1. Medical Case Management for the work related injury claim
Arēté Medical Consulting Services, LLC
Donna Macias, RN BSN CCM
Amy Prince RN BSN

2. A collaborative process that assesses, plans, implements, coordinates, monitors and evaluates options and services to meet a client’s health needs through communication and available resources to promote quality, cost-effective outcomes”
(American Accrediation Healthcare Commission/URAC case managrment organization standards, version 1.1)
So what exactly does a case manager do? We are the eyes and ears for everyone. We assess, reassess, and input. We constantly ensure the injured worker is receiving the best and most appropriate care, and we relay concerns to the team as they arise. We understand resource needs and will investigate and utilize the resources as needs arise. The RN CM will also act as a liasion between all parties.
What is case management……..

3. Early intervention: How we can help
Medical assessment and planning Properly specialized care and treatment Cost savings Better outcomes Return to work programs
We are the “boots on the ground”. Eyes and ears. We speak to the providers, the initial physicians. We obtain the diagnostics and treatment to date. We can help formulate a plan to get the injured worker to the Best Possible treating provider for early intervention, diagnosis, and immediate care.
This saves time, saves dollars. The injured worker feels like he/she is being heard, and is an important member of the team to get his injury cared for. The injured worker will understand his role in his own care and recovery and his input is valued. The RN CCM will move the file along and address any issues as they arise. The case manager will work with the employer and the provider to incorporate the job description into the rehab program.

4. Triggers for Nurse Case Management
More than one body part injured Complex Drug Regimen
Co-morbids Degenerative issues
Abnormal diagnostics Rural areas/lack of providers
Language barriers Compliance concerns
Socioeconomic barriers Re-injury
Surgery requests Uncommon injuries
Multiple providers
Complex injuries
Non progressing file
When more than one body part is involved, this can complicate the recovery process. The nurse case manager will insure each body part has the appropriate treating provider, and that all providers communicate with each other. This prevents duplicate medications and also ensures the flow of care.
The nurse case manager will understand the impact of co-morbids. Diabetes, thyroid disease, heart disease, COPD/Emphysema, Charcot’s disease etc. can greatly impact healing and also needs to be addressed as it applies to the diagnoses.
Language barriers can be addressed by adding translating services, but there are dynamics that the nurse case manager will be aware of that need to be facilitated.
What does the IW house look like? What is the cleanliness like? These things effect the healing plan. Do they have a support system at home? Do they have help once surgery is completed? What does their home look like, and what will they need in terms of changes? The RN can assess these things and communicate them to the appropriate parties.
Once surgery is requested, the RN CM needs to be involved in anticipation of DME and postop therapy concerns.
If the file is stagnant, and the injured worker seems to be stuck and not moving ahead, the RN CM can help. Assessing the mental aspects, the road blocks, the medications, the therapy can really help in getting the entire picture so a plan can be made.
Degenerative issues can also hinder the progression of a claim.
Re-injury is a concern. Return to work plans need to be appropriate for the patient. Just because they have restrictions, doesn’t always mean their regular job can be accommodating to the injured worker. Sometimes an entire new role may need to be created to allow the return to work.

5. Process of Nurse Claim Management
Assess, collect data, and reassess
Evaluate and obtain information
Approval process and contacts
Referrals
Needs of the injured worker
Treatment plan monitoring
Goals
Measurable outcomes
Identify barriers

6. Role of the Nurse Case Manager
Injured Worker’s needs
Information Liasion
Networking
Start to finish coordination of care and referral process
Expedient treatment, therapy, goals and outcomes
Anticipating needs, being proactive and including the injured worker in their rehab process
Updating and informing all parties of goals, treatment, outcomes and issues as they arise for intervention
Safe return to work goals that include the employer, injured worker and treating provider
Prevent gaps in care
Information to payors for services, needs, and options for cost effective outcomes.
Facilitiate coverage decisions
Prevent complications
Appropriate referrals to qualified specialists
The RN CM will work with the injured worker to ensure the referral process starts with the diagnosis. The CM will get therapy approved when it is ordered, and will monitor for any issues as or when they arise.

7. Types of RN Case Management Assignments
Telephonic
Field Based
Task Assignment
Medical Record Review
Nurse case managers have extensive manager care industry knowledge. We offer flexibility to customize all aspects of service to ensure programs meet unique needs of each client. Our claims management approach includes Medical and Disability services to manage each piece of the claim to affect overall costs to achieve program efficacy. We adapt our technology and processes to match the specific characteristics of and the claim. Prompt and concurrent review and management of the medical care of injured employees ensuring the utilization of the best and most appropriate medical care. We provide timely and continuous contacts with the injured employee, work site coordinators, medical providers, and claims adjustor until claim resolution promoting effective communication. Focused return to work coordination by managing the disability duration of injured employees compared to national best practice guideline. We promote employee advocacy and goodwill.

8. What happens when a good case goes bad
Co-morbids, complications, and problems……..

9. What is wrong with this picture
Any wound from amputation or other surgery is at risk of becoming infected because the skin opening can allow germs or dirt to enter the bloodstream. Infections can cause tenderness or pain, fever, redness, swelling and/or discharge. These infections can lead to further complications or surgery or even death if not treated properly. The RN case manager will speak to the injured worker and his/her care team daily to ensure any red flags or concerns are immediately addressed. The nurse will educate the injured worker on signs and symptoms to be aware of, and discuss red light issues that require immediate action. The case manager begins the education process long before surgery is set up. Knowledge is power.
Crush injuries will require daily interaction with the injured worker to ensure it does not turn into crush syndrome. Muscle injury causes large quantities of potassium, phosphate, myoglobin, creatine kinase and urate to leak into the circulation. Myoglobin levels in the plasma are normally very low. If a significant amount of skeletal muscle is damaged (>100 g),excess myoglobin is filtered by the kidneys and can cause renal tubular obstruction and renal damage: the excess myoglobin is nephrotoxic. These injuries greatly benefit from a nurse case manager.

10. Why nursing assessment is important
Frequent communication with the injured worker can prevent life-changing outcomes
Compartment syndrome happens when excessive pressure builds up inside an enclosed muscle space. Compartment syndrome can result from bleeding or swelling after an injury. The dangerously high pressure in compartment syndrome impedes the flow of blood to and from the affected tissues. It can be an emergency, requiring surgery to prevent permanent injury. The tough walls of fascia cannot easily expand, and compartment pressure rises, preventing adequate blood flow to tissues inside the compartment. Severe tissue damage can result, with loss of body function or even death. The RN is trained to understand this possible complication and can intervene early.

11. Arēté Medical Consulting Services, LLC
Amy Prince RN BSN
Contact us, let us help you with your claims. The earlier the intervention, the better the outcome.
Donna Macias RN BSN CCM
Call or your referral