How to Optimize the Nurse Case Management Advantage

A White Paper by Karen Wolfe

Traditionally in Workers’ Comp, nurse case management (NCM) services have been widely espoused, yet often misunderstood and underutilized. The reasons for underutilization are many, including claim ownership tension between NCM’s and claims adjusters. More significantly, is NCM difficulty in defining its work and measuring its value. The issue is not lost on the nurses themselves.

Last to computerize

Medical case management is last and least to computerize. NCM typically cannot attract adequate funding to create appropriate systems. When a process is poorly understood, designing a proper software system is impossible. Too often, computerization for NCM is confined to adding nurse notes to the claim system. Notes cannot be calculated or analyzed and outcomes cannot be measured based on nursing initiatives.

Recognized NCM value

Nevertheless, at long last, NCM value is now being recognized. American Airlines recently reported they are adding NCM’s to their medical management staff and will refer all lost time claims to them. They cite a pilot project where nurse interventions were documented and measured, proving their value in getting injured workers back to work. Additional NCM recognition has been published, as well.

Christopher Flatt, Workers’ Compensation Center of Excellence Leader for Marsh Inc., in an article written for WorkCompWire (http://www.workcompwire.com/) stated, “One option that employers should consider as part of an integrated approach to controlling workers’ compensation costs is formalized nurse case management.Taking actions to drive down medical expenses is an essential component to controlling workers’ compensation costs.”[1]

Formalized NCM process

While Mr. Flatt does not define “formalized” nurse case management, he goes on to say, “Nurse case management is considered a “best practice” in helping to direct treatment, manage medical costs, and reduce disability durations, by providing appropriate care and returning employees to work more quickly. Shorter claim durations and returning injured employees back to work have a direct correlation in reducing workers’ compensation costs”.[2] These are certainly the preferred outcomes, but how does the NCM program achieve them? What are the action steps? How is the process documented and measured for effectiveness? Importantly, how are the NCM initiatives standardized across the organization?

Part of the reason NCM is misunderstood is the lack of a formalized process. The services are delivered by individuals responding to a situation as presented to them or as they perceive it.

Referral criteria

Mr. Flatt continues with some concrete suggestions such as deciding what type of claims should automatically be assigned to the NCM and at what points for existing claims. He suggests predictive analytics can be used to make these decisions. However, a formalized and optimized NCM process can be made far simpler and less costly.

Industry research and individual wisdom

Industry research and wisdom gained through individual and organizational experience can supply the indicators for referral to NCM. For instance, one approach is leveraging the America Airlines experience and set the standard that all lost time claims are referred to NCM.

Another example is research shows comorbidities increase claim duration and cost. These cases should also be referred to NCM for oversight. Yet another example is inappropriate medical providers profoundly increase costs. NCM’s should have efficient electronic tools to direct care to the best in class providers.

The list of valid criteria for referral to NCM is potentially extensive.  Nevertheless, the question should be, how can these conditions be identified in claims as they occur and referred to NCM accurately and consistently?

Computer-aided medical management

As a long-ago nurse and a long time medical systems designer and developer, I believe the answer lies in appropriate computerized system design. To be effective, three components are necessary:

1.      Formalized Criteria for referral

Create electronic profiles containing combinations of data elements found in claims that represent the conditions for referral to NCM’s. For instance, when comorbidity ICD-9’s (diabetes, heart disease, obesity) are found in claims, an automatic referral is sent to NCM. This formalizes and enforces the processes consistently.

2.      Technology Powered

Continuously monitor historic and current integrated claim data. The integrated data should contain five years of history and be sourced from clams, bill review, and pharmacy (PBM).

3.      Referral Alert

The system automatically notifies the NCM when the conditions in a claim match that in a profile. This occurs at the beginning or any point during the claim because the data is continuously updated and monitored electronically in context with the criteria.

The process is simple, yet powerful. Moreover, using a computer-intensified medical management power tool offers even more to the process. All referrals to NCM, the reason for referral, and to whom they were sent is documented by the system, thereby creating a formalized audit trail. Organizational procedures or action steps can accompany the referrals, further formalizing and standardizing the process.

Measuring cost savings

When the system documents the process automatically, individual claim savings can be measured. For instance, directing care to a best practice provider, thereby avoiding a low scoring provider, is a cost savings guarantee. Industry research is used as a basis for estimating cost savings in each instance and since it is a computerized system, cumulative savings reports can be produced on demand to quantify the process.

Analytics inspired, technology powered Medical Management

The NCM advantage can be formalized and optimized with technology. Learn more about MedMetrics WC Medical Intelligence Profiles with Alerts and its other medical management power tools or contact KarenWolfe@medmetrics.org for further information.

---

[1] http://www.workcompwire.com/2013/01/christopher-flatt-the-case-for-formalized-nurse-case-management/?utm_source=WCR+Daily+1%2F22%2F13+-+A+New+Leader+Speaks%21&utm_campaign=WCR&utm_medium=email

 

[2] Ibid.