Targeting Clinical Support to Improve Outcomes
March 01, 2021 | Categories: ODG by MCG
At the beginning of a claim, it can be difficult to know if or when referring to a case manager would be helpful. Having a case manager at the beginning of every claim would seem valuable, but it would dramatically increase overall costs, stretch limited resources too thin, and might fail to focus on critical claims.
Historically, knowing if and when to use these limited resources has been elusive. However, several tools are now available to help identify which claims would benefit from referral: various risk assessment and long-term disability predictor scores, soon to be amplified and automated by artificial intelligence.
Several models support the benefits of case management, with studies going back decades; a 1987 Intracorp study reviewed 300,000 disability claims and identified timely referral to a case manager as the best predictor of a good outcome.1 More recently, a 2015 report from Safety National compared shoulder surgery claims with a nurse case manager at one employer to claims without a case manager at 31 other companies. The study found:
- 57% shorter disability durations for the managed cases
- 18% reduction in projected medical costs
- 26% reduction in total loss dollars
- 15% reduction in additional lost time from work.2
Yet some critics contend case managers are not advocates for the claimant, but simply an extension of the claim adjuster, only representing the interests of the insurance carrier. While there are a few bad actors in all professions, most case managers take their role of patient advocate seriously. While they may be paid directly or indirectly by an insurance carrier, they ultimately help claimants return to their functional baseline by providing education, guidance, and support.
Timing of the referral is critical for achieving the greatest impact. Often referrals are made reactively in scenarios such as these: reported impairments are inconsistent with the documentation, treating providers have been unresponsive or fail to offer a clear rationale to support ongoing impairments, or a case has a complex clinical presentation with no clear course to resolution. For example, consider a person with both a shoulder sprain and a fibromyalgia claim. Using one of the many industry risk assessment scoring tools, the adjuster could identify the fibromyalgia claim as high risk and refer for case management earlier, while managing the shoulder sprain claim themselves, resulting in better outcomes for both.
Such scenarios, and many others, may indeed benefit from a referral, but delays in identifying a complication create problems. A good outcome is more difficult to achieve with a delayed referral. However, most disability programs now have tools available, many integrated into the claim system or through dynamic linking, that can streamline this process allowing for referrals to be made proactively, before going “off the tracks.” This can significantly reduce and/or eliminate the impact of barriers, reducing/eliminating delays.
Much of this is already well established in most claim programs, without requiring a significant investment or system changes. Using these tools does not require extensive training, but claim handlers must be aware of the tools and use them routinely. With awareness to leverage these tools and best practices to proactively identify higher-risk claims early in the cycle, we can allocate clinical resources efficiently to achieve better outcomes.
– Jamie LaPaglia, RN, CCM, ODG Manager of Implementation and Clinical Education, July 1, 2020
This article was previously published in Disability Management Employer Coalition (DMEC) magazine @Work as the author of their July 2020 column, “A Clinician’s Viewpoint.”
The information contained in this article concerns the ODG or MCG care guidelines in the specified edition and as of the date of publication, and may not reflect revisions made to the guidelines or any other developments in the subject matter after the publication date of the article.
Image courtesy Shutterstock/George Rudy
- Henderson MG, Souder BA, et al. Private Sector Initiatives in Case Management. Health Care Financing Review. 1988(Suppl):89‐95. 1988. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4195124/
- O’Donoghue M, S Perilli. How Nurse Case Managers Add Value to Workers’ Compensation Claims. Safety National 2015 National Workers’ Compensation & Disability Conference. 2015.
Retrieved from: https://www.safetynational.com/conferencechronicles/how-nurse-case-managersadd-value-to-workers-compensation-claims/