By Tammy Bradly, Senior Director, Clinical Product Marketing, Genex Services
Measuring outcomes for workers’ compensation is challenging. Return-to-work, avoidance of disability, and cost of care are metrics that have been traditionally used to determine the success of a case.
The missing piece from this calculation is: how could the claim have been better managed in a way that accelerated recovery, avoided disability, and perhaps even lowered the cost of care? Did we do everything possible to achieve the best outcome, or did we miss opportunities along the way?
If there is one word to describe the state of workers’ compensation data today, it’s messy. That is especially true for clinical data, which holds tremendous potential to help payers improve the recovery of their injured employees but is often located in diverse systems. This haphazard environment clouds our ability to see the big picture or total view of the injured employee. The solution is to implement a clinical data Integration strategy. To get actionable insights, payers need clean data, which requires data aggregation and normalization.
Using Data to Identify Opportunities for Improvement
When data is in silos and systems cannot communicate with one another, there is a lack of total transparency. How can we be smarter about finding the right information and presenting it in the right context? To enable meaningful encounters with accurate data about each claim, it is important to bring together data from claim, bill review, network, PBM and clinical interventions. We can make better decisions with integrated data, driving lower costs and better care. Technology designed to compare claims data to evidence based guidelines allows us to identify claims needing intervention throughout the life of the claim. When indicated, targeted intervention ensures that individuals receive the right care at the right time and can improve health and claims outcomes and result in significant cost savings. Collaborative use of all claims and managed care data, leveraging analytic capabilities can support a seamless care management approach that:
- Ensures all stakeholders have information needed to optimize care planning and base decisions on transparent cost and outcomes
- Identifies risk throughout the life of the claim
- Targets engagement only on those who need clinical intervention
- Demonstrates impact thought integrated reporting and analytics to show transparency of spend, validated savings (against benchmarks) and opportunities for program improvements
Engaging the Injured Employee
When the need for clinical intervention is evident, how do we engage the injured employee and identify all the factors that influence their recovery and return to work? We must look beyond the primary diagnosis and ensure data is integrated to give us as much information as possible. But equally as important, we need to consider the human side of the equation and identify the factors influencing patient behavior to ensure we are meeting them where they are at in their journey to recovery. It is critical that the injured employee be an active partner in their recovery. When case managers are involved, they are likely the person closest to the injured employee and the quarterback of the care plan. Case managers guide injured employees through the complexities of the health care system, are present for them and their families and serve as the link between the injured employee, the care team, and the claims handler. Engaging the injured employee in their recovery is a critical component of the case management process and at times can be the most challenging.
Injured employee engagement must be built on a foundation of trust. Only when trust is established can we begin the coaching process. Let us face it, injuries are scary. Anyone who has ever had an injury or serious illness understands how intimidating navigating health systems can be. Add to that, financial concerns and general uncertainty around ever being able to return to normal. At the very least, it creates feelings of uneasiness and anxiety.
Getting injured employees engaged is not complicated, but it does require an investment in time and effort. It requires a process of active listening not a five-minute lecture. It also involves attention to factors that fall outside of diagnosis and treatment but can impact recovery.
Techniques like active listening and motivational interviewing should be core tenants of the case management process, allowing us to understand all the factors that may impact the injured employee’s recovery. Whether you refer to them as psycho-social issues or Social Determinants of Heath, a person’s mental wellbeing, availability of a support system, access to healthy food, access to transportation, adequate housing, financial status, all influence recovery.
When people know more about their own health, they can do more to care for themselves
Understanding that knowledge empowers people and allows them to make informed decisions is paramount. Adopting a coaching and education model enables case managers to have an ongoing, interactive relationship throughout injured employees’ journey to recovery, engaging them throughout the process. It goes beyond helping them understand their primary diagnosis and treatment plan. We must coach and educate on other topics such as general health and wellness, managing stress and anxiety, preparing for return to work, and even building resilience. We must view each injured employee as unique, understanding that one size does not fit all. Education needs to be relevant to the individual’s needs, fears, and motivations, and it must be conducted with a focus on the whole person.
When it comes to engaging injured employees, the fix is not quick—but investing in the process is well worth the effort. It will lead to healthier, more functional, and productive recoveries for many injured employees. It is a win-win for all stakeholders—employers, insurers, and injured employees.
Achieving Impact
The use of risk modeling intelligence combining claim, medical utilization and pharmacy data allows us to identify claims that both predict risk at the onset of the claim and those who demonstrate risk as the claim matures. This creates the opportunity for targeted intervention, only when risk is evident. This application of “high tech, high touch” delivers a holistic approach to patient care that avoids the pitfalls of the past caused by too little or too much information without context. This same data also allows us to measure the true impact of the entire managed care program. Dissect and learn from your data to understand how to detect risk in future claims earlier. Distinct claim outcomes are important, but how is your total program performing? Are you reducing disability durations, controlling medical utilization, and managing overall claim costs? An organization must have the technology, resources, and expertise to use data analytics and patient engagement to improve performance, manage costs and ensure the safe and rapid return to work of injured employees. Integrated data enables you to build, manage and measure your managed care programs.
About Tammy Bradly
Tammy Bradly is senior director of clinical product marketing for Genex Services, a division of Enlyte, where she is responsible for leading the company’s clinical product strategy and growth. 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). Bradly has authored numerous industry articles/whitepapers and spoken at both regional and national conferences on topics such as the aging workforce, pain management, return-to-work, case management, telemedicine and crisis intervention.
About Enlyte
Enlyte (www.enlyte.com) is the parent brand of Mitchell | Genex | Coventry, a leader in cost – containment technology, independent medical exams (IME), provider and specialty networks, case management services, pharmacy benefit and disability management. The three businesses have aligned their joint industry expertise and advanced technology solutions into a combined organization of nearly 6,000 associates committed to simplifying and optimizing property, casualty and disability claims processes and services.
Disclosure:
Enlyte is a WorkCompWire ad partner.
This is NOT a paid placement.