Medical Case Management for the work related injury

Medical Case Management for the work related injury claim Arēté Medical Consulting Services, LLC Donna Macias, RN BSN CCM Amy Prince RN BSN

“ A collaborative process that assesses, plans, implements, coordinates, monitors and evaluates options and services to meet a client’s health needs through communication and available resources to promote quality, cost-effective outcomes” (American Accrediation Healthcare Commission/URAC case managrment organization standards, version 1. 1) What is case management……. . ”

Early intervention: How we can help Medical assessment and planning Properly specialized care and treatment Cost savings Better outcomes Return to work programs

Triggers for Nurse Case Management • • • More than one body part injured Co-morbids Abnormal diagnostics Language barriers Socioeconomic barriers Surgery requests Multiple providers Complex injuries Non progressing file Complex Drug Regimen Degenerative issues Rural areas/lack of providers Compliance concerns Re-injury Uncommon injuries

Process of Nurse Claim Management • Assess, collect data, and reassess • Evaluate and obtain information • Approval process and contacts • Referrals • Needs of the injured worker • Treatment plan monitoring • Goals • Measurable outcomes • Identify barriers

Role of the Nurse Case Manager Injured Worker’s needs Information Liasion Networking Start to finish coordination of care and referral process Updating and informing all parties of goals, treatment, outcomes and issues as they arise for intervention Information to payors for services, needs, and options for cost effective outcomes. Safe return to work goals that include the employer, injured worker and treating provider Facilitiate coverage decisions Expedient treatment, therapy, goals and outcomes Anticipating needs, being proactive and including the injured worker in their rehab process Prevent gaps in care Prevent complications Appropriate referrals to qualified specialists

Types of RN Case Management Assignments • Telephonic • Field Based • Task Assignment • Medical Record Review

What happens when a good case goes bad Co-morbids, complications, and problems……. .

What is wrong with this picture

Why nursing assessment is important Frequent communication with the injured worker can prevent lifechanging outcomes

Arēté Medical Consulting Services, LLC Amy Prince RN BSN 405 -818 -0953 amy@aretemedconsulting. com Donna Macias RN BSN CCM 405 -699 -1068 donna@aretemedconsulting. com Call or Email your referral