Throw some brainpower at your toughest cases

Committee designs treatment for ‘problem’ cases

Any occupational health practitioner will struggle with the occasional patient who just does not seem to be progressing or one who has unusual needs or requests. If you’re not careful, those patients can fall through the cracks and be forgotten, or their care can continue long past a reasonable, cost-effective point.

At St. Joseph’s Occupational Health Center in Stockton, CA, those problem cases are addressed by a special committee that brainstorms on options for dealing with the patient’s needs and then formulates a game plan. The multidisciplinary committee is called the case management review team, and it focuses on any case that is out of the ordinary.

The cases may involve a medical condition that is more complex than normal, for instance, or a patient who is noncompliant. The team also looks at almost all cases involving lost time, says Dawn Bacon, BSN, MPA, COHN-S, coordinator of occupational health.

"We are strongly oriented to getting people back to work, so the committee will get involved in most of those cases to make sure the person will be back on the job as soon as possible," Bacon says. "We also get involved any time we suspect malingering."

Anyone can refer cases to committee

A case can be referred to the team by anyone in the occupational health program, from physicians and nurses, to physical therapists, pharmacists, or even clerks who may notice irregularities in the patient’s records. The person referring the case for attention does not have to attend the committee meeting or present an explanation of the case, though anyone is welcome to sit in on the meeting.

The committee meets weekly. Its members include Michael Fox, MD, the program’s medical director, Bacon and another nurse, a customer service liaison, and the supervisor of the program’s functional services department, which provides work hardening and return-to-work assessments. When a case is referred for the committee’s attention, a nurse pulls the chart for the next committee meeting and presents a short summary of the case to the committee members. The summary will include a description of the patient’s injury or illness, what care has been delivered to date, and why the case is before the committee.

"Then we all discuss the case and raise questions or make suggestions based on our own knowledge," Bacon explains. "We try to make sure we’re bringing together all the information we have collectively because the problem often is not just a clinical one. The medical director can have a lot of input for treatment plans, but sometimes the case is stalled because we don’t have some needed information from the employer, for example."

Whatever the problem, committee members develop a response to make sure the case will progress. That often means creating a treatment plan to guide future decisions. Typical actions by the committee include ordering an MRI scan for a patient who has had back pain for several weeks, referring a patient to an orthopedist for a second opinion, or determining that a patient has reached maximum recovery and should be discharged from care. The committee also may decide on a patient’s request for alternative therapies such as chiropractic and acupuncture.

One benefit of the meeting is that any needed tasks can be assigned specifically to one person. Otherwise, a case may be stalled only because a certain bit of information is needed from the employer or an insurer. If that is found to be the holdup in the case, the committee makes one member responsible for seeing that the information is obtained so the case can move forward. That sounds simple, but Bacon points out that without such a mechanism, many patient visits can go by before a small need is addressed.

Discussion becomes part of patient record

The entire meeting is documented, and the discussion of each case becomes part of that patient’s record, Bacon says. The notes from that discussion, along with any treatment plan or other recommendations, are added to the record in a special form called the case management review team notes. (See example of the notes, inserted in this issue.)

A note also is added to the cover page of the chart alerting everyone that the case has been reviewed by the committee. That helps to ensure that the treating physician and nurses are aware of the committee’s recommendations. Since the committee’s treatment plan was approved by the medical director, the doctor is expected either to follow the committee’s treatment plan or document why it was inappropriate.

"The committee report can save the doctors a lot of time because it summarizes the case and highlights what needs attention," Bacon explains. "The doctor doesn’t have to go back and read through a chart that’s six inches thick to see what’s going on. The notes can be very helpful when the doctor is trying to decide which direction to go in."

Once a patient’s case has been referred to the committee, the team members will monitor the case periodically until the patient is discharged. The case management review team has met weekly for two years, and Bacon estimates that 10% of all cases are referred to the committee.

The meetings last either an hour or 90 minutes, enabling team members to review 10 to 15 charts and make recommendations. The first review of a case will take longer than subsequent reviews. Some cases will be discussed only briefly to see if the treatment plan is being followed and how it is working.

"This multidisciplinary team is a simple concept, but it can be time-consuming to get the charts together, meet, and discuss them all," Bacon notes. "But in the end, we save time by making sure that patients are treated well and treated efficiently. The employers and insurance carriers expect us to work that way, and it helps us provide better patient care."