Workers’ compensation case managers can help injured workers return to work much faster than they would without case management services and monitoring.
• Nurse case managers can start handling a workers’ compensation case while the injured or ill worker is still in the ED, getting the process rolling quickly to ensure the person receives all necessary help.
• The workers’ compensation industry largely follows occupational disability guidelines, which include evidence-based and data-driven methods to help employees return to work after an injury or incident.
• Without case management, an injured worker could become addicted to opioids and languish for weeks before returning to work — sometimes never regaining their previous activities of daily living.
Case managers can make a big difference on the long-term health and economic impact related to workers’ injuries on the job, even when the injury is less serious.
“The unique situation of workers’ comp is we are able, as case managers of workers’ comp, to have an impact and stay in contact with patients from beginning to end,” says Barbara DeGray, RN-BC, CRRN, vice president of case management at Managed Care Advisors in Bethesda, MD.
Case management in other areas are focused on the setting, handing off a patient from one place to the next. “We are helping case managers manage across the continuum of care,” DeGray says. “In workers’ comp, generally, a nurse case manager is assigned soon after an incident, often the same day,” she explains. “That starts the process — identifying that someone has been injured at work, exposed to illness at work, or has a situation where symptoms have developed.”
The industry standard is called occupational disability guidelines (ODG), which also is the name of a company that has extensively studied cases of injured workers and how long it takes them to recover and return to work. ODG employs evidence-based and data-driven guidelines that are used by payers, providers, workers’ compensation, and others. (For more information, see related story in this issue.)
Best and Worst Cases
Workers’ comp case managers are helpful with all injured or ill workers, but sometimes achieve the most striking results when working with employees who suffered a minor injury on the job, she notes.
“Sometimes, it’s the minor injuries that cause more delay [in return to work],” DeGray says. “We pay attention to all injuries and all conditions.”
DeGray offers these two scenarios:
• Worst-case scenario: A worker twists his back at work while lifting and moving a heavy piece of equipment. He is sent to the ED, where he receives muscle relaxers and pain medication, including opioids, since he reported severe pain. They told him to rest, so the man returned home, took his medication, and stayed off work for a day.
“He tries to return to work, but he is in too much pain, so he went home again,” DeGray says. The worker then stays in bed or on the couch, takes his pain medication, stops paying attention to what he eats, and becomes deconditioned.
“His back now causes him more problems because he’s spending time lying down, and he starts to become depressed because he is not contributing to his family and is not involved, and he begins to present as a disabled person,” DeGray says. “After two weeks, he has the potential to go down the opioid addiction track.”
The man visits a doctor for his continued back pain and inflammation, and he receives more opioids. The man does not return to work, and has fallen into a disabled life only one month since he was injured, she adds.
Eventually, a case manager will see the man because of his chronic pain, but it is too late to prevent the downward escalation of his health.
“This is a bad path. Unfortunately, we have seen it happen where no was intervening; no one was checking on them,” DeGray says. “The hospital or ED were not checking on him. He wasn’t referred to home health because that wasn’t appropriate.”
• Best-case scenario: Another worker also twists his back at work. His injury is identical to the first case, but what happens next is much different.
Workers’ compensation assigns a case manager while the man is in the ED, DeGray says. “We contact the ED and find out what their instructions are,” she says. “We have to get something from the ED to justify why they’re out of work. The injured worker has to provide some kind of paperwork to the employer.”
The doctor gives the case manager the discharge information, and the case manager calls the patient after he is discharged to educate him about the use of medication and about how occupational medicine is a specialty area that could help him recover more quickly.
“We direct him into follow-up care with an occupational medicine doctor, who will see him every two weeks,” DeGray says. “Then, the occupational medicine doctor gives him a treatment plan, saying, ‘You can take the opioids, but only take them for a week, and then I want to see you again in a week to see how you’re doing.’”
The occupational medicine doctor advises the patient to use heat and ice, and the doctor writes a treatment plan that is shared with the case manager.
The workers’ comp case manager calls the patient after the occupational medicine clinic visit and explains how to comply with the physician’s instructions and integrate these into his daily life.
The case manager also helps the patient set goals and adjust expectations. “We ask the injured worker patient, ‘What is your expectation? What do you think will happen?’” DeGray says. “We say, ‘Studies about your type of injury and diagnosis show that most people are able to get back to work within six weeks, maybe doing modified work within four weeks, and it’s going to be tough.’”
The case manager emphasizes that the patient should take his pain medication but expect to be taking different types of pain treatment after a couple of weeks. “We set expectations for the injured worker, employer, and healthcare providers,” DeGray says.
For instance, the physician wants the patient to walk, stand, and perform as many activities of daily living as possible. He is supposed to modify his activities to prevent further injury to his back. The man can wash the dishes, but he should avoid bending over to put dishes in the dishwasher, DeGray says.
The treatment plan includes reducing pain medication over time, and encourages the patient to try different pain control methods. The plan refers him to physical therapy several times a week, which has a secondary benefit of helping the worker set a habit of getting dressed and leaving his home, a step toward a return to his prior habits.
“We’re helping him maintain a routine of getting up, getting dressed, and moving out of the house,” DeGray says.
At the patient’s next doctor’s visit, he learns that he is progressing well, and can go back to work. At first, he will return to work with limitations, including not lifting more than 10 pounds.
The providers and case manager find the worker’s back pain is better, so the patient is prescribed nonsteroidal pain medication. Eventually, he can lift up to 20 pounds. Within six to eight weeks of his injury, he is back to his regular work duties.
Return to work within six weeks is the best-case scenario. Eight weeks is average, and workers who recover more slowly might not return for months, DeGray says.
With many workers’ compensation cases, case managers stay involved even after the patient returns to work. “Case managers help them keep on moving along the path of recovery, so they will have all of their symptoms resolved,” she says. “They’re on track to having a productive life. They may need to take anti-inflammatories for the rest of their life, or add some physical exercise they didn’t have before.”
Case managers set patients on a path to where they no longer will need case management. “We’re preventing disability, or minimizing disability by maintaining contact with the patient,” DeGray says. “The idea is to see the whole picture, the whole person, see what is happening, and how to help the person become productive.”