Part 2 of 2: When Not to Use Nurse Case Management in Workers’ Compensation

This is the second part of our two-part series on Nurse Case Management (NCM). While the first article focused on when to use NCM effectively, this article emphasizes the importance of resource optimization and explores equally important criteria for understanding when not to use this service.

Some claims do not benefit from having a nurse assigned to the file because the role of educating, advocating, or ensuring compliance with medical treatment is already fulfilled in another manner. In these cases, the nurse’s role is reduced to “order-taking” or “reporting,” which adds little to no value.

When Nurse Case Management is Unnecessary

1. 1. Positive Employer-Employee Relationship When a strong rapport exists between the employer and the injured worker, the need for an intermediary diminishes. Employers can communicate directly with the employee to provide guidance and support.
   2. Eager and Compliant Employees Workers who are motivated to recover, comply with their treatment plans, and focus on their abilities are less likely to benefit from NCM. Their proactive approach negates the need for additional oversight.
   3. Non-Severe Injuries Without Lost Time Claims involving minor injuries that don’t require time away from work typically don’t justify the cost of nurse case management. These cases are often managed through regular employer-employee communication.
   4. Proactive Employer Involvement Employers who engage injured workers from day one, making follow-up calls and holding weekly check-ins, can often fulfill the role of an NCM. Structured communication strategies amplify these efforts.
   5. Strong Medical Provider Relationships If the treating physician or facility already employs best practices for patient education and return-to-work strategies, a nurse case manager may not be necessary.

When to STOP Using Nurse Case Management

Equally critical is defining when to stop using NCM on a file. Continuing to use a nurse unnecessarily can lead to overcharges and inefficiencies. Stop triggers include:

1. Worker is Back at Work and Progressing Well Once an injured worker is back at work, tolerating restrictions, and generally progressing well, the value of an NCM diminishes.
2. Sufficient Time Has Passed Post-Return to Work As a general rule, if an injured worker has been back at work for 7-10 days without issues, there may no longer be a need for active nurse involvement.
3. NCM’s Role Becomes Administrative If the nurse’s role has shifted to merely passing information between stakeholders, their involvement is no longer essential.

Guidance for Transition The nurse case manager should inform the injured worker that although the file is closing, they can still reach out if follow-up support is needed. This approach ensures continuity while managing costs effectively.

Conclusion Nurse Case Management can be an invaluable tool in complex cases, but it’s essential to recognize when it adds little value. By setting clear criteria for when to use, not use, and stop using NCM, employers can ensure resources are utilized effectively while maintaining optimal outcomes for injured workers.

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: mstack@reduceyourworkerscomp.com.

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

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

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