Articles

A new focus on case management

Dr Mary Wyatt

Dr Wyatt describes the current state of case management in Australia, and asks for your help in identifying a positive path that benefits injured workers and improves conditions for case managers too.

Case management is a collaborative process of assessment, facilitation and advocacy that assists people return to maximum health and function after injury or illness.

It's a broad term. In the RTW field, many of us are involved in case management, even if we don’t actually use the phrase for many everyday situations:

  • Doctors often do case management – e.g. for patients with chronic health conditions;
  • RTW Coordinators are case managers;
  • Insurance staff, whether their title is claims manager, customer service officer or other, are case managers; and
  • Rehabilitation professionals / RTW service providers are case managers. 

Workers’ compensation systems are complex and can be difficult to navigate. Most people with a work injury have little understanding of how the work injury scheme works. Most cope anyway and do fine without much assistance. However, a significant minority run into barriers that contribute to poor outcomes. Case managers can help those in need navigate the journey to recovery and return to work. For this significant minority, the actions and approaches of case managers have a strong impact on outcomes.

Disability, physical health, perceived fairness, long-term recovery, likelihood of RTW, speed of RTW and quality of life all vary according to worker experiences of compensation systems – and in particular the degree to which workers perceive their compensation experience to be fair and low in stress. The behaviour of case managers helps create these perceptions, which are key psychosocial determinants of health.

However, individual case managers are constrained by the expectations and parameters of their employer (often an insurer or claims agent), which is influenced in turn by the culture and financial incentives set by the jurisdiction’s workers’ compensation scheme.

High turnover of case managers can lead to workers receiving suboptimal and impersonal care

For example, if (as we saw in Victoria some time back) the financial incentives set by insurers are based on closing cases, case managers may focus on terminations rather than supporting workers back to work ability. 

Or if, as we saw in NSW more recently, the scheme fails to provide adequate resources in terms of case manager numbers and expertise, and systems that support case manager effectiveness, outcomes will suffer regardless of worker-centric language and good intentions.

Exploring case management (which can also be referred to as claims management) requires us to study how policymakers view and implement their approach to work injury care. 

At the heart of this is a fundamental question. Do policymakers operate on the basis that support and appropriate care and compensation aids in reducing scheme costs? Or, in line with WorkSafe Victoria’s response to the 2019 Ombudsman’s report, are they motivated by a perceived need to balance the payment of just and appropriate compensation against the financial sustainability of the scheme? If policymakers believe the former, then investment in case management logically follows. If policymakers operate on the basis of a trade-off between appropriate compensation and care and the scheme’s financial viability, one would anticipate a focus on controlling costs without deep investment in case management.

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There is no national set of standards for case management practices or responsibilities. Common duties include claims determinations, decisions about access to treatment and rehabilitation services, building relationships and effectively communicating with all claims stakeholders (e.g. injured workers, employers and service providers); and managing paperwork and other administrative aspects of claims.

In most jurisdictions, case managers are expected to have some technical skills, for example knowledge of workers’ compensation legislation, processes and systems, and enough medical knowledge to question workers’ entitlement to medical treatment as appropriate. Case managers must also maintain effective interpersonal relationships with all claims stakeholders, despite varying levels of engagement, cooperation and goodwill.

Responsibilities vary depending on the complexity of the case. Complex cases are time-consuming, and require greater levels of expertise than straightforward cases. However, complex cases are not necessarily allocated to experienced case managers, nor are mental health claims necessarily allocated to a case manager with expertise in that field.

In workers’ compensation, high levels of staff turnover amongst case managers is common. Injured workers in Australia may have multiple changes in case manager over the life of a compensation claim. For some workers – especially those with complex claims – this is a stressful experience. Rapport and claim history is lost whenever a change of case manager occurs. Treating practitioners also describe the frustration of being asked to submit a new report each time the case changes hands.

Other systems issues may pose further challenges. For example, insufficient staffing, ineffective claims management software, negative culture, poorly designed processes and time-consuming bureaucratic demands make it difficult to manage cases effectively.

In contrast, well-trained and adequately resourced case managers who stay with an injured worker over the course of their claim can promote RTW through a partnership approach. The case manager may help the individual overcome obstacles, offer support, provide relevant information about rights and responsibilities, and influence other scheme participants such as the employer or treating practitioner. These approaches are particularly important for people with an elevated risk of delayed recovery and RTW, who may be anxious, unsure, unhappy about their work situation, or coping with other life challenges.

In my view, case management systems need to get back to basics. Case management should be “helpful,” with a focus on personable, respectful and regular communication. Case management should be “early,” with prompt determinations and as little bureaucratic bogging-down as possible. And case management should be proactive, with workers at risk of delayed recovery and return to work identified quickly and offered appropriate supports, at whatever point in the claim their difficulties become apparent.

Supporting workers doesn't mean saying yes to everything. Being nice is a prerequisite in dealing with others, but by itself it's not enough. People are in the middle of a system which may seem straightforward, or may feel like a maze to them.  They need our support but they also need us to help them walk down the path. If we consider they have taken a stumble or the wrong path, we need to have a conversation about what may be a better path for them. 

To do this effectively, particularly in difficult circumstances, one needs knowledge, skills and the ability to communicate effectively. There’s a world of difference between letting someone know in advance about how, for example, coverage for allied health treatments is funded in line with the Clinical Framework, and that if the treatment isn’t helping it is best to stop and consider other options, versus making a decision that funding for treatment will be stopped without advising why and aiding either with a transition to self-management or to other treatment. 

In more practical terms, this means that case management systems should be designed and resourced to allow for:

  • Accurate identification and personalised support for those at risk of delayed recovery and return to work;
  • Timely claims determinations, wage replacements and treatment for injured workers
  • Responsive monitoring of cases, triggering intervention as needed
  • The provision of guidance and support for workers and treatment providers
  • Regular empathetic, supportive, informative and individualised communication with workers
  • Minimal paperwork and other bureaucratic demands, both for case managers and other scheme participants such as treating practitioners and employers
  • Fair and transparent disputes, reviews and investigations
  • Cooperation with other stakeholders, enabling multidisciplinary interventions as needed.

Over the decades, various schemes have adopted different systems: in-house case management, outsourcing to one private claims agent, outsourcing to multiple claims agents, running private schemes in which the private insurer carries the financial risk, and varying incentive arrangements to foster good claims agent practices.

No one approach stands out above the others. What does stand out is the need for a stable workforce of trained and experienced case managers who are supported to provide evidence-based case management. Current approaches in some jurisdictions do not achieve this aim.

Over the next three months, Return to Work Matters will be publishing and republishing content on the good, the bad and the ugly of Australian case management systems, with a particular focus on insurance case management. 

We will draw attention to current challenges as well as suggesting ways forward.

We are also interested in hearing from current case managers about their experiences. We want to know:

  • How well do you feel you have been trained in case management?
  • Has your training balanced communication and engagement sills with the technical skills you need as a case manager?
  • Does your organisation have a regular time for case discussions, to learn from each other?  Is there a system for mentoring? 
  • What is your typical case load? 
  • Do you consider you have sufficient time to do your job effectively?
  • How long have you been in the industry?
  • How long do you expect to stay in the industry, do you see this as long term?
  • Do you consider your salary level is adequate, will it influence your decision to stay or leave the industry? 
  • What are the real barriers to doing better?
  • What do you feel hopeful about?
  • What are the attitudes, practices and system set-ups that limit success?

Please email us with your thoughts / suggestions / answers to any or all of the above questions.

Or, spend a few minutes on our case management survey. We'd greatly appreciate your input as we take on this important topic.