EXECUTIVE SUMMARY

Case managers assigned to patients who have suffered catastrophic injuries can make a huge difference in patients’ outcomes and ability to return to work.

  • Patients with catastrophic injuries see multiple specialists and need case managers to help them navigate confusing and complex health instructions and appointments.
  • The catastrophic case manager is involved in the case within the first 24 hours of the injury.
  • It’s the catastrophic case manager’s job to keep communication lines open between the patient, family, providers, and others involved in the case.

Case managers are essential in helping patients who suffered a catastrophic injury, such as an amputation, head injury, or spine damage.

“I would say that in almost every case out there, insurance companies covering catastrophic injuries will have a case manager on these cases,” says Kathleen Fraser, MSN, MHA, RN-BC, CCM, CRRN, executive director for the Case Management Society of America (CMSA) of Little Rock, AR. Fraser has spoken about catastrophic workers’ comp at national case management conferences.

Patients with catastrophic injuries see a multitude of physicians, specialists, and rehab therapists. Keeping up with these appointments can be overwhelming for patients and their families or caregivers, Fraser notes.

“So, you have a case manager on these claims to really keep the patient from falling through the cracks and to make sure they get all the appropriate care they need,” she says. “If the patient needs a specialist for assistance, the case manager can make certain the patient gets to that specialist immediately.”

Typically, case managers who work with catastrophic injury cases also work for the insurance carrier for the patient’s employer, or they work for an independent case management company that contracts with the insurance carrier, she says.

“The goal is to help patients achieve their maximum medical improvement and to obtain their maximum quality of life,” Fraser says. “And if they can return to their previous employment, this is ideal.”

In some cases, the injured worker will need assistance from a vocational case manager to help find a new career because it’s not possible to resume the old job. An example might be a roofer who loses one or both legs.

“If the person is quadriplegic or ventilator-dependent, then the patient most likely will not go back to any type of work,” Fraser says.

In those cases, the goal is to ensure the patients receive long-term care that could involve home health, lifetime planners, and other types of care and assistance.

“In a large amount of catastrophic cases, the person can return to some type of meaningful employment,” Fraser says. (See case study of catastrophic injury patient in this issue.)

The case manager’s role is to keep communication lines open with physicians, insurance companies, specialists, and therapists.

“Whatever the orders are, we need to make sure all of the doctors are on the same page,” Fraser says.

The following is how case management of a catastrophic injury might work:

• Case management is among the first involved. When an employee has a catastrophic injury on the job, workers’ compensation will pay 100% of the patient’s care and treatment. There are no copays or deductibles, as there are with private insurance, Fraser notes.

And case managers are called in from the start, usually within 24 hours of the injury. “When I was a catastrophic case manager, the person might be on route to the hospital, and I was called,” Fraser recalls. “Case managers obtain information from step one, and they make sure patients get everything they need at every phase.”

The catastrophic case manager will work with the hospital case manager and meet with the patient to provide contact information.

“Patients might be at a point where they don’t remember any of it, so the case manager sets up a relationship with a family member or caregiver so they have that contact and can give them the security of knowing there is someone helping them,” Fraser says.

Families will worry about the various procedures, physician orders, and the bills. Catastrophic case managers can help them understand these better, and that early contact to build rapport is crucial. “We have to develop that relationship,” she says.

• The catastrophic case manager assists with transitions. Once a patient has been treated for the catastrophic injury and the hospital is ready to discharge him or her to a skilled nursing facility, rehabilitation hospital, or elsewhere, the catastrophic case manager works with the hospital case manager on the discharge.

“We address whatever challenges that patient may have to help remove any barriers that would stop the person from getting necessary help,” Fraser says.

For example, a patient who is in a wheelchair might be discharged home, but will need physical therapy. Entering the house will be difficult because of stairs at every entrance. And the person might need medical devices, a hospital bed, and other assistive devices or technology. The patient might not even have someone to drive him or her to a rehab center each day. These are the types of barriers the catastrophic case manager can address, Fraser says.

“The case manager can ask the physician if the person can be put in a rehabilitation hospital first, instead of being discharged home,” she says. “Or, the case manager could suggest giving the patient home health physical therapy instead of having the patient go to the rehab center.”

The case manager also can ensure the patient’s home has the necessary equipment and address any other barriers.

“Patients assume they can’t get to their therapy, but the case manager can call the physician and say, ‘We have XYZ as a problem, and this is what I’m suggesting,’ or, ‘How do you want to handle this?’” Fraser explains.

Without a case manager’s intervention, the patient and family might skip therapy, not realizing they could receive help with transportation or have a therapist come to the home. The physician might assume that all is well and not find out until weeks later that there was a problem. Then, the patient ends up rehospitalized or needs wound therapy, Fraser says.

• Keep communication lines open. Catastrophic case managers will talk to therapists and make sure the patient is progressing. They also will meet with patients at therapy sessions to see what they have to go through. This helps when the case manager is talking to the therapist later, and the patient can see the case manager knows what he or she is talking about, Fraser says.

“Case managers can see whether patients are making progress or at a point where they’re plateauing, and they can communicate this to the adjuster who does the utilization review,” Fraser says.

The case manager’s observations can determine what happens next. “Are they going to request another four weeks of therapy, or keep the same amount, or is it working?” she says.

Without a case manager’s contact with patients and ability to ensure patients are receiving the care they need, patients and families might begin to blame insurers for missed physical therapy appointments or other lapses that lead to insurance denials, Fraser says.

“Maybe the progress notes fax didn’t go through or they forgot to fax, or maybe the progress notes didn’t explain the progress they were making, and case managers can help with that,” she says.

Insurers need information to review and might have to deny a request without that information, she adds.

• Help patients until they reach the MMI. When catastrophic injury patients no longer are progressing under therapy and treatment, they have hit their maximum medical improvement (MMI).

“There’s nothing else medically the case manager can do for the patient,” Fraser says. “They know they have them settled into what will be their life.”

The insurance company still will be involved, but the catastrophic case manager will close files.

The patient’s case could be handed off to vocational case managers, who will ensure the patient receives vocational training to return to work, or retraining to find another job.

“Patients might need medical devices that will help them on their jobs, so vocational case managers can help get them set up and follow through with them,” Fraser says.

Catastrophic injury patients often are very motivated to improve and return to employment — more so than some people who have had minor work injuries, she notes.

“They were always so much more proactive about working to get back to work,” Fraser says.