Comp Clues



By Judi Williams - Pro Active Case Management Services
| Date: 03/01/2005

A physician once said to me, “If a physician is smart, he will know that a Case Manager is his best friend.” What did this physician know and understand about case management? Case Management is a relatively new discipline in nursing and is now being recognized for its importance as a valuable tool in the worker’s compensation claim. Some continue to misunderstand the role of the case manager and how their involvement impacts a file. Case Management historically was used for catastrophic cases, but as the impact on these cases was clearly seen, more and more it was learned that it could impact those less than catastrophic cases.

It is important to understand that the role of an effective Case Manager is not just to observe, record and report information. The Case Manager actively assesses and interprets the medical information for factors that have implications for the file. They look at all aspects of the file including medical, vocational, psychosocial, and situational factors that can affect the rehabilitation of the injured employee.

Case Managers are educators and motivators working constantly with the injured employee to educate them on their medical condition, treatment and what to expect. We spend so much time with the injured worker during physician appointments that we learn a wealth of information on their condition and perspective. We educate them on what is important to relay to their physician. By assuring they are educated on their condition and by motivating them in their recovery, they show an improved compliance and attitude with treatment and the worker’s compensation process, therefore, ultimately a more prompt closure and more optimal outcome to their injury.

Case Managers are facilitators that do not just schedule medical appointments. We review all of the factors and work as a team with the claims adjuster, injured employee, medical providers and employers to put together all of the pieces of the puzzle that will lead to an earlier return to work and improved outcome. When attending an appointment with the physician, I have reviewed all of the medical information, assessed the injured worker’s condition and attitude and have spoken with the employer to identify their regular job duties and modifications that are available for light duty. It is armed with this knowledge that I approach the physician appointment.

A Case Manager’s role is not to tell the physician what to do or how to treat their patient. One aspect of our role working with the physician in an appointment is to assure that he is informed of all the factors that can affect the injured workers progress in their rehabilitation. The physicians often look to the Case Manager for guidance in the employer’s ability to return the employee to light duty and for assistance with facilitating the medical recommendations promptly. We assess the treatment recommendations of the physician to determine if they are appropriate for this injured worker’s work related condition. The Case Manager is assessing whether there are other options available that would be more cost effective while achieving the same outcome and we review these with the physician. Because Case Managers attend appointments with many different physicians, we have the unique opportunity to see other treatment options that have been successful or what did not work. We work with the physician to assist in determining causal relationship and assuring treatment is related to the current work injury versus pre-existing problems again by ensuring that he has the facts. It is common for an injured worker to tell the physician that he normally lifts one hundred pounds at work and that there is no light duty. However, because we have spoken to the employer, we are able to ensure that the physician has the facts on what the regular job really entails and what light duty options might be available.

Most case managers are Registered Nurses with a broad range of experience and knowledge. An RN fresh out of nursing school simply would not have the experience and the knowledge that comes with that to effectively case manage. Because of their experience and knowledge, a Case Manager can be vital in assuring that the medical care is progressing effectively and identifying problems related to that care. We recently had a file handled by our case manager, Laurie, who had an injured worker with a fractured hip and wrist and was treating with a surgeon in another town. The injured worker continued to complain of severe hip pain, however, the physician focused only on that he was taking too many pain medications. From an outside perspective and after reading the physician’s dictations, it appeared that this injured worker possibly had drug dependence issues or was just “whiny”. However, because Laurie was at the appointments and because of her experience and knowledge, she was able to identify that there was most likely a potential medical problem that was not being addressed. She promptly obtained another opinion with a quality trauma surgeon who determined that this patient’s hardware was backing out and his hip fracture was displacing. He replaced the hardware within a week and the patient was on his way to progressing in his rehabilitation. Both her knowledge and experience led to Laurie being able to actively move this case forward saving additional weeks of TTD and wasted therapy. This is not an unusual scenario with case management. It happens frequently.

Case Managers are creative problem solvers. Again, experience and an inner drive to solve problems leads to some very creative solutions. I once had a file where a worker had a serious construction accident and was in a rehabilitation facility. To be discharged she would require a wheelchair ramp at her home. I made several calls to obtain rates, which were exorbitant, not to mention that it would be several weeks before the ramp could be built. Because this employee worked for a construction company and was very well liked, I was able to arrange for the owner to agree to have his other workers build the ramp at the cost of materials only. I obtained the specs for the ramp and several of the co-workers of this injured employee donated their time on a weekend to build a wheelchair ramp. The result? The injured worker was able to go home several weeks earlier than if we had to wait for a contractor to build the ramp. This saved several weeks of costs in a rehabilitation facility plus labor and retail costs of a contractor.

So what does the physician understand about case management? He knows that a case manager is there to be an objective third party that is uniquely experienced in medical, social, vocational, and situational issues. He knows that we are there to work as a team with him, the adjuster, and the injured worker with the common goal of achieving a safe and timely Return to Work and Maximum Medical Improvement.