recovery.
Here are other factors catastrophic case managers proactively monitor and attend to:
Catastrophic case managers are monitoring psychosocial issues that could derail the trajectory of patient recovery. They’re well positioned to recognize when cognitive, emotional, or social barriers may be at play. Injured employees may not feel comfortable disclosing certain information to supervisors or doctors, but they may have built up enough rapport with the case manager to share their fears or family problems.
Case managers are also trained to listen for such cognitive queues, indicating how injured employees are thinking or feeling about their injury or prospects for the future. Irrational fears may come up, and if not addressed, could snowball.
For example, if employees live alone in a remote location away from family and friends, this might preclude them from getting the support they need. Their social infrastructure may be affected in other ways. Perhaps a person was once an active fitness enthusiast, engaged with a community of other like-minded individuals. If the injury prevents this person from now engaging in those activities, the loss could contribute to an inability to cope.
It’s important that case managers proactively perform assessments to identify psychosocial issues early, as they might be indicative of more serious concerns, such as post-traumatic stress disorder (PTSD), a risk of suicide, or other maladaptive coping strategies. The sooner these issues are brought to the forefront, the sooner the treatment team can help to address them.
Return to Work
Catastrophic injuries typically require extensive treatment and recovery time. As such, employees will likely experience significant time away from work, and a person’s ability to work in the future may be impacted.
Catastrophic case managers will begin to assess and discuss return-to-work options from the onset. Of course, they handle these conversations with sensitivity and compassion toward the injured employee. They understand these individuals have gone through a lot, and they’re not trying to rush employees back to work, but it’s something that must be strategized and planned for.
For many employees, work plays a huge factor in their identity, and an inability to return to a position can have huge implications. It can affect the person’s finances, but more importantly, have a psychological impact as well. The person’s standing within the family may be altered. For example, he or she may have taken pride in being the primary breadwinner but is no longer able to assume this role. Worry and anxiety could lead to depression.
If there’s a high-risk individual, the case manager might work with the employer to aggressively utilize transitional or modified duty to get the employee re-engaged in the work setting. Or, the case manager might help reframe the employee’s unhealthy thought process by establishing proper expectations: “Yes, you’re injured now and can’t return to work yet, but you have many professional skills, and you’ll eventually find gratifying work when the time is right.”
Typically, employers also have a lot of compassion toward employees who’ve sustained catastrophic injuries. As such, return to work may not be a key focus. Instead, they might emphasize other aspects of a successful outcome. For example, did the injured employee get the care he or she needed in a timely fashion? Did all of the family’s concerns get addressed?
From Tragedy to Triumph
Catastrophic claims are a significant challenge in the workers’ comp industry due to the severity and complexity of these injuries. As we’ve covered in this column, there are several ways catastrophic injuries differ from other cases. Factors, such as psychosocial issues, can come into play and derail recovery. However, if payers and adjusters have the help of a sophisticated case management company, along with highly experienced catastrophic case managers, they’re on their way to transforming a tragedy into the best-possible outcome for the employee and all parties involved.
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 Tim Howard
Tim Howard is Senior Vice President of Field Case Management at Genex Services, where he is responsible for oversight and delivery of the company’s national field case management services. Mr. Howard joined Genex in 1992 as a local marketing manager in Nashville, TN, and has successfully progressed through various roles including southeast region vice president, where he was responsible for field and utilization management, IME, bill review, Medicare Set-Aside, and all southeast-based managed care services. As SVP of Field Case Management, Mr. Howard has focused his team on a best-practice approach to yield superior medical and financial outcomes by linking telephonic and field case management functions. He holds a bachelor’s degree in marketing from the University of Alabama.
About Genex Services
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.
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