The jewels of case management
Why we are pro case management summarises the results of a study published this year in the Journal of Occupational Rehabilitation.*
The research shows case management can substantially reduce time lost from work, and medical and total costs.
In this article we describe the elements of case management that achieved impressive results.
What was the intervention?
The key component was maintaining a connected relationship between the employee who had sustained the injury and their employer.
This meant the organisation introducing the case management approach (OccCorp) had to influence the employee and the company where the model was being put in place. Case managers needed to be able to influence the company’s senior staff, line managers, employees, and any employee representative such as the union. The case manager also needed to influence health practitioners.
Case managers coordinated the management of each claim. Case managers were assigned to specific companies to enhance working relationships and maximise influence.
Initial discussions with companies focused on their claims and premium costs, and the potential to improve their financial bottom line through better management. While there was interest in improving employee well-being and morale, the financial bottom line tended to be the factor that led CEOs and CFOs to contract the case management provider.
The contract was based on a monthly retainer, which was fixed whether outcomes improved or not. The amount of time spent on managing cases did not affect the retainer. The incentive for the return to work service provider was to retain the contract by achieving better return to work rates and therefore lowered claim and compensation insurance premium costs.
In the State of Victoria, as with most jurisdictions in Australia, claims costs and claims experience have a significant influence on the premium. In Victoria claims costs for the preceding three years influence the annual premium costs. An employer commencing a new entity pays the industry rate. The WorkCover premium then changes based on the entity’s claims costs. The premium increases with poor claims experience and decreases if claims costs are low.
Case management approach
The case management approach incorporated day one reporting. If an individual developed a health problem, such as a shoulder pain, or an acute injury such as a fall resulting in a laceration, they were encouraged to report this early to the supervisor or line manager.
The supervisor called in to a 24-hour available injury reporting phone number, generally in the presence of the employee. Reporting by the line manager within 30 minutes of the employee reporting their condition was expected. Reporting more than 24 hours after the employee had advised of their condition was considered a late report. Feedback regarding on-time reporting was provided to each company.
The person answering the 24/7 injury reporting number was an experienced case manager. A minority had health backgrounds. The case manager's role was to implement sensible steps at the outset, and support the worker to get appropriate medical care without delay. They also advised the employee of their role in helping them stay at work or return to work.
Depending on the medical condition, the worker may have been referred to a local private hospital emergency department or to a local doctor. According to the employee’s choice the local doctor may have been a company preferred doctor or their own general practitioner. At the earliest opportunity further management was handed over to the case manager responsible for the company where the employee worked.
Ongoing follow-up was by telephone and face to face meetings. The case managers visited most companies on a regular basis and if possible would also then meet with the employee with the injury. Phone conversations between visits ensured communication at key points in the claim.
If the worker required specialist health care the case manager assisted the treating doctor to minimise delays. Under the current scheme it is not uncommon for there to be significant delays in obtaining specialist care and arranging approval for surgery. For example, at one of the intervention companies a worker with a cartilage tear could have an MRI scan and see a well respected specialist within a week, undergoing surgery a few days later and be back at work within a week of surgery. In contrast, under the general scheme as it operates within Victoria, a delay of many weeks before seeing the specialist and a delay of months before the arthroscopy occurs is not uncommon.
Case managers worked with the employee and line manager to identify appropriate stay at work or return to work duties. Return to work plans, i.e. a written outline of the return to work agreement, are mandatory within Victoria for most claims and were developed by the case manager. These were signed off by the employee, line manager, and treating health practitioner.
Follow-up depended on individual case needs. The majority of injuries were minor and required no more than one or two phone calls from the case manager to ensure the condition had settled. In many cases there was regular contact between the case manager, employee and supervisor over a number of months to ensure appropriate duties, sensible medicine, and to track the person’s improvement and return to their usual job. A small percentage of cases were very complex and require substantial input and services over an extended period of time.
Case management was supported by specifically designed software for injury management. This allowed easy identification of all claims and their status by company or by department, and whether the employee was off work, on restricted duties or back at their normal job. The software supported efficient development of Word documents, such as letters to the doctor, return to work plans, and housed electronic case notes and records. Action items could be identified as overdue, supporting follow-up and efficient case management.
Case managers were chosen based on their competencies and ability to project manage as well as influence. A number of attempts were made to improve case manager selection but this remained an ongoing challenge. Case managers needed experience and skills to identify obstacles to return to work. They needed skills to overcome these obstacles such as workplace-based conflict, lack of support from a supervisor, employee anxiety, lack of treating health practitioner engagement and system bureaucratic delays.
There was no attempt to reduce the costs of medical care. The focus was on ensuring the employee saw a health practitioner they trusted and who provided sensible care and constructive advice. This included discussions with employees about discontinuing treatment that was not helping.
Case managers also needed excellent time management abilities, confidence in their capacity to deal with difficult situations, and the ability to influence different parties across various organisations. At times they needed to weave their way through company politics and industrial relations issues.
The ability to develop a relationship with the employee, one of integrity and trust, was fundamental to achieving good outcomes. The more difficult the case, the more important this became.
Engaging the workplace
When employer senior managers understood the case management approach and what they could do to ensure effective implementation of the intervention, the return to work model was easier to implement and more effective.
As senior managers had been involved with the decision to go ahead with the case management approach, they were mostly on engaged from the outset. In some large companies the senior executive team put the implementation in place but the next level of subordinate managers were dubious or did not understand the approach. An educative process was then required.
The most effective way of influencing managers turned out to be talking to them about costs and claims. Showing them the potential financial benefits in reducing their WorkCover premium allowed them to understand how they could improve their own results and performance. It was often useful to examine the company’s past claims, in particular those leading to the highest costs. Talking through factors contributing to these complex claims highlighted how the intervention could be effective in reducing claim costs.
The next step was to engage senior managers as much as possible. The enthusiastic managers took this on by asking their staff questions about employees with an injury and what was being done to assist them.
Some senior managers took on calling the employee in the first few days after the injury, to check on their well-being and ask if anything else could be done to support them. The aim was for employees to feel that their company was interested in their wellbeing. Most were surprised at being called by the senior manager, and news of the call spread rapidly within the organisation. This helped ensure all staff, particularly line managers, were aware of the importance of the return to work model.
When introducing the return to work model with a new company it was often useful to identify a couple of employees who were not being well supported by the system, such as having surgery held up by bureaucratic delays in the claims administration process. Resolving issues such as delays in treatment access also emphasized the ‘employee-centered’ approach.
Other facets of the intervention
Working with doctors and other treating health professionals not generally difficult. Maintaining the employee-employer relationship was the foundation of employees wanting to come back to work. When the employee wanted to stay at work or return to work, the treating health practitioner would generally ‘follow suit’.
In a small percentage of cases the worker did not seem interested in returning to work despite return to work assistance. In those cases claims managers employed by the company providing the intervention became involved. They worked with the WorkCover Agent / insurer to obtain independent reviews and used the legislative tools available to discontinue wage replacements.
In Victoria, it can be difficult to dispute a claim and the compensation system tends to favour the employee in the dispute resolution process. As such, this approach was used infrequently and only where there were strong grounds.
It was rare to dispute a claim at the time it was initially lodged. The vast majority of claims were accepted immediately to avoid disputes and focus on return to work.
Because of strong initial input from the employer, and in some claims the intervention company case manager, a handful of claims were rejected at the time of claim lodgement. About half were later accepted when further information came to light, and these cases became the most expensive and difficult to manage. It was extremely difficult to retrieve the situation when the person had been off work for an extended period of time and there had been an initial dispute.
The various elements of this case management return to work model are not new or novel approaches.
As the study* and Why we are pro case management illustrate, comprehensive case management can work. It can assist the employee, streamline their care, reduce unnecessary treatment, and improve return to work results, and reduce costs.
It requires a mindset focused on employee care, supported by strong cooperation at the workplace.
It can be challenging to implement, with workers compensation processes often bureaucratic and not necessarily in line with an employee centered approach. And influencing managers requires confidence and the ability to understand the claims and premium costs and how these can be influenced.
* Multi-Faceted Case Management: Reducing Compensation Costs of Musculoskeletal Work Injuries in Australia.Iles RA, Wyatt M, Pransky G. J Occupational Rehabilitation. April 1, 2012.