When there’s a return to work delay, practitioners often look for problems that occurred during the course of treatment. However, as Mariellen Blue, Genex’s National Director of Case Management Services, tells us in today’s Inside Workers’ Comp, you may have to go back a little further in the recovery plan to find the answer. Check out the five reasons why the initial evaluation may be the culprit.
Tom Kerr (TK): Why is the initial evaluation and physician follow-up so important to return to work?
Mariellen Blue (MB): Well, Tom, there's a common saying that, "You only get one chance to make a first impression," and I really believe this equates quite well in workers’ compensation when we’re looking at the relationship between a patient and the physician that's going to be treating them.
When an individual is injured on the job, they don't know what to expect. They want answers. They want reassurance. The injured worker is really looking to that physician and they want to have confidence in their physician. And, the first visit with that provider really sets the stage for how that case is going to progress going forward.
TK: OK, so let’s get into your top five reasons why the initial evaluation may result in delayed return to work. The first one is limited workers’ comp experience by the physician. Why is industry experience so important?
MB: In workers’ compensation, there are various laws such as mandated treatment guidelines, utilization review laws, drug formularies and state‑mandated forms. It's really important that that treating physician does understand what the laws are for the specific jurisdiction of that particular claim in order to make that claim not stall and to run a little smoother.
We're also looking at an understanding of HIPAA regulations. HIPAA is such a large issue in any type of health care world at this point. And, many physicians that are not experienced in workers’ compensation are almost afraid to share information with any of the stakeholders in a workers’ compensation claim.
And, it's really important to remember that unless there are laws that say otherwise, you are able to share information such as what type of job that patient can return to with this specific employer. And, this can really help in moving that case forward and identifying what types of employment that individual is able to return to at all the various points in their recovery.
TK: The second reason on your list is problems with patient communication and engagement.
MB: This is something that's extremely important during that first encounter between the patient and the physician. There could be issues that, unless you're really delving deep in the conversation with the patient, you may not recognize immediately.
For example, you may have an individual where there is a language barrier and you may have to call in an interpreter. Also, I think many of us have gone through this, you are injured or ill and the physician is talking to you in very complex medical jargon. You really have no idea what he or she is saying. And, the doctor may be giving you instructions or telling you what you should be doing, and you get home and you're a little bit clueless.
So, again, when a physician is speaking in plain language and really ensuring and recognizing what the patient does and does not understand, that can make a big difference in their compliance with their ongoing treatment plan.
TK: The third reason is limited use of evidence-based treatment guidelines? Why do you consider guidelines so important?
MB: Let's say you have carpal tunnel syndrome or a low back injury, you’re looking at what is the expected type of treatment and what is the expected anticipated duration for that particular treatment. The physician, and even a case manager if assigned to the case, is looking at that information and, if the patient is failing to recover going forward, can say, “you know, per this particular guideline, they should have reached this point by now.” And then, hopefully, intervene to help move that case along and address those factors that are preventing them from reaching those benchmarks.
TK: Failure to incorporate return-to-work practices into the treatment plan is the fourth reason you mention. So, the plan isn’t just about recovery?
MB: In workers’ compensation, obviously, the first priority is to ensure that they're getting the appropriate treatment in a timely manner, but we're also looking at the end goal — for them to be able to return to their previous level of function and to work.
Things such as addressing return to work from day one, working with that employer or a case manager as intermediary between the physician and the employer. What types of jobs are available for that individual? What were their physical job requirements of their regular job? Are they able to accommodate any modified or light duty or transitional employment in the interim before they're released to full-duty return to work? And, do they have a structured return-to-work program in place?
This is all extremely helpful information for the physician to have because physicians really only know what they know. And, if they don't know that these options are available, that could significantly delay this individual returning to work. And, the longer the employee is disengaged from the workplace, it tends to be more difficult to get back to work in the long run.
TK: And, the last reason you have is failure to address comorbidities or non-injury related issues.
MB: And, there are some, what we would call biological factors, that can delay recovery, such as the person's age, gender; do they have any comorbid conditions such as diabetes, hypertension, heart disease, obesity, smoking, a history of substance abuse? These are all very well recognized type of factors that most physicians will look at
But, it becomes more complicated when there are psychological or social factors that can delay recovery. These can be things fears that the patient has as a result of the injury. This includes fear of pain, perhaps fear of financial loss or disability, even a fear of being fired or recovery expectations and catastrophic thinking.
You may have an individual who never had any of these issues but, all of a sudden, they have this work‑related injury. They become very fearful and they fall into a role of catastrophic thinking where they feel, “oh, my God. This is the worst thing that could ever happen to me. I will never recover. I will be in pain forever.” And, it's almost a self‑fulfilling prophecy.
So, that's another issue, during those interviews with either the physician or the case manager where they can identify some of these things. Also, maladaptive coping behaviors. Many of us don't know whether we would be able to cope successfully after we've had a significant injury or illness and, unfortunately, you probably won't know that until it occurs.
Also, some social factors can delay recovery. Things such as was the injured worker happy at the workplace? Does the worker have a fear of being fired? Is this person dissatisfied with the job? Does he or she have a home situation that could impede recovery? Let's say it's a working mother. Now, she can't afford daycare, her children are at home and she doesn't know what to do. These are all factors that need to be considered when you're looking at that return-to-work plan.
Tom: What are some ways case managers can intervene and help prevent some of these problems from delaying return to work?
MB: Well, really, the role of the case manager is to serve as the injured worker's advocate, their educator, and, really, the overall liaison between all the parties in the case, throughout the recovery and return-to-work process. That case manager is really able to be that educator of the patient. For instance, you have a patient who is sitting with the doctor who, maybe, is not hearing everything the doctor is saying. By having that case manager be able to sit down with the employee afterwards and, through ongoing contacts, be able to communicate with that person, explain exactly what the doctor has said, what that plan of treatment is, what the return-to-work plan is, can be critical to the success of that particular claim.
In turn, that case manager can be very valuable to that physician. You may be in that first visit and the physician is asking, "What are the job duties? Do they have modified duty work?" That's a key role of a case manager, to again, be that contact between the employer and that provider. They can discuss with the employer, “Do you have a structured return-to-work plan in place? Do you have modified duty employment? Do you have light duty that this person can do in the interim? And, what would be the physical requirements for that?”
Presenting things like the formal job descriptions to that treating provider and working with them. Also, helping that physician at each visit by addressing what this individual can do rather than focusing on what he or she can't do at the present time.
TK: Are physicians fairly open to case management intervention in the initial evaluation phase and throughout the claim?
MB: I would say, yes. You will have some physicians who have not had any experience working with a case manager, and they may feel that it's intrusive or that the case manager is questioning their ability as a physician, but that is absolutely not the case.
Our case managers are really there to serve that patient, to ensure that they're getting the most appropriate care, that they understand the care that is being prescribed. And, in the end, when the patient understands, when the patient is compliant with care, when the patient feels safe and is asking questions, and has a case manager to assist in those communications with the physician — to me, that's really a win‑win situation for all parties.