Holistic approach gets employees back to work

Medical, disability programs share information

By taking a holistic approach to disability management, Aetna's Integrated Health and Disability program is getting employees on disability back to work quicker and healthier.

The health plan's analysis of claims showed that employees whose disability claims were managed jointly by disability case managers and medical case managers were out of work 3.2 fewer days than employees with Aetna disability coverage alone.

Another analysis found that people enrolled in the Integrated Health and Disability program had significantly fewer inpatient admissions and inpatient days than those in a control group.

"The unique feature of this program is that, when the employee provides HIPAA consent, the medical-side information can be shared with the disability staff. Our disability case managers can view all of the employee's medical records, patient history, laboratory results, medications, and any other information Aetna has been able to capture. This allows our disability staff to take a holistic approach to managing the employee's disability and to help him or her have a healthy return to work," says Adele Spallone, LMHC, LMST, head of clinical services for disability at Aetna.

The disability staff include benefits managers, nurses, behavioral health clinicians, and vocational rehabilitation consultants. The employee may work with one or several of these during the course of his or her disability.

The Integrated Health and Disability process gives disability staff access to the employees' pharmacy, medical conditions, and mental health treatment, providing disability staff with information that may not have been reported by the employee or treating physicians as conditions keeping the employee out of work, Spallone says.

Aetna's shared technology platform makes it possible for health and disability team members to share information about the employee's health and functional status on a real-time basis, which in many cases can help speed up the return-to-work process, she adds.

When an employee files a disability claim, the disability intake staff educate the employee on the Integrated Health and Disability process and ask for his or her consent to allow the disability and medical programs to share clinical information and resources, Spallone says.

"This is important for disability management, particularly when we start talking about return to work and managing the member's out-of-work status. When someone calls with a disability claim, they don't always give us all their clinical information. Access to Aetna's medical systems and shared platform allows the disability benefits manager to view the member's medical record and determine if there are other physicians involved in caring for the patient and get information on potential comorbid conditions that could impact return to work," she says.

The disability and medical staff can share information and work together to identify gaps in care and potential obstacles that could prevent or delay the employee's recovery and return to work, she adds.

For instance, some employees have an underlying comorbid condition that may affect their ability to go back to work when the primary condition is resolved, or they may also have a undisclosed behavioral health condition, she says.

"Communication between medical and disability includes updates on disability status, resolution of obstacles to recover or gaps in care, and updates on the outcome of a health event," she says.

By being able to see the member's benefit information, the disability staff also can determine the employee's eligibility for various health and wellness programs and, when appropriate, make a referral to the medical case manager, she adds.

For instance, if the employee is receiving disability because of an exacerbation of diabetes, the disability manager can make a referral to the disease management program where a medical case manager can educate the employee on opportunities that can help him or her get the condition under control.

"The sooner we engage employees with the right level of care and treatment and educate them around their condition, the better they understand the healing process. This holistic approach can enhance the patient's motivation and level of engagement in the recovery process, and helps them become healthier," she says.

Sometimes employees never access their health or wellness benefits because they don't understand them, or don't know how to access them, Spallone points out.

"Employees may be aware of health and wellness programs that are part of their benefits but may feel like they don't have time to participate," Spallone says.

If employees are experiencing a complication with their illness, are not progressing with their health, or are out of work with a disability, the disability staff can educate them on the benefits of engaging in these programs, she adds.

For instance, employees may have back conditions but they aren't taking medication or being treated by a specialist. When the condition exacerbates to the point that they cannot work and they file a disability claim, the disability staff can make them aware of their health and wellness benefits and help them access them, she says.

"Our goal is to assist them in connecting with the right resources so they can get help for their condition and have a healthy return to work," she says.

Being able to access medical records through the shared platform also can expedite the disability benefit decision, she says.

For instance, if an employee files a disability claim because he or she is having a surgical procedure, and provides the appropriate consent, the staff can verify the inpatient stay by accessing Aetna's medical claims system, rather than having to send a request for medical information to the attending physician and wait for a reply.

"It can reduce the number of days the employee has to wait to start receiving disability benefits," Spallone says.

Communication with the employee, the employer, and the treating physician is an important factor in the success of the disability case management process, Spallone says.

The disability benefits manager often has to educate the employee and the physician about what disability benefits are and about the criteria the employee must meet to be eligible for those benefits.

"Most employees don't understand their disability benefits before they go out on disability. Some employers have benefit exclusions. Others have language in their plan that requires the employee to be treated by specific providers. We educate the employee on what his or her benefits cover and educate the physicians on the disability process as well," she says.

Some physicians may think that disability leave is appropriate when employees are disgruntled or are unhappy with working. In these cases, the disability staff educate the physician and the employee on the disability plan criteria, which often requires medical evidence that the employee is unable to perform the core elements of his or her job.

"In many of these situations, the physician is unable to provide clinical information showing that the employee is unable to perform his or her job and ultimately understand that disability is not the vehicle by which employees solve problems with their boss or work environment," Spallone says.

The benefits managers partner with physicians to help them understand the employee's job and their disability benefit criteria and provide published information on what functionality they need to have in order to return to work. They also give them statistics about the normal duration of disability for the employee's particular injury or illness.

"Many primary care physicians who take employees out of work have limited or no information on the type of work employees do in their jobs. We educate them by providing the job description when available and details around the actual work the job entails. By coordinating with employers and providers, we can assist with maximizing the employee's opportunities for a healthy return to work," she says.

The benefits managers communicate closely with treating physicians, and if another physician is treating a secondary condition, keep him or her in the loop as well.

The disability case managers frequently contact the employer to keep them up to date on the disability status and how long the employee is likely to be out of work. They work with the employers on return-to-work planning, including any accommodations the employer can make so the employee can return to modified duty.

They collaborate with the employer, the employee, and provider on the potential for modified or light duty before the employee is able to return to full duty.

"We know that return-to-work outcomes are better the sooner employees get back into the work force," she says.