Interview translated by Jenny Quigley-Stickney MSN, MA, MHA, CCM, ACM-RN, CMAC, CPHM, FCM
Workers’ compensation case management is a process designed to facilitate and optimize the care and recovery of employees who have suffered work-related injuries or illnesses. Each state has its own conditions of work-related conditions for injury and return to work guidelines. The workers’ compensation process involves a coordinated effort between various stakeholders that include the injured worker, healthcare providers, employers, insurance carriers and medical case managers. The medical case managers can be social workers or nurses. In this article, the case manager is a social worker with a master’s in business administration. The primary goal of case management is to ensure the workers receive appropriate medical treatments, rehabilitation services and support to facilitate the return to work for both physical and psychosocial goals for the employee’s reentry to work.
Workers’ compensation case managers are nurses or social workers working for the payer or as a liaison between the provider and injured worker. My role as a workers’ compensation case manager is clearly defined by my education and certifications. I am a BSW with an advanced degree of master’s in business administration. I am certified in case management as a CCM. Each level of education has allowed me to evolve my skills to enhance my knowledge of the workers’ compensation client. I utilize my skill as a social worker to keep the client engaged and motivated to accomplish his or her return-to-work goals. I incorporate my knowledge in business administration to help the client to understand the contract and relationship they have with the provider to work to return to work and collaborate with the healthcare agencies and providers to accomplish the workers’ compensation care-plan goals.
An integral component to understanding workers’ compensation case management is to know the roles of the adjuster, employer and case manager. The adjuster is responsible for the releasing of money and determining the status of the treatment plan. The adjuster determines compensability of the worker’s claim. The adjuster makes a determination on either accepting or denying the claim within 21 days of the first report of injury.
The employer’s role is responsible to review the workers’ compensation medical form and determine if they can safely accommodate the injured worker or find appropriate alternatives The employer is responsible to follow the restrictions placed by the treating providers. When multiple providers are treating the injured worker for a work-related injury, the employer must be able to accommodate the most restrictive work capacity if there are multiple providers. The original job description and or temporary alternative duties should be outlined from the original job or the modified duty available to the injured worker. The employer has to provide the injured worker with the ability to attend medical appointments, but they are not responsible for paying the worker for their time during medical appointments.
The case manager’s role is a key component to addressing any issues in managing the employee’s claims. They are the go between with the employer, adjuster and insurance agent. The case manager as defined by CMSA Standards of Practice for Case Management 2022 as an advocate for the patient.
The certified case manager in workers’ compensation will promote the client’s self-determination and shared decision making educate regarding healthcare needs and services, promote optimal health outcomes, and advocate for timely allocation of resources to provide for a safe and successful return to work and active duty.
The role of the case manager is to act as the worker’s liaison, from the employee to the employer. The case manager provides assessment, monitoring, plan implementation and ongoing communication to maintain an alignment of client to employer expectations. Several key components of workers’ compensation exist to help the case manager guide the injured worker’s care planning, The first is the initial reporting and assessment of the worker’s injury, This begins with the worker’s prompt reporting of a work-related injury or illness by the employee to their employer, The employer is then responsible to notify the workers’ compensation insurance carrier. An initial assessment is then conducted to evaluate the nature and severity of the injury including immediate medical needs of the injured worker.
The patient/injured worker’s role in the care plan is to follow the restrictions placed on him by the medical team both at home and in the work environment. The patient must attend all medical and healthcare sessions. The patient has the right to choose their healthcare providers. If the employer is the provider of the worker’s healthcare, the CM works collaboratively with the worker and employer to keep an alignment of expectations and goals for the care plan. The case manager works closely with healthcare providers to ensure that the injured worker receives timely and appropriate orthopedic medical care and all treatments related to rehabilitation. The case manager may start to coordinate appointments, review treatment protocols and address any barriers to medical services such as social determinants of health, i.e., transport.
A workers’ compensation form is completed on all new injured cases. The form begins with defining the diagnosis related to the workers’ compensation injury. The treatment plan includes all specialties, PT/OT/medications or a functional capacity evaluation. In each form the provider must declare whether the injury or disability is related to the injury described at work. The worker’s current status must be described as to current work status frequency, occasionally the ability to maximally lift and frequency of lifting. The worker’s maximal medical improvement must be qualified or an estimation as to when this might be achieved as a goal. The permanent impairment awards are not determined for the worker until the patient has achieved maximal medical improvement. The goal of the WCF is to never say unable to work.
The case manager is an essential liaison for motivation and behavior health modification for the injured worker when the worker is at the stage of frustration, stating, “I cannot return to work unless at full duty, There is no light duty at my work, or they aren’t following the restrictions.” During these times the case manager rises to the occasion to help the worker visualize alternative options within their workplace. Some questions to the worker might be, what are the usual job duties, or what do they think the hardest thing you will have to do relative to their injury?
The case management documentation and provider documentation are key to a successful return to work. The claim starts with the first report of injury. The initial treatments are documented, to include a comparison of the mechanism of injury reported from the first ED visit, hospitalization and transition to rehab either inpatient or outpatient services. Patient baseline frequency and prior medical history recorded to calculate the exact injury and complications. Any comorbidities that might delay recovery, create barriers to achieving successful outcomes or affect long-term functional outcomes for the injured worker are recorded in the case management record. The case manager must predict maximal medical improvement and be clear about guidelines for recreational activities. The maximal medical improvement once achieved should require no further active treatments and be stable for approximately 12 months.
The next stage is rehabilitation and return to goals and planning. The case manager at this stage collaborates with orthopedic physician and rehabilitation team to develop and implement plans that support the injured worker’s recovery and return to work. This involves physical therapy, occupational therapy and vocational rehabilitation and other services aimed at restoring the worker’s functional abilities.
During the rehab planning stage, the case manager’s most effective tool is communication. It is crucial that the case manager always maintain motivational discussion and a focus with the employees to keep the eye on the target and goal to return to work. The case manager and provider’s toolbox includes for the patient’s healing and recovery the implementation of physical and occupational therapy, medication management for pain management to improve function, job tasks for full duty and light duty, work hardening program and work conditioning program, progression from temporary alternative duty to full duty with increased job tasks within the work environment.
One of the most successful workers’ compensation return-to-work care plans involved a client with dual diagnosis of work-related injury and drug addiction, requiring me to utilize both my social work and business administration backgrounds to motivate and keep the client aligned with expectations to achieve optimal outcomes. Two barriers that often derailed this client’s care plans were his paranoia and noncompliance. The case management tool of communication, negotiations and actively attending all sessions to provide guidance feedback and interpretation of the healthcare providers’ requests, treatments and expectation. Although it was a grueling task to keep him focused and on target with goals, the patient finally accomplished his care plan and met the time frame of 15-18 months return back to work.
As a case manager in workers’ compensation for over 30 years, I find the key to my success is having chosen to work in the workers’ compensation arena directly with the provider and orthopedic center, where the team approach of physician and rehab working together daily allows me to keep a close eye on the clients I work with and maintain effective, often daily, communication with injured workers. I have long been involved in the Case Management Society of New England as a past president and board member. This collegial connection has provided me with networking, support and educational opportunities to evolve my case management skills and develop leadership training that has enhanced me as a professional case manager.
Reference
New Hampshire Workers Compensation Training module and interview with Karen Coish MacKay, BSW, MBA, from NHOC Orthopaedic Center
Jenny 
Quigley-Stickney, MSN, RN, MHA, MA, CCM, ACM-RN, CMAC, CPHM, FCM, is a professional case manager with Cape Cod Healthcare. Jenny has been active with CMSA/CMSNE for over 20 years, serving as the president of CMSNE and chair for both CMSA and CMSNE Public Policy Committees. She is currently serving on the board of directors for CMSA National. She is active in the New England states promoting the advancement of the Nurse Licensure Compact, and telehealth legislation for healthcare provision. She has a passion for legislative works and believes that legislation helps advance the field of professional case management. She has been employed at all levels of the transitions of care, working with traumatic brain injury, stroke and spinal cord for over 25 years. During that time, she provided professional case management for inpatient rehab, hospital-based home care, and outpatient rehab care. She recently has shifted her work back to her first love, acute care, focusing on vascular and trauma care.
Karen Coish Mackey, BSW, MBA, is director of clinical operations at New Hampshire Orthopaedic Center. With almost 30 years of experience as a case manager, Karen first began her practice as a facility-based case manager. She has experience in inpatient rehabilitation, outpatient rehabilitation, workers’ compensation case management, direct patient issues and department management. For the last 19 years, she has worked with a physician-owned orthopedic group in Southern NH. She is a New Hampshire native, married to her high school sweetheart for over 40 years and raised their children in the same New Hampshire town they grew up in. Proud grandparents to Olivia and Jacob (Jake). She has a number of hobbies that include walking, reading and reenacting Revolutionary War events.
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