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Commission for Case Manager Certification, New Jersey, USA
Received date: May 14, 2013; Accepted date: July 01, 2013; Published date: July 03, 2013
Citation:Jensen S (2013) Case Management and Care Coordination: Best- Practice Workplace Solutions. Occup Med Health Aff 1:122. doi: 10.4172/2329-6879.1000122
Copyright: © 2013 Jensen S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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As employers seek to mitigate the impact of the cost and duration workers’ compensation cases, companies are increasingly using integrated solutions to improve employee health and productivity. A key component is early intervention by a skilled clinical professional - a professional case manager. Case managers, particularly those who are board certified, have the requisite knowledge, skills, and expertise to act in a care coordination role to ensure access to the right care and treatment at the optimal time, in pursuit of desired outcomes - especially a successful return to work. Case managers also take a holistic approach that looks at the entire person, with communication and collaboration skills that builds consensus among stakeholders and increases buy-in by the injured employee. Through professional case management services, win/win solutions are pursued to meet the needs of the employee and the employer.
Case management; Manager skills; Workplace solutions
Across the care continuum, professional case management is a proven solution to improve quality and efficiency in care delivery. The same holds true in workers’ compensation, as employers and insurers seek ways to decrease the impact of direct and indirect costs while promoting employee health, wellness, and productivity. Within this context, the professional case manager, particularly one who is board certified, brings important skills in assessment, evaluation, and care coordination to identify the most appropriate and timely resources at every phase, from diagnosis and treatment, to rehabilitation and eventual return to work and beyond.
In this article, discussion will focus on the professional case manager in a care coordination role, delivering services to an employee who has become injured on the job or who has an occupation-related illness or disability. It should be noted that although workers’ compensation, as a state-mandated program, is a specialized area of practice, it falls well within the overall scope of professional case management. Case management is an advanced practice within health and human services, bringing together professionals with diverse backgrounds such as nursing, social work, vocational rehabilitation, occupational therapy, and others.
The delivery of case management and care coordination in a workers’ compensation context is encompassed by the overall definition of professional case management, as put forth by the Commission for Case Manager Certification (CCMC). (As the first and largest nationally accredited organization that board-certifies case managers, CCMC has awarded its Certified Case Manager® credential to more than 35,000 case managers since 1992) [1,2]. Case management is defined as a “collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client’s health and human-services needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes” (CCMC, Definition, 2011). (Client refers to the individual receiving case management services; in workers’ compensation, this person is the injured employee.)
Within employee populations, case management is a proven solution to mitigate the cost and impact of injuries and illnesses, whether occupational cases covered by workers’ compensation or nonoccupational that fall under short-term disability. With their skills, experience, and expertise, board-certified case managers are able to ensure that employees receive the appropriate care and treatment at the right time, while working toward the goal of a safe and timely return to work.
Workers’ compensation case management is aligned with the overarching philosophy of case management to facilitate the individual’s wellness and autonomy. The case manager provides access to “appropriate providers and resources,” while ensuring that care and treatment are safe, effective, client-centered, timely, efficient, and equitable. “This approach achieves optimum value and desirable outcomes for all - the clients, their support systems, the providers and the payers” (CCMC, Philosophy, 2013). One can easily recognize these values as being congruent with the typical objectives in workers’ compensation cases of maximum medical improvement and return to work, while reducing the impact of direct and indirect costs on employers.
As we look at the role of the case manager in a care coordination role, we recognize that a long-standing best practice for managing serious or catastrophic workers’ compensation cases has been early intervention by a professional case manager, usually within the first day or two of the incident. Often, this involves an in-person visit while the employee is still hospitalized to meet with the individual and/or the family or other support system. Increasingly, particularly among large employers, the value of such early contact with the employee in all workers’ compensation cases is being viewed as a valuable intervention (although cost containment remains a priority).
Early referral to and intervention by a professional case manager contributes to positive outcomes and may keep complex or highcost claims from escalating further. In addition, through advocacy, the professional case manager builds rapport with the employee that facilitates communication and can help diffuse ill feelings toward an employer, which may mitigate the risk of litigation. Such contact also facilitates the use of care coordination as an integral part of case management to achieve positive clinical, financial, and stakeholder satisfaction outcomes .
Central to the care and treatment plan is care coordination. Across the broader health care spectrum, care coordination is increasingly in the spotlight as a proven means to ensure collaboration and cooperation among several providers and to establish accountability for communication and integration of a comprehensive care plan. The National Quality Forum states that care coordination is particularly important for patients who see multiple physicians and care providers each year. (NQF, October 2010) . While excellent care coordination may very well be the missing link in the healthcare delivery chain, equally important to consider is who provides this service within the overall treatment team. Clinical professionals such as board-certified case managers bring unique expertise to act as care coordinators.
Central to the care coordination process is assessment that looks at the whole person and his/her health issues. Even in workers’ compensation cases, the professional case manager must assess the impact of other health issues that could impact recovery from a workplace injury or illness; for example, the individual who is diabetic may face longer healing from a laceration or surgery.
In addition, research has shown that care coordination as part of professional case management can decrease claim costs by reducing delays in care and transitioning the employee to the right physician to obtain appropriate diagnosis and treatment. Moreover, board-certified case managers have the expertise to provide ongoing monitoring and case evaluation to ensure that medical progress is achieved. If progress is delayed, the case manager, in consultation with the ill or injured worker and the treatment team, recommends changes to the care plan.
Because professional case managers take a holistic view of the individual, care coordination must also take into account the full spectrum of services the injured employee needs to achieve a positive return-to-work outcome. This may involve visits to the workplace, evaluation of workstation, and/or follow up to ensure that physicianapproved job modifications support the employee’s successful transition back to work. Thus, the rehabilitation component of case management and care coordination is integral in managing workers’ compensation cases (Jensen, 2012).
In its most recent field research, known as the case manager role and function study, the CCMC identified rehabilitation as one of the knowledge domains in which case managers in general must demonstrate competency in order to achieve board certification. Specific knowledge requirements within rehabilitation include workers’ compensation, assessment of physical functioning, disability compensation, assistive devices, ergonomics, functional capacity evaluation, job analysis, job modifications and accommodations, and vocational aspects of chronic illness and disability.
As the role and function study shows, the professional case manager has broad knowledge of the case management process as it is practices across the healthcare continuum. In addition, specific knowledge and expertise are more in-depth in certain practice settings, in order to achieve outcomes related to a specific incident or care episode. At all times, though, the professional case manager maintains a holistic perspective that addresses the needs of the injured worker within the context of workers’ compensation statutes, while promoting overall health and productivity. Often, health and productivity initiatives fall under the broad umbrella of a workforce management approach known as absence management.
Absence management and return-to-work
Controlling the cost and impact of workers’ compensation has been in the spotlight for decades as employers have tried to rein in spiraling costs, while reducing the duration of such absences. Today, many employers see workers’ compensation as part of a broader workforce management program addressing all unscheduled absences (despite differences in benefits programs), whether due to occupational or non-occupational causes. Depending upon the employer, absence management can include workers’ compensation, short-term and longterm disability, and even shorter absences covered by paid time off.
Although many large employers offer integrated health and wellness programs, with initiatives to support employees to return to the workplace as quickly as medically feasible after an illness or injury, some companies do not fully recognize the link between health and productivity. As the Centers for Disease Control stated, “While employers understand that investing in human capital improves the company bottom line, they are only beginning to understand the impact health has on worker productivity” . As a result, indirect costs of poor health in the workplace, including absenteeism or reduced work output, may be several times higher than direct medical costs. Productivity losses related to personal and family health problems have been estimated at $1,685 per employee per year, for a total of $225.8 billion annually (CDC, April 2011).
At the same time, however, industry research has shown companies that offer initiatives to promote employee health and foster faster recovery and return to work experience lower costs and improved productivity. Given the aging of the population and the increased prevalence of chronic conditions, employers are looking for more ways to effectively promote health while reducing unscheduled absences. Here, professional case management and care coordination will play a larger part to pursue improvements in efficiency and quality of care delivery, while bringing together the right resources in support of employee goals around recovery and, whenever possible, return to work.
A standard among workforce management programs, particularly in workers’ compensation but increasingly for non-occupational cases, is return-to-work, which helps ease injured/ill employees back into the workforce, sometimes with modified duties or temporary assignments elsewhere in the company. Such programs allow employees to heal and become work-hardened before they are “100 percent” ready, while treatment and rehabilitation continue, with all work-related activities approved by the treating physician.
Within these initiatives, a professional case manager in a care coordination role acts as a liaison among the stakeholders. While acting as an advocate for the injured employee, the case manager works closely with a multidisciplinary treatment team, including the physician, occupational therapist, physical therapist, nurses, and other clinicians. At the center is always the injured employee, in recognition of the importance of a client-centered care and treatment plan .
Across the care continuum, case management is highly individualized based upon the type of injury or illness involved, the individual’s medical status, and the treatment resources needed. A professional case manager who provides care coordination is able to coordinate and facilitate the delivery of the right care and treatment resources at the optimal time in pursuit of desired outcomes. Specific to workers’ compensation, professional case management keeps the focus on the individual-the ill/injured employee-and his/her goals around return-to-work, which are also congruent with the employer’s objectives to control the cost of claims and reduce the duration of unscheduled workplace absences.
Given the aging of the population, the prevalence of chronic conditions, and the need for quality and cost-effective outcomes across the healthcare spectrum, including workers’ compensation, the professional case manager will likely play an even larger role in the future. As the benefits of early intervention, advocacy for the individual, and emphasis on education and self-care are recognized, workers’ compensation stakeholders will turn to the professional, board-certified case manager to manage and coordinated the delivery of care and treatment that will truly make a meaningful difference in the lives and health of employees.
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