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Respectfully submitted by Judi Williams – Pro Active Case Management
Services
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.
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