Expert Perspective: Plot a Clear Path to Recovery from the Start
Despite the best intentions of everyone involved in an injured worker’s care, treatment missteps can plague any kind of claim, compromising a worker’s ability to recover effectively, as well as driving up both medical and indemnity costs.
Kim Radcliffe, Senior Vice President, Clinical Operations, One Call, spoke with Risk & Insurance® at length about best practices for ensuring that workers receive the right treatment from the right providers at the right time. A big piece of that is being able to see the big picture of recovery from the start.
Following evidence-based guidelines can help drive better outcomes across the spectrum of claims, she said, from complex cases to sprains and strains.
Where are you seeing the most significant opportunity to make an impact on injury recovery outcomes?
The vast majority of workers’ compensation injuries are musculoskeletal. And most of those injuries resolve with a standard course of physical therapy or on their own: bumps, bruises, strains, sprains.
It is when you get into the more complex and severe injuries, which are a very small percentage of claims — that the claims become more costly and difficult to manage and resolve.
Injured workers require different types of care timing and coordination. Treatment may start with acute care, urgent care or even the emergency room. Then the injured worker might go to a different physician. So physicians might be ordering different things at different times. [Adjusters are] generally relying on what the doctors are trying to order, but [they are up against] fragmentation of care. It is pretty prevalent in the U.S. health care system.
What have you found is the best way to get ahead of the situation to prevent fragmentation of care, particularly when multiple providers may be involved in a claim at different times?
Following an early engagement model is about focusing on — as soon as that injury happens — well established evidence-based guidelines that say, “This is what’s going to be supported and what the general best practices are for recovery.”
First and foremost, let’s understand what this patient’s recovery is going to look like. We can look at these guidelines and understand the length of recovery time, engage the patient and give them those expectations up front.
A lot of times that doesn’t happen, so the patient is fearful and doesn’t know what’s going to happen. That fear and anxiety [can compromise] recovery because there are a lot of psychological components to healing.
How important is the coordination of care piece of the puzzle?
From a cost or a practice perspective, there is research that shows when you don’t have coordinated care, you have a 7% increase in deviation from clinical best practices, meaning patients are getting sometimes duplicative or unnecessary services.
I think that is the biggest risk with fragmented care, is if people aren’t talking to each other, you are trying different things and you don’t know what has or hasn’t worked because the right hand is not talking to the left hand. Costs escalate as care gets fragmented.
How does that play out for a typical injury?
A rotator cuff injury, let’s say, is a good example.
A nonsurgical shoulder strain should take about 30 days for one course of therapy. If there is a flag because you see they are not progressing, their range of motion is still bad or their strength is not improving, you might say, “You know what? Let’s call the nurse or an adjuster. Let’s call the physician, maybe get this patient back in. Maybe there is something else going on. The MD is alerted that therapy is not showing benefit.”
Without clinical oversight, they go back to the doctor, who says, “Oh, it’s still painful? Let’s do another month of therapy.”
Then they go back a second month. “No, still not 100%, let’s do one more month of therapy.”
We have frequently seen upwards of three to four months of therapy trying to conservatively manage a shoulder that is not improving and ultimately ends up needing rotator cuff repair.
It should have been identified two, three months earlier. Instead, it is three months of indemnity, you’re on disability, you’ve got scarring. You can end up with a frozen shoulder or another complication. These things exponentially compound the recovery and the cost. Clinical oversight helps to control for those outliers and make sure we keep these patients on track and identify if a different course of action is needed.
Isn’t it enough to have the oversight of the adjuster assigned to the case?
The trouble with the U.S. health care system is no one takes full accountability of that patient’s full spectrum of care — each specialist has a narrow focus on just their specialty. In workers’ compensation, we do have that adjuster, but … except in very severe cases, they don’t actually have a clinical background — they are very often relying on the physician.
Sometimes it takes extra oversight, because unfortunately, not all physicians are practicing evidence-based medicine or holding themselves accountable.
You have to put the right tools or systems in place to assist that care navigator — those guidelines, those red flags. It’s a combination of having the right tools and data and then overseeing and coordinating the care.
What should employers understand about the importance of early engagement and how they can leverage that?
[The great promise] of early engagement is that you are able to influence an injured worker’s caregiving decisions early on. So, based on the severity or type of injury, establishing a triage is key.
[It’s important to] have a consistent manner of reporting injuries, and then to get the injured worker to the right level of medical care, first and foremost.
A lot of cases escalate because a patient goes to the ER. They have a back strain. It was painful but it wasn’t necessarily urgent. But that is where they go because maybe the employer doesn’t have a well-established route to triage that patient to the appropriate type of care.
[That back strain] now may get an unnecessary CAT scan or an MRI, pain medications, all of which is not supported by evidence [for that case]. For instance, we know you don’t need an MRI within the first 90 days if there is not radicular or neurologic symptoms.
In some cases, [unnecessary tests are] actually a rabbit hole for worse recovery or actually harmful care. For example, WCRI just released their 2019 study in August. Their evidence showed that doing an MRI too early results in a higher rate of decompression surgery.
How is early engagement of particular importance in catastrophic cases?
Amputations are a good example. You bring in a prosthetist. You bring in a therapist. You bring in a nurse. You understand, based on the level of the amputation, what’s going to be affected — upper extremity versus lower extremity, above knee, below knee, etc.
By establishing [expectations] up front, you create a target, coordinating that timing between various providers. There might be different physicians with different touch points that you have to coordinate. [That’s an advantage of having] a care coordinator or care navigator — someone making sure all those touch points are there.
The sooner you can get that notice of injury and establish rapport with the patient, with other stakeholders and caregivers, and start down that path, you are better able to achieve that right outcome.
For a simple musculoskeletal issue, there might be a low risk of fragmentation of care. But how can that early engagement still play a significant role in how recovery progresses?
There are psychosocial factors, like fear-avoidance and catastrophizing, that patients start to engage in when they don’t know what to expect. It’s the first time you’ve ever experienced a really bad back strain, and you don’t know really what to expect and how to feel.
So if you can give them information and knowledge about their injury early on, say, “Hey, you don’t have any radicular symptoms. If you’re not experiencing any numbness or tingling or shooting pain, it’s probably just a muscle strain. It will self-heal, but you are going to experience pain for the first couple of days and that’s normal.”
How does early engagement impact the effectiveness of physical therapy?
We’ve seen that if you start therapy within three days of injury, patients require 38% less physical therapy, and need anywhere from three to six weeks less time to discharge. In PT, we focus on, is it safe to move? “Sore, but safe” is something that we say often in PT. You’re going to be sore. It’s going to be uncomfortable, but it’s okay to move.
When you get patients educated, they know they can continue to move and start trying to do normal activity, and it’s not going to make things worse, which is what everyone is concerned about. Then the body starts healing normally, versus when you [don’t move and] get stiff. That’s called fear avoidance. They get stiff, they don’t move, they kind of just lay in bed. Everything stiffens up more and gets a little worse. And then when they do move, it hurts. It’s just this bad cycle of recovery that can escalate. &