EXECUTIVE SUMMARY

Nurse case managers can meet many challenges in workers’ compensation case management.

  • Case managers must help people who have suffered a life-altering injury deal with the physical challenges that arise before they can return to work.
  • A case manager might have only a half day to put resources in place for a workers’ compensation client.
  • They also must keep in mind the client’s and family’s stress and juggle needs from all stakeholders, including providers and payers.

For nurse case managers who enjoy a challenge, workers’ compensation offers the opportunity to use every organizational and creative skill to make things happen for people whose lives are in crisis.

“What is interesting about case management from the workers’ comp perspective is the amount of work that is necessary, and is really important, for the injured workers,” says Hayley Tidwell, BSN, RN, CCM, director of clinical education at One Call in Jacksonville, FL. “There are so many different treatment plans that can be recommended, but that may or may not be found by the insurance company to be a favorable treatment plan.”

Workers’ compensation case managers must be highly skilled in communicating with a variety of stakeholders, including providers, insurance companies, patients, and others. They must ensure everyone understands that the patient should receive the right treatment at the right time to return to work as soon, efficiently, and timely as possible, Tidwell says.

“If a worker has a life-altering injury on the job, the case manager is on the frontlines of communicating with all of the person’s healthcare providers and is an advocate for the injured worker,” she explains. “The case manager helps to coordinate all of the different services that need to be provided for the individual.”

Case managers also are aware that their clients and their families are under tremendous stress, Tidwell notes.

“They are questioning the prognosis and whether they’ll ever be normal or whether this is something that will alter the way they function in their everyday life,” she says. “When this happens, and someone is under this tremendous amount of stress, the nurse case manager can be integral to reassuring the worker and their family and to communicating their concerns to the healthcare workers involved.”

The case manager often works with a neuropsychologist, neurosurgeons, and physical therapy with the goal of successfully transitioning a patient home. The patient’s home might need substantial alterations to make it safe for the wheelchair-bound patient.

For example, Tidwell worked with a truck driver who was in a motor vehicle accident and suffered blunt force trauma from the steering wheel. He was taken by ambulance to the ED and found to have laceration to the kidneys and lung injuries. The man also had bilateral, fractured ankles, she recalls.

“He underwent life-saving surgeries due to internal bleeding and was in the hospital for two weeks,” Tidwell says. “His wife worked full-time and had to take time off work to care for him.”

When the man was discharged, he was given a nonemergent ambulance ride to his home, six hours from the hospital. Tidwell received the call that she needed to have his home ready to receive him by the time the ambulance wheeled in.

“He had to be set up with a hospital bed, durable medical equipment, a shower chair, a wheelchair, and ramping to get in and out of the house because he had a significant injury that altered his ability to perform daily activities,” she says. “He relied heavily on his wife for service.”

The man also needed appointments with local orthopedic services, which is challenging in remote areas such as where the man lived. Tidwell was supposed to have nearly all of it accomplished by the time he arrived home. Her first task was to contact the hospital to obtain the patient’s medical records, his prescriptions, and to call a durable medical equipment provider near his hospital to see if they could provide him with a wheelchair. “They provided the standard wheelchair for him before he left the hospital, and it was in transit with him, costing less than $500,” Tidwell says.

Her next step was to call the patient’s wife and ask for the number of a family member or friend who could let the people delivering equipment into the house. Then, Tidwell needed to source a medical bed, along with sheets. She had to find out if the house had doors large enough to fit the medical bed when it was delivered. “They were able to deliver the hospital bed through the double doors in the back of the house,” she says. “Also, I had to make sure there were sheets delivered that would fit the hospital bed.”

Next, Tidwell found a home health agency to visit the patient and to provide wound care and IV antibiotics. She also found someone to create a ramp to the house, although that would not be completed before he returned home. The shower equipment would not be delivered until the next day, but everything else was ready when he arrived.

“The ambulance would be able to get him on a gurney and take him into the house,” she says.

In cases like this, the insurance company might deny certain requests, saying they are not medically necessary. It is up to the case manager to find an alternative service or work with a provider to make a more compelling case for the service.

“Often, the nurse case manager is a patient advocate, but the case manager also is the go-between for the insurance company and the patient and the provider,” Tidwell says. “The best-case scenario is when you work with injured workers and they have a good experience and they share with you how grateful they are for your services,” she adds. “They realize they would not have had as good of an outcome if they had not had the resources the nurse case manager could provide.”

Once a case manager has helped a worker transition home with all the resources needed to recover and get back to work, more work is needed. For instance, the case manager might need to help the patient find services to cope with the biopsychosocial aspects of the injury, Tidwell says.

“You have to help motivate them to continue on their course of recovery,” she says.

The trucker had to continue with outpatient physical therapy and his wound and fractures had to heal before he could consider returning to work.

“Patients might still have some functional deficits that they are not able to regain due to the severity of their injury,” Tidwell says. “That’s what nurses and physical therapists are there to teach them — new ways to function.”