Improve Your Bottom Line With Nurse Triage

Nurse Triage Uses Experienced Nurses to Determine Care

 

Nurse triage is a concept workers’ compensation has adopted from outside traditional health insurance and claims management fields to control of the cost of medical care.   Nurse triage is the use of experienced nurses, clinical algorithms and software to determine the appropriate level of medical care injured employees need.  While nurse triage can be utilized any time in the course of the workers’ compensation claim, it is most effective when it is conducted immediately after an injury — before the injured employee seeks care that could be too little or too much.

 

 

No Extra Care “Just in Case”

 

When employers do not have nurse triage services available, immediately following an injury it is the employee or the employee’s supervisor who determines the level of medical care that is needed.  An employee, who is in pain from an injury, and with no medical training, will normally opt for the highest level of service available.  Supervisors may default to a higher level of care to mitigate their risk “just in case.”

 

With a nurse triage service, specially trained nurses are available 24/7 to evaluate the injury with the employee by telephone. The best services use highly trained nurses, and sophisticated software, to ascertain the severity of the employee’s medical symptoms and direct the employee to the most appropriate level of medical care.  By guiding the injured employee in the selection of medical care, costly hospital emergency room treatment or unnecessary clinic visits can be prevented.  More serious cases can be identified even when the employee may not recognize the severity.  Plus, when off-site medical care is needed, the employee receives recommendations on preferred “in-network” medical providers.

 

 

Triage Nurse Communicates with Relevant Stakeholders

 

The triage nurse communicates his/her involvement to the medical provider, TPA, and other stakeholders by telephone,  e-mail, fax or even secure server-to-server data feeds to maintain the continuity of the employee’s medical care. Nurse triage assists the medical provider, but it does not replace medical treatment provided by the medical provider. Nurse triage benefits the medical provider by allowing the medical provider to concentrate on the patients in the most need of the medical provider’s services. 

 

The triage nurses are trained and supported to utilize their critical thinking skills and listening skills to understand the employee’s medical condition, and evaluate the pain, anxiety and the employee’s understanding of their medical condition.  The triage nurses use their communication skills to explain to the employee the nature of their injury, the type of treatment needed and their knowledge of the expected recovery time.

 

The software used by the triage will contain a series of algorithms (a set of p for solving a problem in a finite number of steps) to assist in making the best recommendation for the employee, whether it is emergency care, an appointment with a medical provider, or self-care. In one provider’s patented process, the employee’s symptoms are evaluated by asking a series of questions beginning with the most acute and working downward to the least acute.  Depending on the employee’s answers, the algorithms guide the triage nurse to the proper level of medical care.  When the employee needs more than self-care, the triage nurses are trained not to give the employee a diagnosis, but to direct the employee to the most appropriate medical provider.

 

 

Ways Triage Improves Bottom Line

 

In addition to reducing cost by sending the employee to the proper level of medical care, the triage nurse improves the bottom line by:

 

  • Increasing the percentage of self-care, reducing claim volume

 

  • Reducing the number of injuries that become OSHA reportable (by avoiding unnecessary medical claims)

 

  • Increasing the number of claims handled through the medical provider network

 

  • Reducing the employee’s time off work, increasing productivity

 

  • Improving morale by having a trained nurse available immediately when an employee is injured

 

  • Reducing the occurrences of fraud (triage provides immediate documentation of incidents, and the best systems record the call)

 

  • Providing round-the-clock control of medical treatment for employers who have multiple work shift

 

  • Identifying potential life threats and serious cases not recognized by injured employees.

 

 

Check Accreditations Before Selecting Triage Service

 

When selecting a nurse triage service, the employer should look for triage providers who can verify their competency with experience, references, and the proper medical accreditations and certifications.  URAC (previously known as Utilization Review Accreditation Commission, but now known only by their acronym URAC) is the largest accrediting body for health care.  URAC offers many types of accreditation; triage is covered under the “Health Call Center” category.  If the triage provider has a URAC accreditation for Health Call Center, you will know the company is performing in accordance to national standards.

 

Amaxx can assist you in locating a nurse triage service to meet your medical cost control needs and improve your bottom line.

 

 

Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%Contact: RShafer@ReduceYourWorkersComp.com.

 

Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com Contact mstack@reduceyourworkerscomp.com

 


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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.

 

How Nurse Triage and Nurse Case Management Work Together to Reduce Workers Compensation Costs

Employers are continually searching for ways to reduce workers compensation costs. Triage, where a nurse immediately assesses the employee's medical condition and in some cases arranges for the medical care, is growing rapidly as one of the most effective ways employers can control workers comp cost. In triage, the nurse is involved at the very beginning of the claim. The triage nurse evaluates what medical care is needed through a phone call with the injured employee at the time of injury, provides a list of approved in-network doctors or medical clinics, then passes the claim to a nurse case manager who follows through with the medical provider, the employee, and the employer to ensure the needs of each are met. Companies using nurse triage consistently have very high "penetration rates" meaning that a very high percentage of employees utilize in-network providers; penetration rates for companies using nurse triage are frequently higher than 90%, many approaching 100%.
 

 
Triage in workers compensation is a concept that has been borrowed from hospital emergency rooms where the triage nurse is responsible for immediate assessment of the individual's injury and organizing the treatment based on the seriousness of the injury. In workers compensation, the triage nurse immediately evaluates the nature and type of the employee’s injury and directs the employee to the proper level of medical care whether it is first-aid, a walk-in clinic, or an urgent care facility. Sometimes the employee is given home-care instructions. (WCxKit)
 
 
The proper use of triage eliminates lag time and indecision. The injured employee, the employee’s supervisor or a co-worker (in an emergency situation) can report the occurrence of the injury to the triage nurse by phone. Most triage organizations provide a toll-free “hot-line” number for workers compensation claims to be reported and are staffed 24/7. The triage nurses that answer the calls are trained to obtain all necessary information in order to perform a comprehensive evaluation of the medical needs of the injured employee. The triage nurse will use treatment protocols and algorithms to identify the proper course of treatment. The employee is then directed to the nearest appropriate level medical facility. These nurses are specially trained and have had a minimum of 10 years of clinical experience.
 
 

The triage nurse does not stop after directing the employee to the medical facility. The triage nurse can then contact the medical facility to inform them the patient will arrive soon. Or, this can be done by the employer's workers compensation coordinator. The triage nurse provides the medical facility with the information on the employee’s injury along with the employee’s name, address, phone number, date of birth, social security number, employer's name, address, phone number, and contact information. The triage nurse will also provide the medical provider with billing information and adjuster contact information. Reports of daily activity is sent to the carrier/TPA and the employer, if requested.

Nurse triage makes sure the employee gets to the correct LEVEL of care, but the nurse case manager takes over to "manage" care. Note: When triage is too closely integrated into managing care, it looses focus on preventing unnecessary claims and guiding injuries to the right level of care. 

 
Note: The triage system is more likely to refer more often when the triage provider gains economically from opening a claim. Even "features" that seem convenient like 800 numbers and aps that  make it easy for employees to find networks clinics themselves result in employees bypassing triage and going straight to the clinics.  

 
After the employee has had time to be treated, the case managment nurse will contact the medical facility the same day and determine the nature of the medical treatment. Sometimes, this can be done by a senior nurse reviewer or the employer's medical director. A senior nurse reviewer is a nurse who reviews and follows ALL claims from beginning to end; they monitor all claims within an insureds book of claims. A nurse case manager will inquire to see if there are any prescriptions that need to be filled, if there is any diagnostic testing (MRI, CT scan, EMG, etc.) that needs to be done, and if there is a need for durable medical equipment. The case management nurse will then advise the workers compensation adjuster of the prescriptions, diagnostic testing, and durable medical equipment that is needed. Once the adjuster approves the requested prescriptions, testing or equipment, the case management nurse will assist in arranging for it.
 
 
The case management nurse will also ask the medical facility for the return-to-work restrictions placed on the employee by the medical provider. If the employee can return to work with restrictions, the case management nurse obtains all the information on the work restrictions and contacts the employer to see if the employer can accommodate the return-to-work restrictions. IF the employer has a return to work coordinator, the return to work coordinator can make contacts related to transitional duty capabilities.
 
 
The recommendations of the medical facility for future medical care and the date the employee will be returning to the medical provider will be obtained by the case management nurse. If the employee needs diagnostic testing prior to the return appointment being scheduled, the case management nurse can follow up with the medical facility providing the diagnostic testing and provide the test results to the medical provider. 
 
 
The case management nurse (NCM) will facilitate and expedite the communication between the medical provider, the employer, and the workers comp adjuster. NCM also has the responsibility of keeping everyone informed about the medical status of the employee. The NCM will be in regular contact with the employee, the employer, the medical provider(s), and the workers comp adjuster. All information about the medical treatment, medical progress and return-to-work options are shared with all parties.
 
 
The length of time the triage nurse will continue to work on the new workers claim is determined by the arrangement between the employer and the triage company but generally the triage nurse will hand the case to the case management nurse once the initial care is evaluated. The case management nurse will normally continue on the case until the employee returns to work full time however there may be a need for a nurse case manager depending on the severity of the injury or the employee's inability to return to work even in a modified duty capacity. (WCxKit)
 
 
Integrating the triage nurse into the initial medical treatment allows the employer or insurer to set the tone and level of medical care and ensure the employee gets the appropriate level of care immediately. Then the nurse case manager helps to coordinate employee's return to work before the employee has the opportunity to adjust to the idea of not working. By providing medical management at the beginning of the workers comp claim, the triage process improves the return-to-work program results, reduces days lost from work, lowers the cost of indemnity payments, and lowers the cost of medical care. Normally, nurse triage can reduce the number of lost time claims by up to 40%. 
 
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Manage Your Workers Compensation: Reduce Costs 20-50% www.WCManual.com. Contact: RShafer@ReduceYourWorkersComp.com.
 

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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.

Five Benefits of Medical Expertise At Time of Initial Injury

pic6Nurse triage is the process of having an experienced nurse evaluate an employee’s medical needs and direct medical care by determining the appropriate level needed. Employers who do not have their own on-site medical clinic are turning to nurse triage as a means of controlling and impacting workers compensation cost.

 

 

Nurse triage companies operate a call center where experienced, trained nurses are available on a 24/7/365 basis. Also, employers who do not staff their on-site medical clinic during all shifts are using nurse triage to cover their employee’s medical needs when their clinic is not open. (WCxKit)

 

 

When an employee is injured on the job, the employee and/or supervisor reports the accident direct to the nurse triage company where a trained nurse talks with the employee. The nurse, using proven interviewing techniques, listens carefully to the employee’s description of the accident. He or she asks detailed questions and focuses on the employee’s medical needs. By using treatment protocols and sophisticated medical software, the triage nurse is able to provide an injury assessment. Based on the triage nurse’s assessment of the severity of the injury, the most appropriate level of care and the proper course of treatment can be determined. Then, a decision is made as to where the employee should be sent for medical care.

 

 

If the medical care cannot be provided by the employer’s on-site medical clinic or by administering first aid on-site, the triage nurse refers the employee to a preferred medical provider in their network (set up in advance) best suited to provide the medical care needed. By directing the employee to the most appropriate level of medical care, optimum medical care is provided sooner. This also eliminates expensive emergency room visits and prevents the employee from starting medical treatment with a medical provider only to be transferred to a different medical provider later.

 

 

1- A key benefit of using nurse triage is the transfer of making initial medical decisions from the employee’s supervisor to a trained medical professional. The employee’s supervisor may discourage the employee from having the needed medical care, as the supervisor wants the employee at work, or the supervisor will send the employee to a medical provider not best suited to treat the employee’s injury. Triage nurses are experienced RNs with recent clinical experience who are specially trained to do this job, and the training centers are impressive. I have toured Medcor’s training facility which is state of the art.

 

 

2- The nurse triage will notify the medical provider of the employee’s injury and advise the medical provider to expect the employee’s arrival. This is immediately followed by the claim being reported to all appropriate entities including the risk management department, safety, human resources and the work comp claims office. By addressing the injury immediately with the employee, the employer and insurer have the greatest chance of influencing the cost and overall outcome of the claim. If arrangements have been made with the nurse triage company, they can gather all the information needed and file the first report of injury with the claims office and the appropriate state government entity.

 

 

3- Nurse triage can also assist with early return-to-work programs by obtaining an employee’s job description and providing the job description to the medical provider. When the medical provider indicates light duty restrictions instead of returning to work full duty, the triage nurse will contact the employer with the details of the light duty restrictions. A timely determination is made on the employer being able to accommodate the restrictions and place the employee back on the job.

 

 

4- A triage nurse’s immediate involvement in a workers compensation claim shows all employees their physical well being is important to the company. The leads to a higher level of morale and trust in the employer. It also provides a big benefit for the employer – bottom line savings on the cost of their workers compensation – as the benefits of nurse triage greatly outweighs the cost for the employer. The nurse triage company can provide your company a cost benefit analysis that will show you the savings generated from using a nurse triage company.(WCxKit)

 

 

5- Nurse triage provides a way for the employer to be proactive in the management of workers compensation claims while at the same time being compassionate to the employee’s injury and needs. During a recent assessment of 20 locations of a trucking company using nurse triage, we found that the immediate conversation with the nurses turned many potential lost time claims into either med only claims or “self-care” claims where the employee could ice the injury, for example, and remain at work with his or her ankle inclined.

 

To learn more about nurse triage and other services, please find sources in our Directory.


Author Rebecca Shafer
, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing, publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com.

 

 

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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.

 

Know Six Levels of Medical Case Management

Risk managers have come to realize that proper medical case management can have a major impact on the cost of workers compensation claims. Medical case management from the initial report of the work comp claim to the final conclusion of the claim will impact the overall outcome. An understanding of the various levels will ensure the proper utilization of medical case management.

 

 

Medical case management is often broken down into five primary areas (which occasionally overlap). The five areas of medical case management (also sometimes referred to as nurse case management) are: (WCxKit)

 

  1. The triage nurse gets the claim at the time the injury is reported to the employer

 

  1. The senior nurse reviewer (SNR) gets the claim at the time it is reported to the insurer or third party administrators claims office

 

  1. The telephonic case manager (TCM) gets the claim from the adjuster when the claim triggers a predetermined parameter as specified in the account instructions, or in the judgment of the adjuster, is needed

 

  1. The field case manager (FCM) is assigned the claim when the adjuster determines the employee needs in-person medical assistance5.   Complex Case Management is a specialty service where a team of health experts and claim experts move a long-term claim, often over 30 years, to closure.

 

  1. The medical director, a doctor, is involved in the complex medical cases or medical cases where causality is in question.

 

 

The triage nurse will review the initial report of injury to determine the immediate medical needs of the employee. The triage nurse will direct the employee to the appropriate medical provider (in the states where the employer selects the medical provider) and arrange for immediate medical care in emergency situations. The triage nurse will evaluate whether or not the employee may need to see a specialist and whether or not the injury may cause the employee to lose time from work.

 

 

The initial directions provided to the employee and the triage nurses assessment of the severity of the claim is reported to the work comp adjuster. Many insurers and third party administrators will have the triage nurse follow up with the employee and the medical provider immediately following the initial treatment to determine the medical providers diagnosis and the need for further medical care.

 

 

The responsibilities of the senior nurse reviewer are to address the need for medical case management on the unusual or complex medical cases. For example, an airplane pilot flying long distances develops pulmonary emboli (a blood clot from the leg or another part of the body that gets stuck in the pulmonary artery leading to the lungs). The senior nurse reviewer needs to have extensive medical knowledge to assess whether the development of pulmonary emboli is due to the pilots many hours of sitting in the same seat or is due to a medical cause not related to the pilot’s occupation.

 

 

The TCM nurse is the busiest of the different levels of medical case management. Some employers and insures have a claims handling parameter that a TCM will be immediately involved in any case determined to be an indemnity benefits case. Other employers and insurers allow the adjuster to determine whether or not the TCM is needed. The nurse case managers role in the workers compensation claim will often include:

 

  1.  Facilitating the medical rehabilitation of the injured employee
  2. In consultation with the treating physician……evaluate the options for the best treatment plan for the injured employee
  3. Coordinating the medical care to achieve the best possible medical results in a cost-effective manner
  4. Insuring the proper utilization of medical treatment
  5. Providing guidance to the adjuster about the medical care needed
  6. Monitoring the employees medical progress
  7. Acting as a liaison between the physicians, the employee and the insurer
  8. Facilitating the communications between the employee, employer and physicians
  9. Keeping the adjuster informed of the employees medical status and progress
  10. Meeting with the employee and the employer to complete a detailed job evaluation
  11. Assisting the employer in identifying the return to work options
  12. Coordinating the employees return to work (either modified duty or full duty) with the employer, employee and physician
    The Field Case Manager(FCM) has a role similar to TCM with the principal difference being the “hands-on” approach of the FCM. The FCM will normally meet with the employee to discuss their injuries, especially if the employee has been hospitalized. The FCM will also accompany the employee to the various medical appointments. The FCM will normally be involved in the more serious injuries where rehabilitation will be needed or the nature of the injury is such that a permanent disability is expected. (WCxKit) Field Case Management Nurses can also assist with Life Care Planning, assisting with those issues that an injured employee with permanent disability might need to make their environment safer.

 

The most expensive claims can be almost life-long, long term claims, sometimes 30 years old. For some reason, these claims have been difficult to progress. This medical case managment service assists in removing obstacles the employee has had over a long period of time including medical problems, health challenges, and mental or psycho-social challenges. A team of health professionals work together to determine obstacles and develop a care plan to progress the case forward. These are the claims many risk managers and carriers simply give up on. Call me for a reference to this type of resources, or check in our Directory.

 

Important: nurse case managers and nurse triage nurses should be URAC Certified which has stringent protocol for education, credentials and training for these services.

 

 

The medical director is a doctor who has extensive knowledge and experience in the evaluation of medical conditions and the implementation of appropriate medical care. The medical director will act as a consultant and an adviser to the triage nurses, the senior nurse reviewer, the TCM nurses and the FCM nurses. The medical director can be called on to provide in depth medical reviews and to collaborate with the treating physician on the best course of medical care for the employee. Peer-to-peer doctors should be URAC certified; the best TPAs and carriers are URAC certified. This should be included in your RFP.

 

 

Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. See www.LowerWC.com for more information. Contact:RShafer@ReduceYourWorkersComp.com.

 

 

WC IQ TEST:  http://www.workerscompkit.com/intro/

WORK COMP CALCULATOR: http://www.LowerWC.com/calculator.php

MODIFIED DUTY CALCULATOR:  http://www.LowerWC.com/transitional-duty-cost-calculator.php

WC GROUP: http://www.linkedin.com/groups?homeNewMember=&gid=1922050/

SUBSCRIBE: Workers Comp Resource Center Newsletter

 

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.

 

©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com

 

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