Nurse Case Management

On the Case

Payers are looking for spirited nurse case managers who will be patient motivators and advocates, not slaves to process.
By: | October 15, 2014

Chances are greater today than ever that a workers’ compensation claimant will speak with a registered nurse, either telephonically or in person.

There is also greater likelihood that an injured worker with an ongoing claim will interact with a nurse case manager earlier in the life of that claim than occurred in the past. Those with new injuries, meanwhile, are more likely to speak with a “triage” nurse to help determine whether they need further medical assistance.

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Increasingly, nurses are being used in a variety of workers’ comp roles, from providing counseling for injured workers, to becoming more aggressive questioners and overseers of medical treatment.

Hence, the constant appearance of want ads placed by workers’ comp companies seeking registered nurses, usually with case management skills, capable of helping manage disabilities and returning injured workers to the job.

Expect to see the number of those want ads grow as workers’ comp payers look to stem increasing claims complexity and medical expenses.

Over the next several years, employment of U.S. nurse case managers is expected to grow 3.3 percent annually. At the same time, the medical case management industry’s revenue is expected to grow by 3.6 percent annually, to an estimated $6.7 billion in 2018, according to a September 2013 report by IBIS World, an industry intelligence and research firm.

Those statistics reflect an expected growth in demand for all nurse case managers, including those working in group health. But much of the growth will come from workers’ comp, as the number of workers in the U.S. increases, the report stated.

Historically, hiring trends for nurses in group health and workers’ comp are cyclical.

Efforts to hire workers’ comp nurse case managers plateaued about five to seven years ago following a “huge increase,” said Linda Walker, a board member of the American Association of Occupational Health Nurses.

The growth spurt came when workers’ comp insurers and third-party administrators found they needed more registered nurses to help comply with increasingly complex medical laws and to ensure medical providers followed treatment guidelines, she said.

The hiring run ended due to the Great Recession’s impact on employment, according to IBIS World.

Part of the reason case nurses are so much more in demand today is that claims are much more complex today than in years past, said Liz Thompson, CEO at Encore Unlimited LLC, a case management company in Stevens Point, Wisc.

Comorbidities, an aging workforce, and narcotic prescriptions are driving claims complexities. Nurses are also spending more time addressing behavioral and psychosocial issues beyond the original workplace injury, Thompson said.

“Nurse case managers are really needed to help the insurance community navigate through these complex issues,” Thompson said.

Burgeoning Job Rolls

The proof of that need is that workers’ comp insurers and third-party administrators interviewed for this story said they employ many more nurses today than they did a decade ago.

Sedgwick Claims Management Services Inc., for example, employs more than 400 nurses, double the amount of five years ago, said Teresa Bartlett, senior VP and medical director at the company.

Travelers employs more than 500 registered nurses servicing workers’ comp claims nationwide. Their use was made necessary as the ratio of medical expense to indemnity costs for an average claim increased, said Jim Wucherpfenning, VP of workers’ compensation for Travelers.

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Assigning nurses with the knowledge and communication skills to interact with injured workers and doctors alike speeds the recovery process and gets workers back on the job sooner, he said.

“We believe you get the best medical case management when those pieces of a claim are handled by a medical professional,” Wucherpfenning said.

Other claims payers have also increased in-house nursing staff to manage medical care costs.

“The operational models of carriers or payers increasingly have some commitment to in-house nursing to supplement adjusting staff,” said Ronald J. Skrocki, VP, product management and development at GENEX Services Inc. “Maybe 15 years ago there was some of that.”

Skrocki said it is hard to find a major payer today that isn’t using more nurses either in-house or in an outsourced function. No matter how the industry accesses the talent, it needs more of it, he said.

Melinda Hayes, president and CEO of managed-care company MHayes, said that while some large workers’ comp insurers employ hundreds of nurses, they also contract with her company for nurse field case managers and to bolster their telephonic nursing staff.

For older, complex claims, she has seen her nurse field case managers called in earlier today, with the average time from injury to referral dropping from 2.53 years in 2011 to 1.84 years in 2014, Hayes said.

Predictive analytics also plays a role, as it helps adjusters determine which cases will benefit from nurse oversight of medical care. The technology also helps ensure nurses are not unnecessarily assigned to cases that won’t benefit from their involvement, preventing wasteful expenses, experts said.

Slaves to Process

Insurers and other companies providing case managers and other nursing services also have best practices, treatment guidelines, protocols and client handling instructions that their nurses must follow. The measures are intended to help deliver proper care to speed recovery.

But some workers’ comp observers express concern that today’s case managers spend their workday adhering to those processes, rather than critically evaluating claims and applying their medical expertise to improve outcomes.

“I don’t need to pay for you to scribe. I need a critical thinker and a decision-maker and to challenge what is happening in the exam room.” — Judie Tsanopoulos, director of workers’ comp and loss control, St. Joseph Health System

Field case management nurses are now far less likely to engage in critical practices such as questioning a doctor’s treatment decisions when necessary, said Sherri Hickey, director of medical management for workers’ compensation insurer Safety National.

Instead they focus on following protocols and processes, such as making sure patients find their way to a contracted medical provider network. She doesn’t see as many nurses with the “more aggressive, challenging attitude” she believes is necessary.

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“I find some of the nurses now are a lot more process-oriented,” she said.

“They get a little busy with all that work and they are not really focusing on what is the best outcome for the patient. It is more processing than it is looking at the best outcome and how to facilitate that best outcome.”

Hickey is a registered nurse supervising two other Safety National nurses. Hickey and the Safety National in-house nurses in turn police the field case managers assigned to claims by TPAs to make sure the field case managers are doing their jobs properly.

“We are calling those case managers and having discussions on the phone and saying, ‘Have you asked the [medical provider]this question, have you pursued this theory, have you asked them why they are doing this versus that,’ ” she said.

Sherri Hickey, director of medical management, Safety National

Sherri Hickey, director of medical management, Safety National

“We force them into that a little more.”

Judie Tsanopoulos, director of workers’ comp and loss control at St. Joseph Health System in Orange, Calif., agreed that some field case managers have become increasingly process-oriented to the detriment of good patient care.

“Absolutely,” she said. “We have had difficulty finding good nurse case managers.”

She discontinued relations with some field case management companies because their nurses merely accompanied claimants to medical appointments and took notes, but did not ask enough probing questions.

“I would get their reports and all they did was scribe,” Tsanopoulos said.

“I don’t need to pay for you to scribe. I need a critical thinker and a decision-maker and to challenge what is happening in the exam room,” she said.

“That is what I want to pay for and I want them to take their technical skills and clinical skills and utilize them.”

Done right though, nurse case management can have a huge impact on resolving claims.

Tsanopoulos said she spends significant sums for the liberal use of nurse case managers. It increases spending up-front but ultimately reduces claims durations and the costs of ongoing claims.

Motivational Interviewing

Over the years, the roles and training of workers’ comp nurse case managers has evolved, experts said.

Today’s nurses, for example, are more likely to be trained in “motivational interviewing,” said Susan DeMarino, vice president of accreditation services at URAC, a Washington, D.C.-based nonprofit that accredits case management and other health care programs.

The training includes best practices for eliciting information from claimants and empathizing with patients who may be mistrustful of the workers’ comp system.

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“Case managers are getting additional training and education on how to ask questions to better engage the injured worker,” she said. “We started hearing about it about five years ago, but we are starting to see it being applied more.”

Of course, how well nurse case managers perform will be up to the individual. Rest assured, the workers’ compensation risk management industry needs as many of the good ones as it can get these days.

_______________________________________________________

Read more of our three-part series on nurse case management:

10152014_04_indepth_series_nurse_150x150Part IOn the Case

Payers are looking for spirited nurse case managers who will be patient motivators and advocates, not slaves to process.

11012014_09_indepth_150x150Part IIHow Much Is Too Much?

Nurse case managers can provide vital consultation, but contractual limits to the expenses associated with the service are advisable.

Part III: Available in the December 2014 issue.

 

Roberto Ceniceros is senior editor at Risk & Insurance® and chair of the National Workers' Compensation and Disability Conference® & Expo. He can be reached at [email protected] Read more of his columns and features.

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The R&I Editorial Team can be reached at [email protected]