WORKER’S COMPENSATION CASE MANAGEMENT1
Worker’s Compensation Case Management: Case Manager’s Responsibilities While Managing Workers with Work-related Injuries to Successfully Return to Work
Nadzeya Lazarev, RN, ASN
Case Management
Professor Emma Kontzamanis
November 28, 2012
Worker’s Compensation Case Management: Case Manager’s Responsibilities While Managing Workers with Work-related Injuries to Successfully Return to Work
Concept: A case manager’s job responsibilities
A case manager’s job responsibilities are extensive and continue to evolve because of incessant changes in the healthcare system. The responsibilities are not seen as “a set of distinct job actions; rather… a tapestry of many aspects of life woven together” (Powell & Tahan, 2010, p. 41). A case manager’s responsibilities are so complex that no national standard exists for them. Based on scientific evidence, experiences, and opinions of case management experts, the Case Management Society of America defines all possible case managers’ job responsibilities; however, not all the responsibilities may be relevant to one’s clinical area of case management practice. At the same time, someof the responsibilities are incorporated in every form of case management. These primary responsibilities are classified into five broad categories: clinical care management, management and leadership, financial and resource management,information management, and professional responsibilities (Powell & Tahan, 2010).
In the healthcare environment, wherein costs are skyrocketing, the reimbursement process is undergoingmany changes, and human resources are limited, a case manager still has the most essential responsibility to act in patients’best interests. Patients – not insurance payers, nor other providers of care, nor institutions – are at the center of case management practice. A case manager is obligated to maximize patients’ opportunities for available services and for optimal desired outcomes. While being a patient advocate, a case manager communicates, collaborates, and, if necessary, negotiates with other healthcare providers and insurance companies regarding optimal services and scarce resources.
It is necessary to carefully study a case manager’s job responsibilities, consider what responsibilities are required for a specific care setting, and be clear about the responsibilities since the responsibilities which are stated unclearly and misunderstood may interfere with accomplishing case management goals. In turn, unmet case management goals may lead to inadequately met desired outcomes, includingpoor quality of care and poorallocation of healthcare resources (Powell & Tahan, 2010).
Cultural Competence
A case manager’s responsibilities are modified based on the client population served and its needs, the context of the care setting, the reimbursement method applied, and the case management perspective. The workers with work-related injuries who wantto successfully return to work have their own unique healthcare needs. To address these workers’needs, the case manager takes on the responsibility of looking at the workers’ compensation cases with a whole person approach.With a broader perspective in the whole person approach, the case manager not only assists the workers with physical restoration of health but also provides them with access to the financial, social, and emotional services required for leading healthier lives (Langstaff, 2011).
For the case manager in a workers’ compensation practice setting, the primary ethical responsibility is to advocate for the injured workers receiving services and as well for their families.The case manager balances the needs of the clients and the constraints of a state-mandated benefit system. While meeting what the clients wants, the case manager may come into conflict with the workers’ compensation insurance carriers since the carriersdo not allow or are not responsible for certain services. Moreover, the situation even worsens when there is a cap imposed by the workers’ compensation statute(Carter, 2011).
In the following example, the case manager is an advocate for an employee Johnwho breaks his ankle at work and requires surgery. Nonetheless, the complexity of his treatment and prognosis for recovery is impacted by preexisting medical conditions including obesity, diabetes, and cardiovascular disease. In this case, the case managerfinds out what is covered and not covered by the workers’ compensation carrier, and what other benefits the employee may be entitled to. The case managerexplores all availableresources,and communicates and educates all stakeholders thoroughly about the options available. The case manager explains to all parties involved the benefit to the employee -- as regards successfully returning to work -- of both having surgery and at the same time managing other health conditions. “Advocating for the injured worker in this setting means clarifying what services can be obtained through workers’ compensation and which services require other resources, and then working with the injured worker to make informed choices regarding his or her care”(Carter, 2011, p. 95).
Being a manager and leader in workers’ compensation cases, the case manager takes the responsibility to facilitate consistent communication and collaboration among all healthcare team members, employers, insurance adjusters, and injured workers. To achieve a successful return to work, the case manager assures that all members of the teamunderstand oneanother’s roles and responsibilities in the process of the return and are aware of how they can help and assist one another. For instance, when the injured worker is not compliant with the physical therapy, the physical therapist should, upon previous counsel from the case manager, immediately notify the case manager so that he/she may work directly with the worker to explore and address his/her concerns. The case manager also reminds the worker that nonparticipation and noncompliance can affect his/her compensation benefits (Watson, 2011). Furthermore, the case manager keeps all lines of communication open and mutualregarding current rehabilitation goals and provides frequent updates of any changes on the file to all involved parties. The case manager does not hide the information about expected disabilities from either employers or employees. It is imperative to relay such data to employers and to involve their human resources departments in reviewing return-to-work options and exploring possible positions that can accommodate workers' abilities (Ferris, 2007).
Before determining a possibility of a return to work at an old, modified or new job, the case manager assumes the responsibility for clarifying medical restrictions and physical abilities of the injured workersand then making sure all parties, including physicians, employees andemployers, understand.The case manager communicates and collaborates with all parties involved to provide as safe and quick as possible a return to work from an initial transition stage to actual employment. During this process, the development of a transitional employment program is one of the case manager’s primary responsibilities because the well-designed program promotes both physical and psychological recovery of the workersand thetimely return to productive employment. The case manager communicates to the injured workers that they are valuable to their employers and the transitional employment program should not be seen as threatening to the employees (Strickland, 2011).
Prior to initiating the transitional employment program, the case manager contacts employers, obtains a written job description, and completes a job analysis that can be helpful for physicians in understanding work environment and specific job duties and requirements, so physicians may more clearly set ranges for certain physical job aspects. The case manager identifies potential and actual problems before the program of return-to-work is started, during the implementation of the program, and after the realization of the program. Hence follows another of the case manager’s responsibilities– problem resolution. For instance, during the transitional employment program, if the employee reports a problem in accomplishing assigned actions, the case manager assesses the problem, contacts a physician and employer, and determines with them if it is necessary to postpone the program until additional medical treatment is provided (Strickland, 2011).
Case Management
Successful return to work is a complex outcome for case management. When all responsibilities of the case manager in workers’ compensation setting have been clearly defined and consequently carried out, case management facilitates safe, timely, and successful return to work for the workers with work-related injuries. Successfully returning the workers to their employers is a win-win strategy for all involved parties:
…the employer who reduces lost time days and regains a skilled employee; the claims rep who moves closer to file closure; the physician who sees restored productivity from his or her treatment; and the injured worker who returns to a job in familiar surroundings and, in most cases, retains seniority and a salary level he or she has worked to attain. (Strickland, 2011, p. 43)
When the case manager utilizes a multifaceted approach, intervenes early in the course, manages the process proactively, and supports injured workers, all stakeholders benefit in the return process.An effective case management leads to substantial financial gains to employers and insurance companies since employers andinsurance companies have significant reduction in the number of days of compensation and the overall costs associated with workers’ compensation claims (Iles, Wyatt, & Pransky, 2012).
An effective case management also causes considerable physical, psychosocial, emotional, and financial gains to employees. When the case manager assumes the designated job responsibilities of assessing, planning, implementing, coordinating, communicating, monitoring, and evaluating options and servicesavailable to the injured employees, he/she will be able to meet their health needs (Lai & Chan, 2007). The case manager who involves the employees in the planning at an early stage and accommodates suitable employment for them will more likely achieve optimal return-to-work outcomes (Schultz, Stowell, Feuerstein, & Gatchel, 2007).
There is no doubt that when the case manager fulfills the job responsibilities of returning the injured workers to work, he/she helps control costs as well as improves outcomes for both employers and employees.
References
Carter, J. (2011). Workers’ compensation case management: Being an advocate amid complexity. Professional Case Management, 16(2), 95-97.
Ferris, K.A. (2007). Communication is the key to a successful return to work. Professional Case Management, 12(2), 116-117.
Iles, R.A., Wyatt, M., & Pransky, G. (2012). Multi-faceted case management: Reducing compensation costs of musculoskeletal work injuries in Australia. Journal of Occupational Rehabilitation, 22, 478-488. doi:10.1007/s10926-012-9364-2
Lai, H.S., & Chan, C.C.H. (2007).Implementing a pilot work injury management program in Hong Kong.Journal of Occupational Rehabilitation, 17, 712-726. doi:10.1007/s10926-007-9110-3
Langstaff, M.A. (2011). Case managers take “whole person” approach to workers’ compensation cases. Professional Case Management, 16(5), 267-269. doi:10.1097/NCM.0b013e318225d47e
Powell, S. K., & Tahan, H.A. (2010).Case management: A practical guide for education and practice. Philadelphia, PA: Wolters Kluwer/ Lippincott Williams & Wilkins.
Schultz, I.Z., Stowell, A.W., Feuerstein, M., & Gatchel, R.J. (2007).Models of return to work for musculoskeletal disorders.Journal of Occupational Rehabilitation, 17, 327-352. doi:10.1007/s10926-007-9071-6
Strickland, T. (2011).Workers’ vs. worker’s.Professional Case Management, 16(1), 43-45.
Watson, E.M. (2011). Vocational case managers and therapists working together.Professional Case Management, 16(1), 45-47.