Tammy Bradly
Sr. Director, Clinical Product Marketing
The goal of any workers' compensation case management program is to minimize the impact of an injury and assist injured employees in realizing their maximum functional abilities. However, to accomplish this goal, understanding that an individual's recovery is impacted by more than just the healthcare they receive is the first step in improving clinical outcomes. Studies have shown that the healthcare received only accounts for 10 to 20 percent of their outcome. The other 80% to 90% can be attributed to social and environmental factors, genetics, and individual behavior. While case managers cannot change an individual's genetic make-up, they can address the social and environmental factors as well as behavior by viewing the individual holistically.
To understand drivers affecting the injured employee and their path to recovery, case managers need to first establish trust, allowing them to begin to know more about the individual and put together a total view. Techniques like active listening and motivational interviewing should be core tenants of the case management process as they allow us to understand all the factors that may impact an individual's recovery. Whether you refer to them as psycho-social issues or Social Determinants of Health (SDoH), a person's mental wellbeing, availability of a support system, access to healthy food, access to transportation, adequate housing, and financial status all influence recovery.
Navigating the health system is intimidating for anyone, and when you are ill or injured, it becomes even more challenging. Add to that, potential financial concerns, the uncertainty of a full recovery, or having a job to return to, which can all lead to stress and anxiety. To further complicate things, what if the individual has no support system or lacks access to transportation or healthy food? These can become barriers to recovery and result in poor outcomes as the injured employee can become overwhelmed, disenfranchised, or unengaged in their own recovery.
As an example, let's look at Margie. Margie is a 55-year-old individual who sustained a left knee injury on the job and had recently undergone meniscal repair. She was prescribed outpatient rehab post-surgery. Margie has a high school education and has worked in a school cafeteria for ten years. She lives with her daughter. Her daughter recently started a new job. Margie's post-op progress is slowing, physical therapy attendance is sporadic, and she missed her first post-op appointment.
Margie had been a model patient prior to surgery, attending appointments and following her treatment plan. Recovery was proceeding according to the established treatment guidelines. Post-surgery, Margie was prescribed outpatient physical therapy. She attended the first couple of sessions and then stopped attending and missed a post-op appointment. Margie's claim was assigned to a case manager.
It did not take more than an initial conversation for the case manager to understand that circumstances in Margie's life were affecting her recovery. Margie let her car insurance lapse due to the financial strain she experienced following her injury. Her daughter initially provided transportation but has since started a new job which prevents her from transporting her mother to appointments. Margie also disclosed to the case manager that she was feeling very isolated and knew she was not progressing on her own as well as she would if she was attending outpatient physical therapy. Transportation was immediately coordinated, and Margie returned to therapy as prescribed, supplementing in-person physical therapy with home exercises.
After the case manager established a rapport with Margie and utilized motivational interviewing techniques to understand the obstacles she faced, Margie shared that her bedroom was on the second floor and that she was having difficulty navigating the stairs. She even confessed to minor falls and her concern over being a burden to her daughter. The case manager met with Margie and her daughter, and a mutually agreed upon plan was formulated to swap rooms until Margie was safely able to navigate the stairs. The physical therapist agreed to work specifically on improving Margie's ability to ambulate up and down stairs and prepare her for return to work.
Within a few weeks, Margie had progressed to home exercises and, upon recheck by the physical therapist, she had met the previously set goals and was discharged. The case manager coordinated follow-up with the provider and secured a release to return to work. She also talked with Margie about the need for transportation when she returned to work and helped her explore available options. A temporary solution using her daughter and a co-worker to provide transportation for the first couple of weeks was formulated. Margie felt she could reinstate her insurance after her first pay period and at that point drive herself.
Margie's story is like many injured employees that case managers encounter every day, and encompasses several SDoH including transportation, finances, deteriorating mental health and living conditions. Her problem was not hard to solve and could have been prevented with pre-surgical planning, but it did require someone to really assess her unique situation.
This example illustrates how important it is to have a clinical management program that incorporates best practices such as behavioral coaching. This model starts with establishing trust, listening to the individual and helping them identify potential barriers to recovery and motivators for change. Gaining trust and engaging the individual is not complicated, but it does require an investment in time and effort that involves active listening and more than a five-minute lecture. It also involves attention to factors that fall outside of diagnosis and treatment that can have a substantial impact on recovery.
