Case Management
Content
Suzanne Kuder September 28, 2009 RMI 4596
Effectiveness of Case Management
Case Management is simply the coordination of medical care, usually involving a single episode of inpatient care. It is a critical part of a health plan s utilization management department that actively coordinates the care of members who incur or are expected to incur unusually high medical care costs from complex courses of treatment resulting from injury or illness (Beam). However, how effective is this process? Is it worth the high cost to employers? The issue may be part of a company s disability management strategy and the types of interventions used to get employees with disabilities back to work. Ultimately, there are two goals of Case Management; to reduce lost work time and reduce disability costs. There are many factors that contribute to getting the employee back to work in a timely and inexpensive manner. Reduced number of days of hospitalization, increased quality of life, increased level of functioning, reduced use of community services, reduced costs of treatment, and reduced symptoms are all objectives of effective Case Management (Bedell). In today s economy, employers are struggling to remain competitive in the workforce. Between the declining economy, escalating costs of health care, and attention to human and civil rights, it is getting harder for employers to manage
1
employees with disabilities. Employers are seeking new means to maintain the productivity of workers with disabilities through effective disability management policies, strategies, and interventions. The legislative and constitutional framework plays a significant part in the costs employers will face when it comes to occupational and non-occupational injury and illness. While America does not have a highly regulated employment policy towards employment of people with disabilities, it is assumed that employers will adhere to civil and human rights, equal employment opportunities, and disability discrimination legislation. Overall, there is a general consensus that employers should assume more responsibility for disability management (Shrey). The Americans with Disabilities Act (ADA) is a major civil rights legislation that prevents discrimination onthe basis of disability in all employment practices for both public and private employers. The ADA does not establish quotas or mandatory employment practices, but encourages employers to hire individuals based on abilities. It requires that employers with 15 or more employees provide qualified individuals with disabilities and equal opportunity to benefit from the full range of employment-related opportunities available to others. This expands to the prohibiting of discrimination in recruitment, hiring, promotions, training, pay, social activities, and other employment privileges. If an individual feels they have been discriminated against on such conditions, it is their responsibility to file a complaint (Dept. of Justice). In addition, an employee must also take responsibility to request an accommodation from their employer that will allow the individual to perform his or her job better. For an employer to respond to worker¶s accommodations, they must first identify
2
the employee¶s illness or disability as occupational or non-occupational illness or disability. Private insurance companies and state workers¶ compensation boards are the primary administrators of workplace injury benefits and services. Separate health care and social security benefits are available for workers who become injured or disabled outside of work. Generally, workers who are injured on the job, who are covered under and insurance policy and workers¶ compensation, receive more benefits and services than those who become injured outside of work. Many employers assume that only social programs are responsible for the care of persons with disabilities once those workers are unable to perform at work. As a result, employers do not take the responsibility to accommodate or retain injured workers, causing a lack of incentiveon both the employer and employee side of job retention and returning to work (Shrey). In an attempt to take responsibility for injured and disables workers, workplaces have developed more creative disability management programs intended to assist these workers in returning to work. Disability Management is a return-to-work process for workers with disabilities that utilize services, people, and programs that are designed to minimize the financial and social impact of disability to workers, employers, and society. This collaboration of workers, managers, employers, and rehabilitation service providers has proven to be an effective way to reduce disability costs and getting workers back into the workforce (Shrey). Early intervention and monitoring of workers¶ injuries is a vital part of the returnto-work process. Monitoring should be supportive to the worker, ensuring that he/she has access to information related to medical treatment, job accommodations, and resources to
3
assist the return-to-work process. This helps to give the worker assurance that the employer values he/she as a member of the work group. Case Management services assist in the implementation of Disability Management strategies, specifically return-to-work plans for workers. Most plans offer trained case managers to help patients during a time of illness or disability (Mincer). Case managers are part of the disability management team who function as a liaison between employers, labor representatives, injured workers, community health care providers, and others (Shrey). They coordinate rehabilitation plans and return-to-work transition programs for workers. Providing injured workers with case managers can be one of the largest cost savers for employers (Mincer). Case managers are trained to recognize problems and gaps in their client¶s treatment. They ensure patients are receiving the right treatment and tests and that they are following normal recovery time. By seeing that the patients get the necessary exams and avoid any unnecessary treatment, the case manager plays an active roll in reducing the patient¶s hospital stay, the use of community services, and the cost of treatment. Another important role the case manger plays is the fact that they are in constant contact with the patient. They are also able to make sure the person is taking their prescribed medications according to doctor¶s directions. This is beneficial in ensuring the patient is doing what they can to get better and return-to-work. If out-of-pocket costs are the patient¶s concern, the manager could potentially find alternative medications or refer the patient to generic brands. The case manager can also get the patient assistance in finding transportation, home care, and housekeeping, as needed. Getting a case
4
manager involved in a case is cost effective for an employer and has proven to be effective in getting workers back to work (Mincer). An effective return-to-work program requires coordination and communication between the worksite and the external community, including medical services and rehabilitation providers. The disability management team ensures that the steps from injury to work are clearly defined for the both the worker and the employer. The team must establish communication lines, explain the program¶s objectives to the injured worker, develop and implement the return to work plan with the injured worker and others, and monitor the worker¶s progress and coordinate additional services or interventions as required (Shrey). In an effort to decrease on-the-job injuries, employers can apply erogonomics. Ergonomics involves fitting the job to the worker and is designed to reduce the risk of injury. It ensures that the job duties required for a position are within the physical capabilities of the worker, thus reducing injury. This approach can be used proactively to reduce injury, or as a method to accommodate workers who recently return from medical leave who may not be able to return to their previous position. The role of ergonomics in this situation is to not only to make job accommodations, but it involves determining residual work capacities of injured workers, developing ergonomically designed physical training programs to enhance their capabilities, designing work and schedules during the transition from being occupationally disabled to a full return-to-work status, and finally making changes in the workplace, if needed, to accommodate the individual (Shrey). An employer can also reduce losses by speeding up the return-to-work process through transitional work options. Transitional work is considered any task or job that a
5
worker who has functional restrictions can perform safely, for pay, and without risk of further injury. The job duties include tasks that are modified, over time, to accommodate the injured worker during the physical recovery period. With assistance from a case manager, an employee can get a full evaluation of their functional abilities and an analysis of job tasks help determine the types of jobs they can perform. The transitional work plan assigns periodic modifications in the worker¶s job task assignments, as the worker¶s capacity to work is increased. The worker is thus accommodated and is given an opportunity to transition back to work. The worker receives a paycheck and ³lost time´ is reduced for the employer (Shrey). While there have been many advancements in evaluating the effectiveness of disability management interventions,the use of case management services continues to be challenged. Studies have proved that when comparing case management services to standard care, case management has proved effective in overall satisfaction of care. Patients receiving case management services typically spend fewer days in the hospital and develop fewer needs for care. Case management services have not been proven to improve mental health, quality of life, or social functioning (Bjorkman). Determining how much to invest in disability and case management services is not easily determined. It is hard for an employer to calculate the total cost of injury they face when a worker goes on disability. It can be determined though, that overall the costs of disability management interventions are worth taking. Studies that offered (1) early contact with the worker by the workplace, (2) work accommodation offers, (3) contact between health care providers and the workplace, (4) ergonomics in the work site, and (5) return-to-work coordination, all supported the financial merits of interventions (Tompa).
6
Interventions with work/ vocational rehabilitation showed a strong return on investment as well. While a number of high quality studies have been performed on the topic, it still cannot be proven that investing in disability management will always be worth the cost. The strongest study adjusted costs and consequences for inflation and time preference. It also included a cost-effectiveness analysis in addition to a cost-benefit analysis, providing greater insight into the health consequences of the intervention, not just a monetary measure of consequence (Tompa). Effectiveness evaluation and economic evaluation go hand-in-hand, and their results should complement each other. When assessing the investment in case management services, it must be broken down into the three forms in which the service can be provided: Full Service, Broker Case Management, and Hybrid. Full Service provides all of the clinical and support services to the client from a specialized team. Brokerage provides very little direct service to patients, instead services are provided to the client from various participants in the health system. In a hybrid program, some services are provided and some services are brokered. Studies have proven that full service approaches are the most effective, providing the consumer with a well-trained staff and use of specialized treatments to ensure a quick and fast recovery, significantly lowering costs for the employer. It seems to be time to abandon the other models of case management that rely heavily on brokering of services (Bedell). While financial outcomes and productivity issues may be the primary interest of many firms, the value of human capital seems to be forgotten. The value of good health to workers and the value of health associated with the ability to better perform other
7
social roles should not be looked over (Tompa). Today, employers are forced to adjust their health care plans to accommodate for the increased number of older individuals in the workplace. Increased life expectancy, aging baby boomers, improved medical care, and an emphasis on fitness and healthy lifestyles has led to a high number of older workers in the workforce. The frequency of work limitations, occupational disability, and total disability is greater for workers over 55 than for any other work group (Shrey). Older workers who become injured or disabled also have a longer recovery time, leading to longer periods of work disruption and lost time, and increased dependence on health care systems. Overall, it is apparent that starting with a good disability management program is the foundation in providing effective case management services. Case management has proven effective in decreasing hospital stays, reducing symptoms, and overall satisfaction from the patient. It is still undetermined that case management will always yield a good return on investment, but the satisfaction and care it provides to the employee is an important aspect that should not be overlooked.
8
Effectiveness of Case Management
Case Management is simply the coordination of medical care, usually involving a single episode of inpatient care. It is a critical part of a health plan s utilization management department that actively coordinates the care of members who incur or are expected to incur unusually high medical care costs from complex courses of treatment resulting from injury or illness (Beam). However, how effective is this process? Is it worth the high cost to employers? The issue may be part of a company s disability management strategy and the types of interventions used to get employees with disabilities back to work. Ultimately, there are two goals of Case Management; to reduce lost work time and reduce disability costs. There are many factors that contribute to getting the employee back to work in a timely and inexpensive manner. Reduced number of days of hospitalization, increased quality of life, increased level of functioning, reduced use of community services, reduced costs of treatment, and reduced symptoms are all objectives of effective Case Management (Bedell). In today s economy, employers are struggling to remain competitive in the workforce. Between the declining economy, escalating costs of health care, and attention to human and civil rights, it is getting harder for employers to manage
1
employees with disabilities. Employers are seeking new means to maintain the productivity of workers with disabilities through effective disability management policies, strategies, and interventions. The legislative and constitutional framework plays a significant part in the costs employers will face when it comes to occupational and non-occupational injury and illness. While America does not have a highly regulated employment policy towards employment of people with disabilities, it is assumed that employers will adhere to civil and human rights, equal employment opportunities, and disability discrimination legislation. Overall, there is a general consensus that employers should assume more responsibility for disability management (Shrey). The Americans with Disabilities Act (ADA) is a major civil rights legislation that prevents discrimination onthe basis of disability in all employment practices for both public and private employers. The ADA does not establish quotas or mandatory employment practices, but encourages employers to hire individuals based on abilities. It requires that employers with 15 or more employees provide qualified individuals with disabilities and equal opportunity to benefit from the full range of employment-related opportunities available to others. This expands to the prohibiting of discrimination in recruitment, hiring, promotions, training, pay, social activities, and other employment privileges. If an individual feels they have been discriminated against on such conditions, it is their responsibility to file a complaint (Dept. of Justice). In addition, an employee must also take responsibility to request an accommodation from their employer that will allow the individual to perform his or her job better. For an employer to respond to worker¶s accommodations, they must first identify
2
the employee¶s illness or disability as occupational or non-occupational illness or disability. Private insurance companies and state workers¶ compensation boards are the primary administrators of workplace injury benefits and services. Separate health care and social security benefits are available for workers who become injured or disabled outside of work. Generally, workers who are injured on the job, who are covered under and insurance policy and workers¶ compensation, receive more benefits and services than those who become injured outside of work. Many employers assume that only social programs are responsible for the care of persons with disabilities once those workers are unable to perform at work. As a result, employers do not take the responsibility to accommodate or retain injured workers, causing a lack of incentiveon both the employer and employee side of job retention and returning to work (Shrey). In an attempt to take responsibility for injured and disables workers, workplaces have developed more creative disability management programs intended to assist these workers in returning to work. Disability Management is a return-to-work process for workers with disabilities that utilize services, people, and programs that are designed to minimize the financial and social impact of disability to workers, employers, and society. This collaboration of workers, managers, employers, and rehabilitation service providers has proven to be an effective way to reduce disability costs and getting workers back into the workforce (Shrey). Early intervention and monitoring of workers¶ injuries is a vital part of the returnto-work process. Monitoring should be supportive to the worker, ensuring that he/she has access to information related to medical treatment, job accommodations, and resources to
3
assist the return-to-work process. This helps to give the worker assurance that the employer values he/she as a member of the work group. Case Management services assist in the implementation of Disability Management strategies, specifically return-to-work plans for workers. Most plans offer trained case managers to help patients during a time of illness or disability (Mincer). Case managers are part of the disability management team who function as a liaison between employers, labor representatives, injured workers, community health care providers, and others (Shrey). They coordinate rehabilitation plans and return-to-work transition programs for workers. Providing injured workers with case managers can be one of the largest cost savers for employers (Mincer). Case managers are trained to recognize problems and gaps in their client¶s treatment. They ensure patients are receiving the right treatment and tests and that they are following normal recovery time. By seeing that the patients get the necessary exams and avoid any unnecessary treatment, the case manager plays an active roll in reducing the patient¶s hospital stay, the use of community services, and the cost of treatment. Another important role the case manger plays is the fact that they are in constant contact with the patient. They are also able to make sure the person is taking their prescribed medications according to doctor¶s directions. This is beneficial in ensuring the patient is doing what they can to get better and return-to-work. If out-of-pocket costs are the patient¶s concern, the manager could potentially find alternative medications or refer the patient to generic brands. The case manager can also get the patient assistance in finding transportation, home care, and housekeeping, as needed. Getting a case
4
manager involved in a case is cost effective for an employer and has proven to be effective in getting workers back to work (Mincer). An effective return-to-work program requires coordination and communication between the worksite and the external community, including medical services and rehabilitation providers. The disability management team ensures that the steps from injury to work are clearly defined for the both the worker and the employer. The team must establish communication lines, explain the program¶s objectives to the injured worker, develop and implement the return to work plan with the injured worker and others, and monitor the worker¶s progress and coordinate additional services or interventions as required (Shrey). In an effort to decrease on-the-job injuries, employers can apply erogonomics. Ergonomics involves fitting the job to the worker and is designed to reduce the risk of injury. It ensures that the job duties required for a position are within the physical capabilities of the worker, thus reducing injury. This approach can be used proactively to reduce injury, or as a method to accommodate workers who recently return from medical leave who may not be able to return to their previous position. The role of ergonomics in this situation is to not only to make job accommodations, but it involves determining residual work capacities of injured workers, developing ergonomically designed physical training programs to enhance their capabilities, designing work and schedules during the transition from being occupationally disabled to a full return-to-work status, and finally making changes in the workplace, if needed, to accommodate the individual (Shrey). An employer can also reduce losses by speeding up the return-to-work process through transitional work options. Transitional work is considered any task or job that a
5
worker who has functional restrictions can perform safely, for pay, and without risk of further injury. The job duties include tasks that are modified, over time, to accommodate the injured worker during the physical recovery period. With assistance from a case manager, an employee can get a full evaluation of their functional abilities and an analysis of job tasks help determine the types of jobs they can perform. The transitional work plan assigns periodic modifications in the worker¶s job task assignments, as the worker¶s capacity to work is increased. The worker is thus accommodated and is given an opportunity to transition back to work. The worker receives a paycheck and ³lost time´ is reduced for the employer (Shrey). While there have been many advancements in evaluating the effectiveness of disability management interventions,the use of case management services continues to be challenged. Studies have proved that when comparing case management services to standard care, case management has proved effective in overall satisfaction of care. Patients receiving case management services typically spend fewer days in the hospital and develop fewer needs for care. Case management services have not been proven to improve mental health, quality of life, or social functioning (Bjorkman). Determining how much to invest in disability and case management services is not easily determined. It is hard for an employer to calculate the total cost of injury they face when a worker goes on disability. It can be determined though, that overall the costs of disability management interventions are worth taking. Studies that offered (1) early contact with the worker by the workplace, (2) work accommodation offers, (3) contact between health care providers and the workplace, (4) ergonomics in the work site, and (5) return-to-work coordination, all supported the financial merits of interventions (Tompa).
6
Interventions with work/ vocational rehabilitation showed a strong return on investment as well. While a number of high quality studies have been performed on the topic, it still cannot be proven that investing in disability management will always be worth the cost. The strongest study adjusted costs and consequences for inflation and time preference. It also included a cost-effectiveness analysis in addition to a cost-benefit analysis, providing greater insight into the health consequences of the intervention, not just a monetary measure of consequence (Tompa). Effectiveness evaluation and economic evaluation go hand-in-hand, and their results should complement each other. When assessing the investment in case management services, it must be broken down into the three forms in which the service can be provided: Full Service, Broker Case Management, and Hybrid. Full Service provides all of the clinical and support services to the client from a specialized team. Brokerage provides very little direct service to patients, instead services are provided to the client from various participants in the health system. In a hybrid program, some services are provided and some services are brokered. Studies have proven that full service approaches are the most effective, providing the consumer with a well-trained staff and use of specialized treatments to ensure a quick and fast recovery, significantly lowering costs for the employer. It seems to be time to abandon the other models of case management that rely heavily on brokering of services (Bedell). While financial outcomes and productivity issues may be the primary interest of many firms, the value of human capital seems to be forgotten. The value of good health to workers and the value of health associated with the ability to better perform other
7
social roles should not be looked over (Tompa). Today, employers are forced to adjust their health care plans to accommodate for the increased number of older individuals in the workplace. Increased life expectancy, aging baby boomers, improved medical care, and an emphasis on fitness and healthy lifestyles has led to a high number of older workers in the workforce. The frequency of work limitations, occupational disability, and total disability is greater for workers over 55 than for any other work group (Shrey). Older workers who become injured or disabled also have a longer recovery time, leading to longer periods of work disruption and lost time, and increased dependence on health care systems. Overall, it is apparent that starting with a good disability management program is the foundation in providing effective case management services. Case management has proven effective in decreasing hospital stays, reducing symptoms, and overall satisfaction from the patient. It is still undetermined that case management will always yield a good return on investment, but the satisfaction and care it provides to the employee is an important aspect that should not be overlooked.
8
