Tag Archives: medical conditions

A How-To on Nurse Case Management

Nurse case management (NCM) has a powerful impact on workers’ compensation claim cost and outcome. Positive results of nurse involvement have long been anecdotally accepted, but widespread evidence of nurse impact has not emerged, and objective proof of value is still missing. Several factors account for this.

Inconsistent Referrals

For one thing, NCMs are usually considered an adjunct to the claims process, called upon in sticky situations. Too often, referrals to nurses is a last resort rather than an integral and standardized part of claim management. When claims adjusters have the sole responsibility to refer to NCMs, it can be subjective, uneven and therefore unmeasurable.

Besides receiving referrals for sundry issues at different points in the course of the claim, nurses have not clearly articulated their case management interventions. Claims adjusters sometimes misunderstand the nurses’ approach. However, consistent referrals and standardized procedures can bring about major change.

Consistent referrals

Referrals to NCM should be made based on specific medical conditions in claims such as comorbidity like diabetes or problematic injuries like low back strains that tend to morph into complexity and high cost. Specific risky situations found in claims data should automatically trigger NCM notification.

A recent article published in Business Insurance, “Nurses a linchpin in reducing workers’ comp costs,” points out how Liberty Mutual has developed a tool that notifies claims adjusters of cases that would most benefit from a nurse’s involvement. Decision burdens for claims adjusters are eliminated. Referrals to NCM are automatic based on specific high-risk situations found in the claim. Inconsistency disappears, and several benefits evolve from this approach.

Process standardization

An operational process can be dissected and categorized, thereby gaining better understanding of its components and relative importance. Review the data to determine which medical conditions in claims result in longer disability, lower rates of return to work and, of course, higher costs. Select the conditions in claims that should activate an NCM referral.

An example is a mental health diagnosis appearing in the data well into the claim process. A mental health diagnosis appearing during the claim for a physical injury such as a low back strain is a strong indicator of trouble. The injured worker is not progressing toward recovery. However, the only way to know this diagnosis has occurred in a claim is to electronically monitor claims on a continuous basis.

Data monitoring

To identify problematic medical situations in claims and intervene early enough to affect outcome, the data should be monitored continually. Clearly, this is an electronic, not a human function. When the data in a claim matches a select indicator, an automatic notice is sent to the appropriate person.

Standardized procedures

Catching high-risk conditions in claims is just the first step. NCM procedures must be established to guide responses to each situation triggered. Standardized procedures should describe what the NCM should evaluate and advise possible interventions. Such processes not only explain the NCM contribution, they assist in documentation and are the basis for defining value.

Measuring value

NCM has been under-appreciated in the industry because measuring apples-to-apples cost benefit has been impractical. When claims adjusters decide about referring to NCMs and individual nurses create their own methodology, variables are endless and little is measurable.

In contrast to the subjective approach, specific conditions in claims found through continuous data monitoring can automatically trigger a referral to the NCM. In response, the nurse is guided by the standard procedures of the organization. When referrals are based on specific conditions in claims and response procedures are delineated, outcomes can be analyzed and objectively scored.

Breaking the Silence on Mental Health

Shh, it’s time for another round of “let’s discuss depression or suicide in the workplace.” That’s right, shh. After all, we aren’t supposed to discuss these issues. If we do, someone else may try to commit suicide. If we hush up the problem, maybe it will go away.

So, help me to understand why we tolerate this silence with mental illness and not with any other medical condition. I think it is because mental health is a bit more mysterious and scarier than most other conditions.

But mental health does account for a large percentage of the costs related to lost productivity ($51 billion). It generates direct costs of treatment of $26 billion a year[1] — and “absence, disability and lost productivity related to mental illness cost employers more than four times the cost of employee medical treatment.”[2]

We need to get over our fear and get the discussions out in the open. Only then will we have a chance to break the cycle.

The goal of breaking the silence is already occurring on the high school level and is showing results. I realize that this is a different population, teen-agers, but talking about it really does matter in prevention. This most recently occurred in a high school in Crystal Lake, Ill., after two teen-age friends took their lives. The school and community leaders made a point of getting information to other students about the warning signs so that they could possibly identify those in danger and encouraged parents to talk with their teens about their grief. Leaders also provided grief counselors onsite and gave the students different options for grieving, which included holding vigils, providing groups and allowing for other forums of expression.

This is an excellent model that can be adapted for the workplace in partnership with your employee assistance program (EAP). Here are some things employers can do for their workplaces after a suicide:

  • Openly discuss suicide and offer grief groups to anyone directly or indirectly involved with the people who took their lives. Make it okay to talk about the suicide. For more information on steps employers might take, go to “A Manager’s Guide to Suicide Postvention in the Workplace.”
  • Provide information about the warning signs so that employees can help identify others who might be at risk. Make sure that employees and their family members get information about resources that they can access for themselves, their family members or other co-workers. And stress the confidential nature of these sources. A great first step is the National Suicide Prevention Lifeline (800-273-TALK (8255)).

The best defense, however, is a good offense. To encourage prevention, I suggest the following:

  • Create a “mental health/wellness” friendly workplace that involves openly discussing mental health and stress and making sure that employees know that there is confidential help available.
  • Provide employees and managers with training on signs of depression, anxiety, etc. and encourage them to seek help if they or a colleague is showing any of these signs.
  • Have your EAP visible through consistent promotional efforts using print, email and social media.
  • Make sure that the company’s benefits plans have good mental health coverage.

I have been lucky enough to have spent the last 36 years in the field helping individuals and organizations become more open to dealing with psychological issues that may interfere with their professional or personal growth. And I have been amazed at how successful treatment can be when the issue is confronted head-on.

As leaders in the insurance industry, those of you who subscribe to this blog are trusted advisers to the leadership and decision makers in organizations of all kinds. I therefore implore you to use these relationships to encourage them to face mental health in an open and forthright manner. Only when people are able to openly seek out help for mental health related concerns in the same manner that they seek out medical treatment for other issues will we be successful.

[1] Managed Care Magazine (2006, Spring) Depression in the Workplace Cost Employers Billions Each Year: Employers Take Lead in Fighting Depression.

[2] Partnership for Workplace Mental Health, A Mentally Healthy Workforce—It’s Good for Business, (2006), www.workplacementalhealth.org.