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Acute Care and Workers' Compensation Case Managers

A Necessary Alliance

Fraser, Kathleen, MSN, MHA, RN-BC, CCM, CRRN; CMSA Executive Director

doi: 10.1097/NCM.0000000000000352
Departments: CMSA Highlights
Free

Address correspondence to Kathleen Fraser, MSN, MHA, RN-BC, CCM, CRRN, Case Management Society of America, 6301 Ranch Dr, Little Rock, AR 72223 (kfraser@fraserimagineers.com).

The author reports no conflicts of interest.

My mission in life is not merely to survive, but to thrive; and to do so with some passion, some compassion, some humor, and some style.

—Maya Angelou

As professional case managers, we know that there are essential skills case managers must have in order to have successful transitions of care. Some of those requirements include the case manager's ability to:

  • Coordinate medical and behavioral interventions;
  • Have a professional, yet empathic demeanor;
  • Collaborate and advocate with all stakeholders to develop a care plan;
  • Focus on patient-centered autonomy and assist the patient in defining goals; and
  • Have meaningful communication with all stakeholders (see Figure 1).
FIGURE 1

FIGURE 1

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The Role of Case Managers

Case management is neither linear nor a one-way exercise. Assessment responsibilities of the case manager occur at all points in the process, with facilitation, coordination, and collaboration occurring throughout the client's health care encounter. When the payer is workers' compensation, this coordination of care cannot occur successfully without collaboration.

It is the case manager's role to coordinate cost-effective plans and to provide high-quality continuous care that eliminates duplication of services and wasted benefit dollars. Case management is a collaborative process promoting quality care and cost-effective outcomes in order to enhance the physical and psychosocial health of individuals.

Throw in the vocational health aspect and what do we have? A workers' compensation case manager.

Alone we can do so little; together we can do so much.

—Helen Keller

Fractionation of care can be avoided when an important alliance occurs: The acute care case manager works with the workers' compensation case manager. Although the patient benefits greatly from this collaboration, there is the added benefit of making life easier for the acute care case manager. Workers' compensation case managers can achieve in-stay approvals as well as handle discharge care needs, including durable medical equipment, home health, transportation, therapy, and more.

The case management process is carried out within the ethical and legal realm of a case manager's scope of practice, using critical thinking and evidence-based knowledge. We are patient advocates and serve as resources to one another. Our health care system operates in silos and information queues, making reciprocal operation with other related management systems and different departments of organizations difficult. However, by working together we can achieve the best possible outcomes for our patients.

Assessment with a patient or injured worker is an ongoing process; keep it a fluid process by:

  • Keeping assessments flexible, varying with presenting problem or opportunity.
  • Regularly reassessing the patient's/caregiver's needs and progress in meeting objectives.
  • Facilitating goal-setting discussion based upon their needs during all phases of their care.
  • Assessing the effectiveness of interventions in achieving patient's goals.
  • Communicating changes to the health care team.

Case managers on both sides (in this case, the workers' compensation and acute care settings) have roles in educating the patient. Of course, the primary focus is patient safety and self-management. In addition, we need to:

Be the thermostat, not just the thermometer.

—Dr. Martin Luther King

  • Verify with the patient that he or she is knowledgeable about and is adhering to the treatment regimen as prescribed.
  • Notify the treating physician and/or the specialist of any discrepancies, inconsistencies, or misunderstandings by the patient.
  • Keep the employer informed and help allay fears and uncertainty for the patient/injured worker (See Figure 2).
FIGURE 2

FIGURE 2

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Moving From Engagement to Activation

Motivating our patients and injured workers to wellness requires recognizing the knowledge, skills, confidence, and resources patients possess to manage their disease state in an active and informed manner. A patient-centered approach to case management meets patients at their personal level of readiness to learn and accomplish their health-related goals, focusing on patient–provider shared decision-making in all phases of their treatment.

Patients with highest levels of activation display interest, involvement, and actively decide best course of involvement for him or her. In addition, high activation levels are associated with decreased health care costs.

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Barriers to Collaboration

Although alliance between organizations and care settings is important, there are barriers to collaboration. One common barrier is caseload and work overload, in which particularly acute care case managers can feel bombarded and overwhelmed. In addition, sometimes case managers might experience a reluctance to change how cases are coordinated. Workers' compensation case managers can assist acute care case managers in many areas, which can lighten the responsibilities involved in the case of injured worker cases as well as speed up transitions. Moving beyond the status quo of how cases are typically handled, as well as the trust issues that can arise between professionals, benefits the patient and his or her caregivers.

Integrating the physical and behavioral health aspects through active communication by the acute care and workers' compensation case managers can and will decrease these statistics:

  • An estimated 26% of physically healthy Americans 18 years and older are living with a mental health disorder in any given year;
  • 46 percent will have a mental health disorder over the course of their lifetime; and
  • An estimated 8% of Americans are in need of drug or alcohol abuse treatment.

The U.S. Department of Labor reports on the likelihood that a worker will return to work (RTW) following an injury:

  • Off work 6 months: 50% chance of RTW
  • Off work 1 year: 25% chance of RTW
  • Off work 2 years or more: Virtually no chance of RTW

These statistics demonstrate the importance of acute care and workers' compensation case managers working together to ensure workers can RTW sooner, healthier.

Another reason for case managers to collaborate across care settings involves the opioid epidemic. Opioid analgesics are now responsible for more deaths than the number of deaths from suicide, motor vehicle crashes, and cocaine and heroin overdoses combined! Together, we can improve outcomes for individuals with complex injuries or diagnoses. These cases tend to be complexity-focused and relationship-based, with few cross-disciplinary case manager handoffs. Medication reconciliation between case management genres can decrease the pitfalls of opioid addiction.

Yes, another reason to collaborate to improve transitions of care is the opportunity to communicate with non-English-speaking patients. In these cases, we can:

  • Use a professional medical interpreter to be less affected by “false fluency” with medical phrases.
  • Use words that are more easily understood by people outside of medical care.
  • Inform interpreter you want interpretation as literal as possible and to tell you if there is not a literal translation.
  • Ensure in advance that the interpreter and the patient understand the conversation will be confidential.
  • Speak directly to the patient and watch the patient while the interpreter speaks and when the patient replies paying attention to the body language.
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Case Manager Survival Skills

As case managers, we have the opportunity to make a difference not only with our patients but also with our fellow case managers across the care continuum (see Figure 3). How do you keep your passion for case management when our patients, their families, bosses, physicians, employers, adjusters, etc., can drain the passion completely out of you? Just remember: “The pessimist may be right in the long run, but the optimist has a better time during the trip” (Anonymous).

FIGURE 3

FIGURE 3

Kathleen Fraser, MSN, MHA, RN-BC, CCM, CRRN

CMSA Executive Director

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