Program gets ill, injured patients back to work

Proactive approach helps health plan exceed

The award-winning medical and disability case management program developed by Blue Cross and Blue Shield of Texas has shown a significant impact in getting employees back to work in a timely manner.

In the first year of the program, more than half of the participants returned to work earlier than expected, based on national averages for their type of injury.

"Statistics show that the longer an employee remains off the job, the less likely he or she is to ever return. The key to our success is that we begin coordinating the care of members early on in their illness and injury and ensure that they get all the services they need to recover and go back to work, says Patricia Sumner, RN, CCM, COHN-S, disability nurse case manager with Blue CareLink Disability Case Management.

For example, after six months of disability, the worker's chance of not returning to work is about 50%, Sumner says. After nine months, the figure climbs to 90%, she adds.

The program has received a BlueWorks Award from the Blue Cross Blue Shield Association for its success in decreasing the time that injured or ill patients need to return to their job, reducing costs, and increasing employee productivity.

The Richardson, TX-based health plan started the disability case management program in 2005 to help members who are ill or injured get well and back to work as soon as possible. The program emphasizes early intervention and coordination between the medical benefit and the disability carrier as well as proactive patient management across the spectrum of care, Sumner says.

Before the program, injured and ill members were eligible for case management, but there was limited coordination with the disability carriers, Sumner points out.

Most members enroll in the volunteer program after they file claims for short-term disability. However, in the first year, 24% of participants entered the program before they filed a claim. Those members were identified through the health plan's predictive modeling, which mines claims data to identify members who have the benefit through their employer and who have an illness or injury that is likely to result in a short-term disability. Other members are referred by their disability carrier or by referrals from other Blue Cross and Blue Shield of Texas programs.

"The beauty of this program is that through our internal processes and predictive modeling, we identify members as early as possible and can start them on the road to recovery earlier," she says. For example, real-time referrals identify members who have had a recent hospitalization for catastrophic injuries, such as those who have suffered a stroke or have been involved in a motor vehicle or other type of accident. The predictive model identifies those who are at risk for joint replacement surgery, such as members who are older, are taking anti-inflammatory medications, or are receiving frequent physical therapy.

"By identifying them in the early stages of their illness or injury, we can see that they receive appropriate care by the right providers, help them understand and adhere to their treatment plan, and make sure they know how to file for disability benefits if they need them," she says.

If the member needs to file for short-term disability, the case managers can help them do so. "If they need help with community resources, we help them find what they need. We work in any way possible to help them get moving and back to work," Sumner says.

If they have complications or comorbidities, the case managers also refer them to other Blue Cross Blue Shield of Texas programs. If patients aren't appropriate for the disability management program, the case managers refer them to programs where they can get assistance. For example, if the disability carrier refers a member with a spinal cord injury to the program, the disability case manager would refer him or her to the catastrophic case management programs so the patient can get the help he or she needs, she says.

The program's focus is on early intervention with members who are likely to file to have a temporary disabling condition and are likely to be able to return to some type of employment within six months after their injury or illness. Most members are in the disability case management program for a maximum of six months.

The care for catastrophically injured or more seriously ill patients who will need more long-term management is coordinated by the company's catastrophic case managers.

When members are identified as eligible for the program, they are contacted by a disability case manager who offers them the option to enroll. When members enroll, they work with the disability case manager to define their goals. "We want to ensure that realistic and appropriate treatment, financial, and psychosocial needs are identified and met. Our goal is for the patient to achieve maximum health benefits and be able to return to work," she says.

The disability case manager works with the physicians and other medical providers to coordinate the plan of care and treatment plan and ensure that the ill or injured worker receives timely assessments and referrals for necessary medical, surgical, and/or rehabilitation services. At the same time, the disability case managers work with the patient, helping him or her comply with the treatment plan and ensuring that he or she is progressing according to expectations.

The interventions are based on standard guidelines for treatment of the patient's condition, the severity of the injury or illness, and the patient's progress.

The case managers use national standardized measurements, such as the Workloss Data Institute's Official Disability Guidelines, to develop their plan of care. The guidelines include evidence-based medical treatment guidelines and an estimated time of duration of each condition, allowing the case managers to track the patient's progress.

The program integrates the health plan's medical management and disability management program. The disability case managers are able to access the claims system for the disability carrier to determine patient demographics, physician contact information, and claims status. Case managers add current case management notes to the system, which allows the claims handler to expedite the processing of the patient's return-to-work status.

"The disability case management program addresses any medical and psycho-social needs of the patients with interventions that assist them in moving efficiently and facilitating early return to work" Sumner says. For example, when appropriate, the case managers refer the members to a mental health provider or their employee assistance program for help with mental health issues.

"Statistics reveal that depression and other mental health disorders may be brought on by a potentially disabling physical illness, and progress toward recovery depends on early treatment of mental health issues," Sumner says.

When the case managers talk with the members, they identify what other comorbidities they might have and refer them to other programs that are part of the medical plan. For example, if a member has had a stroke and has hypertension, the case manager would link the patient with the health plan's wellness initiative, which would help the patient control his or her blood pressure and develop an exercise and weight loss plan, if needed.

"We want to create a continuum of care so once we have gotten them through the process of getting back to work, they can continue with the other wellness programs and stay healthy," Sumner says.

The case managers help members connect with community support programs, such as those provided by the American Cancer Society. They also provide the member with access to resources available through their company's employee assistance plan.

The disability management team coordinates with all other programs offered by the health plan, including the wellness initiative, catastrophic case management, and specialty programs such as disease management or behavioral health management. When appropriate, the member is co-managed by the disability case manager and a case manager from a disease management and behavioral health management program.

"An integrated medical and disability management program promotes early identification of patients with conditions that may place them at risk for prolonged disability," Sumner says. "Our wellness initiative programs, predictive model tool, and trigger diagnosis reports allow us to identify and reach out to members and provide them with tools that may help them maximize their health benefits and minimize or prevent a permanent disability." (For more information, contact Patricia Sumner, RN, CCM, COHN-S, disability nurse case manager, Blue Cross and Blue Shield of Texas. E-mail:Patricia_Sumner@BCBSTX.com.)