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Case Management
Objectives: <ul><li>Define case management </li></ul><ul><li>Describe role of case manager </li></ul><ul><li>Reasons for r...
Case Management <ul><li>Case management is the collaborative process of assessment, planning, facilitation and advocacy fo...
Premise <ul><li>When an individual reaches the optimum level of wellness and functional capability… </li></ul><ul><li>EVER...
Types of Case Management <ul><li>Telephonic </li></ul><ul><li>On-site </li></ul><ul><li>Combined </li></ul><ul><ul><li>Fie...
The Players  or the “three point contact” * Injured worker Medical Providers Claims Management
Goals: <ul><li>Achieve wellness through advocacy </li></ul><ul><li>Communication </li></ul><ul><li>Education </li></ul><ul...
Advocacy <ul><li>Active support of an idea or cause etc.; especially the act of pleading or arguing for something  </li></...
Communication <ul><li>The exchange of information  </li></ul><ul><li>The exchange of ideas, opinions and information throu...
Education <ul><li>The activities of educating or instructing; activities that impart knowledge or skill  </li></ul><ul><li...
Identify Resources <ul><li>Assets available and anticipated for operations. They include people, equipment, facilities and...
Facilitation <ul><li>A guided process of decision-making which  insures that all affected individuals and groups are invol...
Cost Containment <ul><li>A wide variety of strategies or methods whose primary goal is to control the rising cost of healt...
Reasons for referral <ul><li>To obtain definitive diagnosis  </li></ul><ul><li>Causal relationship of treatment is undeter...
Continued…. <ul><li>Prolonged conditions that may or may not need surgery  </li></ul><ul><li>No medical reports  </li></ul...
Goal:  Return to Work <ul><li>The major factor in returning to work is: </li></ul><ul><li>Self-employment </li></ul><ul><l...
Qualities <ul><li>Available </li></ul><ul><li>Experienced </li></ul><ul><li>Certification </li></ul><ul><li>Background in ...
Outlining Expectations <ul><li>Tell them what you expect </li></ul><ul><li>Insist they visit the job site at least once (n...
Other Services <ul><li>Ergonomic Assessment  </li></ul><ul><li>Life Care Planning </li></ul><ul><ul><ul><li>(CNLCP vs. CLC...
ISSUES <ul><li>Muscle strains </li></ul><ul><li>“Limited use” or “minimal use” of limb </li></ul><ul><ul><li>Operations jo...
QUESTIONS?
THANK YOU! <ul><li>Victoria Powell </li></ul><ul><li>RN, CCM, CNLCP, ALNC, CEAS II </li></ul><ul><li>VP Medical Consulting...
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Case Management

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A presentation on the role of the nurse case manager with particular interest in the area of workers compensation.

Published in: Health & Medicine, Business
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Case Management

  1. 1. Case Management
  2. 2. Objectives: <ul><li>Define case management </li></ul><ul><li>Describe role of case manager </li></ul><ul><li>Reasons for referral to case management </li></ul><ul><li>How to obtain the best in case management </li></ul><ul><li>Discuss other services offered by CM </li></ul>
  3. 3. Case Management <ul><li>Case management is the collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes. </li></ul>
  4. 4. Premise <ul><li>When an individual reaches the optimum level of wellness and functional capability… </li></ul><ul><li>EVERYONE BENEFITS </li></ul>
  5. 5. Types of Case Management <ul><li>Telephonic </li></ul><ul><li>On-site </li></ul><ul><li>Combined </li></ul><ul><ul><li>Field Assignment (typical) </li></ul></ul><ul><ul><li>Task Assignment (specific) </li></ul></ul>
  6. 6. The Players or the “three point contact” * Injured worker Medical Providers Claims Management
  7. 7. Goals: <ul><li>Achieve wellness through advocacy </li></ul><ul><li>Communication </li></ul><ul><li>Education </li></ul><ul><li>Identification of resources </li></ul><ul><li>Service facilitation </li></ul><ul><li>Cost containment </li></ul>
  8. 8. Advocacy <ul><li>Active support of an idea or cause etc.; especially the act of pleading or arguing for something </li></ul><ul><li>Clear expression of support for the rights of another </li></ul><ul><li>Representing the cause or interest of another, even if that cause or interest does not necessarily coincide with one's own beliefs, opinions, conclusions, or recommendations </li></ul>
  9. 9. Communication <ul><li>The exchange of information </li></ul><ul><li>The exchange of ideas, opinions and information through written or spoken words, symbols or actions </li></ul><ul><li>Reciprocal sharing with individuals of written, oral and non-verbal information according to a common set of rules (e.g. language). </li></ul>
  10. 10. Education <ul><li>The activities of educating or instructing; activities that impart knowledge or skill </li></ul><ul><li>Knowledge acquired by learning and instruction </li></ul><ul><li>The profession of teaching </li></ul>
  11. 11. Identify Resources <ul><li>Assets available and anticipated for operations. They include people, equipment, facilities and other things used to plan, implement, and evaluate programs </li></ul><ul><li>A source of supply or support, the means of meeting a need or deficiency, especially an economic or social need or deficiency </li></ul>
  12. 12. Facilitation <ul><li>A guided process of decision-making which insures that all affected individuals and groups are involved in a meaningful way and that the decisions are based on their input and made to achieve their mutual interests. </li></ul><ul><li>Act of assisting or making easier the progress or improvement of something </li></ul>
  13. 13. Cost Containment <ul><li>A wide variety of strategies or methods whose primary goal is to control the rising cost of health care, thus making health care more affordable. </li></ul><ul><li>Features in a plan of benefits or in the administration of a plan designed to reduce or eliminate certain charges to the plan </li></ul>
  14. 14. Reasons for referral <ul><li>To obtain definitive diagnosis </li></ul><ul><li>Causal relationship of treatment is undetermined </li></ul><ul><li>Illusion of sufficient medical care without resolution </li></ul><ul><li>Long standing pre-existing conditions prolonging disability </li></ul><ul><li>Complicated diagnoses; diagnosis/prognosis without progress </li></ul><ul><li>Two or more conditions related or unrelated to the work injury </li></ul><ul><li>Claimants seeing several physicians or frequent emergency room visits </li></ul><ul><li>Need for medical reports and coordination of services for timely conclusion </li></ul><ul><li>To establish causal relationship between a work injury and current condition </li></ul>
  15. 15. Continued…. <ul><li>Prolonged conditions that may or may not need surgery </li></ul><ul><li>No medical reports </li></ul><ul><li>Conflicting reports and/or extended disability without apparent medical cause </li></ul><ul><li>Prolonged medical care when the injured worker is able to return to work </li></ul><ul><li>Documentation insufficient to return claimants to work or support disability </li></ul><ul><li>Jobs which are inappropriate to sustain attendance at work </li></ul><ul><li>Return to work difficulties because of unresolved medical conditions </li></ul><ul><li>To prevent employer and employee misunderstandings regarding return to work </li></ul><ul><li>Employment with a new company as disability continues </li></ul><ul><li>Claimants suspected of working while on workers' compensation disability </li></ul>
  16. 16. Goal: Return to Work <ul><li>The major factor in returning to work is: </li></ul><ul><li>Self-employment </li></ul><ul><li>Good Management of WC claims </li></ul><ul><li>Workers involvement </li></ul><ul><li>If an employee is not involved there is a significant increase in the probability of their becoming disabled. </li></ul>
  17. 17. Qualities <ul><li>Available </li></ul><ul><li>Experienced </li></ul><ul><li>Certification </li></ul><ul><li>Background in ortho/neuro/occ med </li></ul><ul><li>Familiar with Job or Worksite </li></ul><ul><li>Rapport with many specialists </li></ul><ul><li>Familiar with WC laws-state specific </li></ul>
  18. 18. Outlining Expectations <ul><li>Tell them what you expect </li></ul><ul><li>Insist they visit the job site at least once (no charge) </li></ul><ul><li>Be proactive not reactive </li></ul><ul><li>Next scheduled work day </li></ul>
  19. 19. Other Services <ul><li>Ergonomic Assessment </li></ul><ul><li>Life Care Planning </li></ul><ul><ul><ul><li>(CNLCP vs. CLCP) </li></ul></ul></ul><ul><li>Medicare Set-Aside </li></ul><ul><li>Vocational Management </li></ul>
  20. 20. ISSUES <ul><li>Muscle strains </li></ul><ul><li>“Limited use” or “minimal use” of limb </li></ul><ul><ul><li>Operations job description </li></ul></ul><ul><li>Company doctors </li></ul><ul><li>Obtaining medical reports </li></ul><ul><li>Communication-plant, PMA, TPA, etc. </li></ul><ul><ul><li>Employee vs. physician report </li></ul></ul>
  21. 21. QUESTIONS?
  22. 22. THANK YOU! <ul><li>Victoria Powell </li></ul><ul><li>RN, CCM, CNLCP, ALNC, CEAS II </li></ul><ul><li>VP Medical Consulting, LLC </li></ul><ul><li>Benton, Arkansas </li></ul><ul><li>www.VP-Medical.com </li></ul>

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