Part 1 of 2: Understanding Nurse Case Management and When to Use It

Navigating workers’ compensation claims can be challenging for employers, especially when injured employees struggle to understand or adhere to the medical and administrative processes involved. Nurse Case Management (NCM) offers an effective solution by providing guidance, advocacy, and support throughout the claims process. Effective communication between stakeholders is critical to the success of this approach, as even small improvements in communication can lead to significant savings.

This blog will explore the value NCM brings to a claim and provide clear criteria for when to use it to maximize outcomes for employers and injured workers.

What is Nurse Case Management?

Nurse case management involves assigning a dedicated nurse to a workers’ compensation claim to assist injured workers, communicate with stakeholders, and ensure compliance with medical treatment plans. Their role is multifaceted, focusing on education, advocacy, and coordination to support recovery and return-to-work efforts.

The Role of the Nurse Case Manager

1. Patient Advocacy and Education An injured worker may feel confused and overwhelmed by the unfamiliar rules of workers’ compensation compared to general healthcare. Nurse case managers act as patient advocates, guiding workers through the process and helping them understand:
   • Medical restrictions and their importance both at work and home.
   • How to prepare for and maximize physician visits.
   • When and which specialists to consult.

Additionally, nurse case managers educate workers about potential risks like medication interactions and the importance of adhering to prescribed treatments.

1. Communication with Stakeholders Effective communication is a cornerstone of nurse case management. Coordinating updates between the injured worker, employer, and adjuster ensures everyone stays informed and aligned on the worker’s recovery. Employers should prioritize timely updates about medical visits and work restrictions.
   • Employer: Keeps the employer informed about medical visits, progress, and any accommodations needed for a smooth return to work.
   • Adjuster: Ensures adjusters are updated about changes, such as a release to work, that impact claim payments.
   • Employee: Builds trust with the injured worker, reducing litigation risk and facilitating quicker recovery and return to work.
2. Compliance and Accountability Many delays in recovery stem from noncompliance with medical instructions, such as missed appointments or neglected treatment plans. Nurse case managers help mitigate these issues by ensuring patients follow through, ultimately reducing recovery times.

Benefits of Nurse Case Management

• Reduced Litigation Rates: Injured workers who feel supported are less likely to seek legal representation.
• Improved Engagement: Workers are more likely to attend appointments, take medications as prescribed, and follow through with physical therapy.
• Faster Return-to-Work (RTW) Rates: Coordinating light-duty or accommodations ensures a smoother transition back to work.

When to Use Nurse Case Management The key to effective NCM lies in identifying specific triggers that warrant its use. Clear communication strategies during decision-making can significantly enhance program outcomes.

Triggers to Use Nurse Case

1. Lost Time Claims Injured workers who are off work typically need guidance and help to ensure they understand the workers’ compensation process and are complying with medical treatment recommendations. For example, American Airlines, which has one of the best injury management programs in the country, refers every lost-time claim.
2. Failing to Attend Physician Visits Some workers who are back at work, even in a light-duty capacity, need additional accountability to ensure they attend their medical appointments and follow the recommended treatment plan.
3. Any Surgery Surgery involves multiple complexities. Nurse case managers help by preparing injured workers for pre-surgery requirements, home arrangements, medication pickup, and any necessary durable medical equipment. This support significantly reduces stress.
4. Doctor Shopping An employee seeking treatment from multiple providers signals a red flag for resistance to returning to work. A nurse case manager can address this behavior.
5. Comorbid Issues Injured workers with conditions like obesity, diabetes, or hypertension often face more complex recovery processes and benefit from additional guidance through the system.
6. Uncooperative Treating Physicians A physician who continually restricts an employee from returning to work in any capacity may require intervention. Nurse case managers can facilitate conversations to shift the focus from “what the employee cannot do” to “what they can do,” enabling accommodations.

By addressing these triggers, nurse case managers play a crucial role in ensuring injured workers’ recovery is managed efficiently while supporting return-to-work outcomes.

Michael Stack, CEO of Amaxx LLC, is an expert in workers’ compensation cost containment systems and provides education, training, and consulting to help employers reduce their workers’ compensation costs by 20% to 50%. He is co-author of the #1 selling comprehensive training guide “Your Ultimate Guide to Mastering Workers’ Comp Costs: Reduce Costs 20% to 50%.” Stack is the creator of Injury Management Results (IMR) software and founder of Amaxx Workers’ Comp Training Center. WC Mastery Training teaching injury management best practices such as return to work, communication, claims best practices, medical management, and working with vendors. IMR software simplifies the implementation of these best practices for employers and ties results to a Critical Metrics Dashboard.

Contact: [email protected].

Workers’ Comp Roundup Blog: http://blog.reduceyourworkerscomp.com/

Injury Management Results (IMR) Software: https://imrsoftware.com/

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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional.