To Solve Complex WC Claims, this New Model Takes an Interdisciplinary, Proactive Approach to Care
Complex claims, as their name would suggest, always present challenges in workers’ compensation. These are the claims that seem to have no resolution in sight, either because the injury itself is catastrophic and involves a long, difficult recovery, or because other variables come into play that complicate recuperation from even simple injuries. These variables include physical comorbidities like diabetes, hypertension and obesity, as well as psychosocial factors.
Bringing complex claims to a close is particularly difficult because these cases require a multidisciplinary clinical approach. Multiple providers need to be involved from the get-go to address the myriad of physical, emotional, mental and social factors. However, that’s not often the way workers’ comp works.
“The challenge today is that the workers’ comp model is very siloed and focused on product and cost. Every vendor wants to deliver their product at the best price, and after they deliver it, they check the box that they did their job and sign off,” said Zack Craft, National Product Leader, Durable Medical Equipment & Complex Care, One Call. “It’s a very fragmented approach that does not address the multidisciplinary needs of patients in complex cases.”
Another challenge is the lack of a clear, predefined outcome to drive toward. In workers’ comp, the goal is always to return to work, but that does not encompass all of the clinical outcomes that should be achieved in order to restore the injured worker to maximal medical improvement.
When multiple providers are involved at different stages without alignment over a set of clear outcomes, the result is disjointed care, dollars wasted, and an injured worker who isn’t getting better.
To address these challenges, One Call developed One Call® CarePath™, which is a specialized model that shifts the focus of care delivery away from providing products and toward a more fluid and integrated approach to treatment. The model considers recovery not as a discrete period of time that ends with return to work, but rather as an ongoing pathway to full function. The model is defined by four key characteristics:
1. Early Engagement of all Stakeholders
The defining feature of CarePath™ is that it is directed by a designated “care navigator.”
“The care navigator is the central point of contact for all stakeholders — patient, clinical providers, workers’ comp carrier, nurse case managers and claim adjusters,” said Kim Radcliffe, SVP, Clinical Operations, One Call. “They will bring everyone together early in the process to establish an evidence-based pathway with clearly defined objectives and expectations.”
One patient – a 35-year-old female paraplegic — came to One Call with a chronic wound that had been open for two and a half years and left her bed bound.
“The carrier engaged our Wound PathwaySM. The care navigator on the case immediately conferred with the case manager and adjuster, who were desperately seeking support, and engaged everyone involved in her care, including the home health provider, equipment provider, and family members,” Craft said.
At key touch points throughout the claim, the navigator will check in to make sure everything is on track. In this case, the navigator monitored how the patient and her family adapted through recommended changes in equipment and care providers.
“If there’s been some critical medical and/or psychological shift or a provider quality issue causing things to veer off path, they’ll course-correct,” Craft said.
2. Injury-Specific, Evidence-Based Care
CarePath™ establishes a framework for coordination among all parties involved in a claim. But the resources and expertise that are brought to bear for each claim are specific to the injury. Evidence-based guidelines dictate these decisions.
“We’re looking at ACOEM and ODG guidelines to establish a recovery pathway that is injury specific,” Radcliffe said. “We’re looking at what has been proven, and that’s critical to ensure we get the most appropriate care for the injured worker while avoiding duplication of care and unnecessary care.”
In the case of the patient whose wound would not heal, wound specialists were able to identify problems with the equipment being used, including her bed, the lift system, and her shower chair. None were helping to relieve pressure from her wound and were in fact inhibiting the healing process.
“She needed to be rotated every two hours, and that wasn’t happening overnight. The lift system’s sling was also positioned directly over her wound. We swapped out the inappropriate equipment, engaged with the home health team, and educated her caretakers on the proper way to rotate and lift her,” Craft said.
Using evidence-based guidelines also brings some standardization to the approach for specific injury categories. Though care plans can be tweaked to meet the unique needs of each patient, a standard approach provides a starting point. It also helps workers’ comp carriers better understand the process and reassures them that there will be some consistency with how claims are handled.
“It’s critical that there is some effort at standardization using proven evidence-based recovery paths. So whether it’s a knee injury or a finger injury, the treatment modalities and the providers involved will be different, but the phases of recovery are the same,” Radcliffe said. “That makes everyone more comfortable and gets their buy-in.”
3. Tailored to Patient-Specific Psychosocial Factors
Evidence-based guidelines also apply to patient-specific factors like co-morbidities, pre-existing injuries and psychosocial factors. “A big component of our pathways is addressing the psychology and emotion of healing,” Radcliffe said.
Spinal cord injuries, such as paraplegia, can significantly impair quality of life. The 35-year-old paraplegic patient had been spending 23 hours of her day in bed and was entirely dependent on caretakers, with no return-to-work plan in place. Her persistent wound didn’t help.
“There was no quality of life. We had to support a positive mindset to help her realize she could heal and become more self-sufficient,” Craft said. “We had to set specific goals and get her actively involved.”
That required looking beyond the wound to make changes to her nutrition, sleep, transfers and daily activities. Addressing these contributing factors improved quality of life and supported both emotional and physical healing.
4. Driven by Functional Outcomes beyond Return to Work
This highlights that there are important outcomes of a workers’ comp claims besides return to work.
“Each injury pathway has its own clinical measures and outcomes. So, if you’re talking about chronic pain, we’re looking at morphine equivalency doses, and we are getting these patients off the opioids,” Radcliffe said.
“Along with amputations, there’s range of motion and gait analysis we use to gauge improvement, and our goal is to get them as functional as possible,” Craft said.
This is the other distinguishing feature of the pathway model: care navigators follow the injured worker from the onset of injury during the recovery process, and through to return to work or maximum medical improvement.
After she was placed on the Wound PathwaySM, the paraplegic patient’s wound closed in 120 days and she was spending up to five hours per day out of bed. But that wasn’t the end of the road. The care navigator continued to check in for several months to ensure the new equipment and new home health team were working well.
“If there’s a back slide or a regression, we’re able to engage with the stakeholders again before it becomes worse,” Craft said.
A Scalable and Adaptable Resource Model
So far, One Call has developed pathways for amputations, wounds and pain, but the core components of CarePath™ can be adapted to address the needs of a variety of injuries. Though One Call has always taken a patient-centric approach, the development of care pathways takes that a step further by proactively connecting clinical priorities with claims management.
“We had the clinical expertise that was needed, but it wasn’t positioned at the right time. We realized we had to change our model. We’ve got incredible operational support. We’ve got people who understand the actual product. And then we had the clinical support, but we had to align all of it much earlier to make a real difference,” Craft said.
“We wanted to become both a partner and a resource,” Radcliffe said. CarePath™ is designed to be a resource model, not a claims management model. “We’re not trying to take over the claim for the carrier. What we’re trying to do is provide a holistic, knowledge-based resource approach that supports both the claim and adjuster, rather than just providing a product.”
The outcome is a physically, mentally and emotionally recovered worker, a simpler claim, and cost savings for carriers and employers.
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with One Call. The editorial staff of Risk & Insurance had no role in its preparation.