Quality Assurance in Case Management

Quality assurance is a vital part of any workers’ comp claim. No more so than in case management, where details and communication matter most. In today’s Inside Workers’ Comp, I’m joined by three Genex experts — Judy Speirs, Case Management Senior Product Manager, Linda Mastropaolo, Case Management Product Manager, and Linda Wolf, Case Management Senior Product Manager — to discuss how case managers ensure quality in their cases and why it’s so important to meet these objectives.

Tom Kerr (TK): Thank you all for joining me.

TK: Judy, let’s start with the basics. What does quality assurance and case management mean to you?

Judy Speirs: Well, it means that the case management organization adheres to standards that are focused on delivering the best product possible. Since case management is not a tangible product like a factory produces, it delivers on its people to deliver the best results.

A strong quality assurance program ensures that the organization has made a commitment to quality case management. In my view, a strong quality assurance program encompasses the following four basic items.

The first are internal standards the organization holds itself accountable to relative to evaluating, monitoring, and improving their quality.

The second is hiring case managers who meet specific educational and experience backgrounds. Then, the organization encourages professional certification by their case managers. This is another layer of case manager commitment to the career of case management. And there are several well‑known and recognized case management certifications.

The third is the organization's value and commitment to quality case management are in alignment with the national standards of practice outlined by the Case Management Society of America.

Finally, the organization seeks external validation of their commitment to quality. For many, this is achieved through outside URAC accreditation in case management.

TK: Linda Mastropaolo, why are case management quality standards so important to help drive positive outcomes?

Linda Mastropaolo (LM): Quality standards are the baseline for success in the case management industry. So, when it comes to positive case outcomes, they are driven by Genex's best practice policies and procedures. These also include CMSA standards of practice, URAC standards, not to mention state and jurisdictional medical and vocational requirements.

Having said that, these standards are incorporated into all of our new‑hire training modules as well as ongoing training programs. We also measure success by customer satisfaction. We customize guidelines based on customers' expectations, without compromising our standards.

We also send out patient satisfaction surveys to obtain feedback from the patient, then analyze them year after year to determine areas of improvement. Our quality assurance program is measured on all of these standards. We hold ourselves accountable to drive and maintain positive outcomes.

TK: This next one is for Linda Wolf, what are good case managers trained to look for during an initial assessment?

Linda Wolf (LW): Case planning begins with that initial assessment of the client. Case managers obtain information, including the client's past medical history, details on the present injury, including the current treatment they have received so far.

Case managers ask the client if they have any comorbidities such as diabetes, hypertension, smoking, as these could have a significant impact on their recovery. They ask the clients to provide a list of their current medications, and this includes medications for the injury as well as other health‑related issues.

They assess the client's knowledge and adherence to the medication plan. And if opioids are prescribed, they discuss the client's functional status and pain level.

Case managers will also discuss any concerns the client has related to their activities of daily living. They are trained to focus their questions on behavioral health, psychosocial, and socioeconomic issues, as well as any cultural or language concerns.

They will also ask about the client's employment and education history as well as any family support at home. Obtaining thorough information during the initial assessment sets the stage for developing the case management plan.

TK: Follow-up question here, Linda, what are the expected quality standards when working with various parties on a case?

LW: Throughout the life of the case, case managers must adhere to internal quality assurance standards, customer‑specific guidelines, as well as all state and jurisdictional case management requirements as it relates to working with the various parties on a case.

They make initial and ongoing contact with the client or their attorney, the employer, provider, and adjuster, as appropriate to the file. When first speaking with a client, case managers are required to disclose their role and responsibilities and obtain oral consent for services.

Case managers are expected to communicate significant updates or any change in the client’s status to the appropriate parties within established time frames. Our initial progress and closure reports are sent to the customer within standard time frames or based on customer or state requirements.

We also have timeliness standards for the completion of the initial assessment as well as documentation of the case management plan. And finally, case managers are required to notify the client of case closure. And that can be done by phone, in person, or by letter.

TK: Linda Mastropaolo, can you tell us how attention to quality impacts your case management results?

LM: Genex has an ongoing internal focus and commitment to quality. This includes our initial and ongoing training programs for case managers, our quality assurance program, corporate initiatives, and action plans. These in‑depth programs contribute to all of our quality results. I'm happy to report, in 2020, our overall score improved above our quality standard of 95 percent.

TK: Thanks, ladies, for sharing your insight. In our next Inside Workers’ Comp, we’ll begin an in-depth series on mental health. Until then, thanks for listening.