A workers’ comp injury begins a long journey, starting with initial treatment and ideally ending with a return to work. Getting the patient to that successful outcome is a team effort, and nurse case managers play a critical role in keeping that team together.
Cost-effectiveness is only one of the nurse case manager’s goals for treatment, but it is an important one. After all, keeping total costs down is an indicator that the patient is progressing through treatment. The faster an employee can reach MMI and return to work, the lower the costs of a workers' comp injury.
The goal is not to rush rehabilitation at the cost of a full recovery, potentially increasing the risk of re-injury. Instead, nurse case managers and providers must design programs that restore functional capacity completely. Even so, keeping efficiency in mind benefits everyone involved.
How Long Will Workers' Comp Pay for Physical Therapy?
Workers' compensation must pay for all medically necessary care associated with a workplace injury, including physical therapy ordered by the patient's treating physician. Physical therapy sessions are covered until the patient has reached maximum medical improvement (MMI), as determined by the physician. After MMI, the patient must pay for any additional therapies out of pocket.
The insurer, employer, and patient all share the same primary goal — to get the injured employee to MMI as efficiently as possible without compromising the outcome. The nurse case manager shares that goal.
What Nurse Case Managers Can Do
Nurse case managers play a critical role in reducing costs. A 2015 white paper by claims management leader Mitchell calculated that the involvement of a nurse could lower overall costs by 26% and result in 15% faster claims processing. Mitchell has translated these numbers into an 8:1 return on investment (ROI) in the nurse role and $6,100 in savings for the insurer.
The more a case manager can reduce costs while supporting positive patient outcomes, the more valuable they will be to the insurer. Here are seven ways a nurse case manager is uniquely positioned to achieve those goals.
1. Advocate for Evidence-Based Care
Many workers' comp injury claims involve medically complicated situations, including patient comorbidities and multiple injuries. An insurance company can call for a medical review, but a medical professional must make that happen and guide the process.
Nurse case managers can quickly access medical records and review them with an expert's eye. They can identify the necessary next steps and advocate for the right care for each patient.
The proper care is both effective and cost-efficient. The nurse case manager has the expertise to find that "sweet spot" that helps the patient see progress while saving on coverage costs. Those saved costs lead to loyal partnerships between insurance adjusters and nurse case managers.
2. Communicate and Interpret Provider Instructions
Workers' comp injury claimants often have multiple care providers related and unrelated to the claim. The nurse case manager can coordinate with all providers and ensure the patient receives the correct rehabilitative treatment.
Bobby Stephenson, Director of Business Development for Rehab Select, describes the crucial role nurse care managers play there. Because many Rehab Select patients have external providers in the community, the facility relies on nurse case managers to consolidate available information. "It's important to communicate proactively which plan of care to follow," Stephenson says. "As the liaison, the nurse case manager can help with the cost-effectiveness by making sure that process is streamlined."
3. Improve Treatment Adherence
Patient participation is critical to the success of any treatment or work rehabilitation program. When patients don't follow doctor recommendations, it costs the health system hundreds of billions of dollars annually and increases the risk of poor outcomes.
Nurse case managers are uniquely positioned to improve adherence for workers' comp injury patients. They become patients' trusted advocates, explaining the treatment process and each step’s purpose. Patients feel more informed and comfortable complying with treatment instructions.
If the patient needs extra attention or a different approach, the nurse case manager can communicate that need to the provider. This prevents a costly trial-and-error approach and can keep treatment on the right track from the start.
4. Empower Patients and Avoid Litigation
A classic study attributed many medical lawsuits to "insensitive handling and poor communication after the original incident." Only 15% of litigants felt that their providers gave them enough information.
As patient advocates and points of contact, nurse case managers can explain the treatment plan and process. They can answer questions and help the patient understand the treatment team has their best interests at heart.
5. Prepare Patients for Effective Transitions
Workers' comp injury recovery becomes unnecessarily costly when the patient lingers at a certain level of care, potentially because they don't feel ready to go home or don't understand their options.
Nurse case managers can identify when a patient is ready to step down to a lower level of care. They also make those transitions smoother, easier, and more cost-effective by coordinating details with everyone involved. That includes:
- Communicating with providers to ensure the new treatment plan is appropriate
- Explaining changes to the patient and their family
- Ensuring the patient has what they need to be successful with stepped-down care
If the patient is progressing to home-based therapy, the case manager plays a key role in preparing the home and family. They ensure the patient has the right setup, equipment and support to do well. This reduces the risk of regression and a return to higher-level care.
6. Get Patients Back to Work With "Bridge" Roles
Employees, employers, and insurance adjusters often hear "return to work" and assume an all-or-nothing approach. For many injured employees, this method isn't realistic. Some injured employees need a transitional position that corresponds with their current level of functioning before they can safely return to their normal roles.
A nurse case manager is uniquely positioned to identify these roles. They understand the patient's condition, functional capacity, and overall recovery timeline and can work with employers to develop a plan that works for everyone.
7. Choose the Most Appropriate Facility
Rehab is critical in workers’ comp injury recovery. It sets the tone for the entire physical therapy process, including the patient’s mindset.
Therefore, a nurse case manager's most important task is selecting the most appropriate rehab facility. It’s essential not to default to a hospital setting, where patients may receive less individualized attention.
Instead, nurse case managers should look for facilities that prioritize patient needs. These facilities will have a proactive approach and welcome the level of oversight a nurse case manager provides.
Workers’ Comp Injury Recovery at Rehab Select
Rehab Select welcomes nurse case managers and the expertise they bring to the process. Dedicated to keeping costs down, we provide inpatient work rehabilitation services for half to a third of hospital-based care.
Unlike facilities that rely on contracted physical therapists, whose attention is split between our patients and many others, Rehab Select supports a dedicated in-house team. This lets us ensure our patients get the care they need to recover and return to work.