Center of Occupational Health Education COHE Renton COHE

Center of Occupational Health & Education (COHE) Renton COHE APP 2013 -2014 Annual Training

What is a COHE? Each Center of Occupational Health & Education (COHE) is a contractual partnership between the Department of Labor & Industries (L&I) and healthcare organizations. ◦ Facilitate the implementation of occupational health best practices during the early phase of a claim. ◦ Promote collaboration between stakeholders (Labor, Business, Unions, Providers, Insurers) involved in a worker’s injury or illness.

COHE – What Claims Qualify? COHE Claim ◦ WA State Workers’ Compensation State Fund claims ◦ NOT: Federal, Self-Insured, Tribal or Out of State Workers’ Compensation claims. Claim filed with a COHE provider and/or COHE provider is the attending provider on the claim. Resources focused on claims within the first 90 days of claim being filed.

COHE Goals & Mission Reduce Worker Disability Improve Employment Outcomes Promote Patient Satisfaction Enhance Clinical Efficiency

Current COHE’s Community ◦ Renton COHE – Valley Medical Center ◦ Western WA COHE – Franciscan Medical Center ◦ Eastern WA COHE – St. Luke’s Medical Center Institutional ◦ The Everett Clinic ◦ Group Health Cooperative ◦ Harborview

COHE – More Details Best Practices Provider Training • Based on evidence • Orientation & best practices training • Designed with provider input • Focused on reducing disability & improving outcomes • Incentives • Regular feedback • Access to resources that will help them better manage an injured worker’s recovery Health Services Coordination • Resource focused on coordination & return to work Community Outreach • Community communication & involvement • Program advocates • Broad provider, employer & labor involvement in quality improvement

COHE Expectations Establish Mechanism to Identify High Risk Cases for Long Term Disability Develop Procedures for Coordinating Care Implement Quality Procedures & Best Practices Foster Communication between Providers, Workers & Employers Offer Training & Mentoring in Occupational Health Best Practices to Participating Providers Provide Feedback to Providers on their Performance

Avoiding Disability 100 80 % IW 60 Receiving Disability Payments 40 Early Intervention Period Focus of COHE Activities 20 0 0 1 2 3 4 5 6 7 8 9 10 11 12 Time-Loss Duration (months)

Keypoints from COHE Effectiveness Research Substantially prevented long-term disability, reducing costs by an average of $480 per claim & lost work time by an average of four days. Savings continue to accrue three to four years after the claim is filed, even though the current COHE intervention occurs during the first 90 days of the claim. In the first year alone, the COHEs (Renton & Eastern Washington) saved approximately $8 million compared to control groups.

May 2013 L&I COHE Program Report Claims treated by COHE providers resolve faster ◦ Faster resolution may be due to COHE Best Practices preventing some medical-only claims from becoming time-loss. (Wickizer, et al, 2007) Majority of COHE providers are medium or high adopters of COHE Best Practices ◦ Currently 62% of COHE providers are high & medium adopters. COHE’s are striving to improve the adoption rate to 80%. 50% of inured workers have access to a COHE provider

Overview of Renton COHE Community based Reduced disability Encourage clinical best practices Provider must be in catchment area Deliverables ◦ ◦ ◦ Physician Recruitment, Enrollment & Training Clinical & Occupational Health Advisors Health Services Coordinators Best Practices & Quality Improvement Methods Communication & Community Outreach Performance Monitoring & Annual Review

Attending Providers in the Program (APPs) Over 200 Providers ◦ Chiropractors ◦ Emergency Physicians ◦ Family Physicians ◦ Nurse Practitioners ◦ Physician Assistants ◦ Specialty Providers Neurology, Occupational, Orthopedics, Podiatry, Physical Medicine & Rehabilitation Around 5, 500 Claims Annually

Center of Occupational Health & Education (COHE) Occupational Health Best Practices

Occupational Health Best Practice #1 Report of Accident (ROA) ◦ Timeliness To L&I within 2 business days of initial office visit § Speeds up processing & adjudication of claim § Strong association between time from injury to receipt of claim at L&I and substantially longer duration of time loss 80% benchmark

Provider Portion of ROA Must complete each box to avoid delay in claim adjudication

Report of Accident Claim is initiated at L&I by the completion of the ROA. Missing information may unnecessarily delay the adjudication of the claim, delaying treatment and payment for services. When the ROA is received at L&I within 2 business days of the initial office visit, you receive higher payment for completing this form. L&I processes COHE claims twice as fast as non-COHE claims.

Report of Accident When determining whether to file a claim for a patient: ◦ If patient asks you to file a claim, you must regardless of your opinion as to it’s workrelatedness. Indicate on the ROA that the claim is work-related or not. Inform the patient that inappropriate filing of a claim can cause delays in payment by other insurers. ◦ Claims should be filed even for minor injuries. ◦ Fear of retaliation by employer. Inform patient that the law protects them from discrimination for filing a claim.

Report of Accident If patient refuses to file and you feel condition is work-related: ◦ Tell patient of his/her rights under the law (Title 51) and provide assistance with filing claim. If patient still refuses, should not file claim. ◦ L&I will not pay for visit if ROA is not completed and filed. ◦ Patient cannot seek payment from other insurers by withholding that condition is work-related. Title 51 prevents an employer from paying directly for an injured worker’s care to avoid filing a claim.

Report of Accident Determining Work-Relatedness ◦ Depends on a variety of factors (medical, legal and administrative) ◦ May be difficult to determine ◦ In box 7 on the ROA, you are required to answer yes/probably or no/possibly By law, a claim can be accepted only if the provider states the condition is work-related “on a more probable than not basis” or greater than 50% certainty, e. g. , yes/probably. ◦ For condition to be work-related, the industrial injury or exposure must be a “proximate cause” of the diagnosed condition.

Occupational Health Best Practices #2 Activity Prescription Form (APF) ◦ Complete at first office visit ◦ Complete with any work status change Gives claims manager & employer information on the tasks worker can do. Better chance of worker returning to work in a timely manner. Claims manager uses form for time loss certification & treatment authorizations. HSC uses the APF to facilitate return to work efforts with employer. ◦ 80% benchmark

APF Key Points General Info General Section Injured Worker’s Name: Visit Date: Claim Number: Doctor’s Name printed: Date of Injury: Diagnosis: ◦ Patient stickers may be used, as long as all the requested information is provided. ◦ Either ICD-9 codes or written diagnoses may be listed in the diagnosis box. ◦ Providing this information will ensure the form gets into the correct claim file. ◦ Including the provider’s name and the visit date is important for billing purposes.

APF Key Points Released for Work Section Required: Key Objective Finding(s) ______/_______ to _______/_______ Worker may work limited hours: ______hours/day from (date): Check at least one Required: Released for work? Worker is released to the job of injury without restrictions on (date): ____/____ Skip to “Plans” section below. Worker may perform modified duty, if available, from (date): ______/_______ to _______/_______ Worker is working modified duty or limited hours Please estimate capacities below and provide key objective findings at right. Worker not released to any work from (date): ____/____ to ____/____ Prognosis poor for return to work at the job of injury at any date May need assistance returning to work Capacities apply 24/7, please estimate capacities below and provide key objective findings at right. ◦ If released to job of injury without restrictions, skip to “Plans” section. ◦ Objective medical findings are needed to certify time loss or loss of earning power benefits. ◦ Be realistic on “to” dates. May not necessarily be the next office visit, but the point at which patient’s status is expected to change.

APF Key Points Released for Work Section Cont’d ◦ Must include at least one “key objective finding”. ◦ Examples of objective findings are: Limited ROM Decreased strength Swelling Muscle atrophy Do not include subjective complaints such as pain, tenderness or fatigue. ◦ Be specific with date ranges.

APF Key Points Estimate Section What Worker Can Do

APF Key Points Estimate What Worker Can Do Section ◦ Enables employers to identify potential light/modified duty positions. ◦ Complete with assumption that light/modified duty is available. ◦ Check as to how long the current capacity will last or if are permanent. ◦ Estimate based on provider’s clinical opinion. Conservative estimates are acceptable. ◦ MUST be completed even when worker is not released to work. For worker to understand what should physically do and not do to enhance recovery.

APF Key Points Estimate What Worker Can Do Section ◦ Only address restrictions applicable to claim covered condition. Boxes left blank will be considered as not restricted. ◦ “Other instructions” could include need to elevate limb periodically, no use of left arm, etc. Be specific. ◦ Note to claims manager is intended to help you draw their attention to an issue, i. e. “need authorization for…” Also has space for new diagnosis and opioid prescriptions.

APF Key Points Plan/Sign Section Worker progress: As expected / better than expected. Required: Plans Slower than expected. Address in chart notes Next scheduled visit in: _______ days, _______weeks. Treatment concluded, Max. Medical Improvement (MMI) Any permanent partial impairment? Yes No Possibly If you are qualified, please rate impairment for your patient. Current rehab: Surgery: PT OT Home exercise Will rate Will refer Request IME Other_______________ Care transferred to: ________________ Consultation needed with: ______________ Not Indicated pending: __________________ Possible Planned Study Comments: ◦ ◦ Quickly/briefly establishes plan for rehabilitation. Succinctly indicates whether patient is progressing. Comments are strongly encouraged. Identifies what should happen next. Alerts claims manager to actions needed, e. g. , impairment rating exam schedule, Independent Medical Exam needed, claim closure.

Occupational Health Best Practices #3 Provider-Employer Contact ◦ Provides timely communication between provider and employer regarding return to work ◦ Call employer at or after the initial office visit. Ascertain if light/modified duty available. Provide information on worker’s restrictions, treatment planned, etc. ◦ Note outcome of contact with employer on section in APF. ◦ Contact employer at or after subsequent office visits as needed. ◦ Be sure to bill for phone call and use appropriate modifier. ◦ 25% benchmark

Occupational Health Best Practices #4 Barriers to Return To Work Addressed ◦ Worker has been off work 4 weeks or greater Receiving time loss ◦ Ascertain reasons worker is off work ◦ Develop action plan ◦ Identify clinical evaluation/rehab services needed ◦ 80% benchmark

Occupational Health Best Practices #4 Barriers to Return To Work Addressed ◦ Barriers Exam Can be completed by the APP or a COHE Advisor. In addition to the regular exam. Must include an extensive SOAPER note addressing barriers. ◦ Medical Case Conference ◦ HSC Services Billed

SOAPER Chart Notes S: The worker’s subjective complaints O: The provider’s objective findings A: The provider’s assessment P: The provider’s treatment plan E: Employment issues R: Restrictions to work

Center of Occupational Health & Education (COHE) In Summary

How to “Do Good” in L&I System? Set expectations for injured workers regarding return to work. Help avoid administrative claim delays. Eliminate barriers to care. Facilitate communication with all parties. Establish & maintain communication with employer. Enhanced payment for services if provider meets the Occupational Health Best Practices benchmarks. ◦ Scorecards are published by L&I on a quarterly basis.

APP’s Role Care of the injured worker. ◦ ◦ ◦ Make the diagnosis. Comment on work-relatedness. Complete ROA. Always consider work abilities. Complete APF. Include claim number, date of injury and employer on each patient encounter. If help is needed with the patient’s return to work process, please contact an HSC.

Resources Available for APPs COHE Project Directors ◦ Jaime Nephew, PT, DPT, MBA, FACHE ◦ Grace Casey COHE Medical Directors ◦ Karen Nilson, MD ◦ Scott Morris, MD COHE Advisors ◦ Wide variety of disciplines represented COHE Health Services Coordinators (HSC) ◦ ◦ Diena Wasson, RN-BC, CCM, BSN Ellen Hull, M. Ed. , CRC Heather Latvala, M. Ed. , CDMS Kathryn M. Visser, M. Ed. , CDMS

HSC & APP One-on-one training Assist with return to work coordination ◦ Promote occupational health best practices ◦ Provide training for nurses and other office staff ◦ Even missing 3 to 7 days of work can increase disability and a long-term earning capacity. ◦ Research has shown that a worker remaining on payroll during recovery has a greater chance of full recovery and a higher family income while recuperating. Evaluate potential barriers to return to work early to prevent ongoing disability

Early Return to Work

HSC Responsibilities Identify claims that are at risk for long-term disability. Intervene on claims that need HSC assistance. Track claims to ensure early return to work services, care coordination and improved clinical outcomes of injured workers. Act as a liaison, on behalf of the provider, between injured worker, employer and L&I. Help employers, providers and injured workers navigate the Workers’ Compensation system.

Satisfactions Survey Summary of Findings Renton Worker Survey ◦ As satisfied as on key satisfaction measures of: Quality of Care Coordination of Care Overall Treatment Experience ◦ Better employment outcomes 55% more likely to return to same employer 65% more likely to be working at time of survey

Satisfaction Survey Summary of Findings Renton Provider Survey ◦ 75% indicated they have improved ability to treat Injured Workers ◦ 74% are satisfied with their experience ◦ 70% reported improved ability to communicate with employers ◦ 50% stated they are more willing to treat Injured Workers

Center of Occupational Health & Education (COHE) Quiz

Quiz Please see attached COHE APP Quiz 2013 Microsoft Word document for instructions and to complete the quiz.