How to Optimize the Nurse Case Management Advantage, 2nd Edition

by Karen Wolfe

This is an update to an article posted in January, 2013. The response to it was excellent, suggesting the topic is important.

Traditionally in Workers’ Comp, nurse case management (NCM) services have been widely espoused, yet misunderstood and underutilized. The reasons for underutilization are many. Tension between NCM and claims adjusters for claim ownership is one. Even though overburdened, adjusters often overlook the opportunity to refer to NCM.

Also to blame is the NCM process itself. In spite of professional certification for NCM, the process is poorly defined for those outside the nursing profession. Moreover, and more importantly, NCM has difficulty measuring and reporting proof of value.

Underlying issues

Continuing to do business as usual is not acceptable. NCM needs to address several issues to qualify as legitimate value contributors to the claim process. First, they need to articulate their value. To do that, NCM must computerize and standardize its process, measure and report outcomes, just like any other business in today’s world.

Computerize

NCM is last and least to computerize. When a process is poorly understood, funding and designing an effective software system is impossible. Too often, computerization for NCM is relegated to adding nurses’ notes to the claim system. However, such notes cannot be analyzed to measure outcomes based on specific nursing initiatives.

Package through standardization

Packaging a process is the way to standardize it so it can be understood and valued by others. In most situations, an individual NCM interprets the problem or issue, decides on an action, and delivers the response. The organization’s medical management is thereby a subjective, illusive interpretation rather than a definable, quantifiable product.

Granted, the NCM is a trained professional who reacts to events and conditions in the claim based on a medical knowledge base. But when the product is unstructured, variables in delivery cannot be measured or appreciated.

A process that is different every time can never be adequately defined. Establish organizational standards of conditions in claims to be referred to NCM—without exception. Remove the myriad of decisions made or not made by claims adjusters to involve the NCM. The referral can be automated through electronic claims monitoring and notification. NCM takes action on the issue according to organizational protocol and the claims adjustor is notified at the same time.

 
Measure
When the conditions in claims that lead to intervention by NCM are computerized and standardized, the outcomes or effects can be measured. Apples can legitimately be compared to apples, but not to oranges and tennis balls. Similar conditions in claims are noted and approached the same way every time, so the results can be validly measured.

Results in claims such as indemnity costs, time from DOI to claim closure, or overall claim cost can be compared before and after NCM standardization. Compare across different date ranges for similar injuries going forward to measure continued effectiveness and honing of the process.

Measuring outcomes is the most essential aspect of the process. Value is disregarded unless it is defined, measured, and reported. Many options for measuring success are available when the components are standardized and computerized.

Report

Report and communicate measured outcomes. Never assume others will recognize NCM value without delineating it for them. For non NCM’s, the dots in medical management must be connected to see the picture. Describe what was done, why it was done, and how it was done the same way for similar situations and in context with the organization's standards. Then report the outcome value. Establish a continuing value communication process.

Define process in advance

NCM constituencies should be informed in advance of the process and outcome measurements. Define in advance how problems and issues are identified, executed, and how results will be measured. Then proceed consistently.

Recognized NCM value

Nevertheless, at long last, NCM value is now being recognized. American Airlines recently reported they are adding NCM to their staff and will refer all lost time claims. They cite a pilot project where nurse interventions were documented and measured, proving their value in getting injured workers back to work.

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]

Industry research and corporate wisdom
Industry research and corporate or professional wisdom regarding risky situations can supply the standardized indicators for referral to NCM. American Airlines uses the standard that all lost time claims should be referred to NCM. But there are many, sometimes more subtle indicators of risk and cost in claims that can be identified early through computerized monitoring and referred for NCM intervention.

Another example of developing standard indicators for referral is based on industry research that shows certain comorbidities, such as diabetes can increase claim duration and cost. These claims should also be referred to NCM for oversight. Yet another example is steering away from inappropriate medical providers who can profoundly increase costs.

Computer-intensified medical management
As a long-ago nurse and a longer-time medical systems designer and developer, I believe the solution lies in appropriate computerized system design. To be effective, the components are those described above. The elements need to be simple to implement, easy to use, and consistently applied. Only then can NCM offer proof of value.

MedMetrics®, LLC offers Medical Intelligence Profiles with Alerts, an online app that serves as a smart container for an organization’s medical management standards and rules of referral. MedMetrics monitors all claims continuously and sends electronic alerts when conditions in a claim match those in a profile. This and other MedMetrics apps link medical analytics to operations, thereby making them actionable. karenwolfe@medmetrics.org

[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