On Allison’s first day as a case manager for a workers’ compensation insurer, her new employer had been impressed with her nursing experience as a case manager for an HMO and felt her skills would be an asset to the company. Allison shouldn’t worry about getting started, they explained; a case manager experienced in workers’ compensation and occupational health would be responsible for Allison’s orientation.

Allison’s mentor handed her a folder that included notes, assessments, and summaries to use as reference. Allison realized she was in uncharted territory when she came across abbreviations and acronyms she had never seen before:

“This IW, since FROI, has complained of LBP. The EE has been with ER since DOH on 1/1/02. PP is the local OH. RTW on LD until FCE, which could identify WC. If not, IME may be of benefit. Next OV with MP may give anticipated time of FD/FT release. MMI & PI to be determined at a later date.”

“Uh-oh,”Allison thought. “I don’t understand a word of this.” Not to worry, though. This code is really no mystery. It is insurance language with terms she needed to learn.

Translation: This injured worker, since first report of injury, has complained of low back pain. The employee has been with (the) employer since (the) date of hire on January 1, 2002. (The) preferred provider is the local occupational health (physician). (The injured worker will) return to work on light duty until (the) functional capacity evaluation, which could identify work capacity. If not, independent medical examination may be of benefit. Next office visit with (the) medical provider may give anticipated time of full-duty/full-time (work) release. Maximum medical improvement and permanent impairment to be determined at a later date.

In the weeks to come, Allison learned the ropes. Her immediate team of adjusters, associates, and managers was supportive, answered questions, and welcomed her as part of the team. She realized that other nurses entering this field would appreciate some basic instruction before they landed their first job. Allison had been sure of her case management skills in an HMO, but workers’ comp was a new challenge. She needed to do some research to answer some questions like “What is it? “Where did it come from?” and “How does it work?”

Workers’ compensation legislation was the first U.S. no-fault legislation. Before 1911, when the first state laws were enacted, injured workers had to prove employer responsibility.¹ However, the average worker couldn’t afford the cost of proof plus ongoing medical care. As industry grew, so did injuries in factories. Progressive thinkers pushed for a more equitable solution.

The basic twofold concept has remained intact since 1911. Regardless of responsibility, 1) the worker receives wage replacement and medical care for the work-related injury, and 2) the employer cannot be sued by the employee for wages and injury-related costs.

Today’s system of disability management and case management combined with preventive safety programs has evolved over more than 30 years, beginning with federal recommendations in 1972.² Essential reforms made case management and nurse involvement integral to a successful program. This entailed improving a fragmented system riddled with escalating medical costs. Benefits were standardized, and cost containment and equity between state regulations were addressed. Return-to-work programs to benefit employer and worker were introduced.

Your new role

The Bureau of Labor Statistics’ 2004 figures show close to 4 million recorded cases of nonfatal workplace injuries and illnesses. The largest category of cases, 12%, included sprains, strains, and tears. This was followed by falls and injuries to the back, at 6% each. Respiratory problems, highway incidents, and even dermatitis are examples of other recorded injuries. The toll in lost productivity was more than 1.2 million days away from work.³

Enter the nurse. When a nurse case manager is involved, days away from work, or “lost time,” can be reduced without affecting quality of care. Care often is enhanced by the expertise the nurse brings to the case.

Nurses who become case managers in workers’ compensation come from varied backgrounds. According to the Commission for Case Manager Certification, “Case management is not a profession in itself but rather an area of practice within one’s profession; it is collaborative and transdisciplinary in nature.”⁴ Typically, nurses bring experience in occupational health, managed care, discharge planning, and home health to this position. Most employers require such experience. But no matter what your background is, nurses new to this arena often are mentored by experienced case managers.

Employers of case managers who focus on workers’ compensation include insurance companies, occupational health clinics, and specialty providers, such as orthopedists. The job title of “workers’ compensation case manager” is the most common, but others exist, such as “disability management coordinator” or “injury management facilitator.” Whatever the name, the employment requirements are similar; the nurse case manager is present for the worker as “a means for achieving client wellness through advocacy, communication, education, identification of service resources, and service facilitation.”⁴

Tools and techniques

Was Allison’s experience in case management going to help ease her transition into workers’ compensation case management? She was skilled in communicating with patients and medical providers on a regular basis. What could be different here?

Three case management methods are recognized as standard: telephonic, on-site, and combined. A telephonic case manager contacts all involved parties by phone, letter, or fax. On-site case managers visit injured employees and their workplaces and attend physician and treatment appointments. The combined method applies both telephonic and on-site techniques.

The telephonic approach relies on the cooperation of providers, the employer, and the injured worker. Often, the caseload is larger because the case manager doesn’t leave an office setting. To obtain the information necessary and achieve goals, a nurse case manager must possess a strong clinical background and use interpersonal skills that relate well telephonically.

The on-site approach requires face-to-face interaction. The caseload may be lighter because of the demands of frequent travel and the need to attend appointments. Strong clinical skills also are important, and the nurse needs to be able to create successful relationships dealing directly with workers, employers, and providers.

The combined method is just that: The caseload is a mixture of each type. Simpler, straightforward cases remain telephonic when the goals can be met in this manner. Files that are complex, possibly with catastrophic circumstances, may be managed with on-site visitation. Often, insurers use a combined approach to meet the varied needs of their clients.

Your team

The nurse case manager is a contributing member of two interacting teams. The internal team usually consists of a claims adjuster and case manager. At times, there is interaction with other departments in the company, such as inside counsel, loss control, or underwriters. The external team consists of the injured worker, medical providers, and the employer. This external team is the source of your most valued information and the “three-point contact,” the basis of your daily workflow.

The two teams interact regularly. For example, the worker needs payment information and speaks with the adjuster. The adjuster calls the employer about weekly wages. The case manager obtains documentation from the provider on medical necessity and discusses authorizations with the adjuster. Most important, the case manager maintains consistent collaborative contact with the injured worker, employer, and provider to promote a safe and timely return to work.

Communication and cooperation are essential, and the case manager is the link. If issues exist between employer and employee about when the employee should return to work, the case manager may be able to mediate. The case manager can expedite care and treatment and act as an advocate for the worker.

Tasks and workflow

Each file or case requires a “three-point contact,” another new term Allison needed to learn. Of course, contacting the injured worker is one contact. Then what?

The employer and medical provider join the injured employee as the three elements of a “three-point contact.” There are two three-point contacts: one by the adjuster, one by the nurse. Each has different perspectives.

The adjuster tries to determine causation, contributing factors, or compensability. This contact, performed within 24 to 48 hours of claim notification, is a requirement of many commercial insurers for their adjusters.⁵

The nurse case manager’s “three-point contact” deals with other issues. Specifically, the goal of case management is to “assess barriers to return to work, communicate with the employer, and provide education on the positive effects of returning the injured worker to work; address medical concerns that may prevent return to work; and coordinate the return to work process.”⁶ A referral for case management can occur at any time during the life of a claim. Generally, sources of a referral are the employer, the claims adjuster, or the injured employee.

Before making contacts, the case manager needs to review the records for background information. The nurse’s initial calls to each of the three parties should be twofold: introduction and inquiry. The introduction creates the basis of the relationship that will evolve. In each case, the nurse case manager should seek to establish trust and confidence, and confirm that he or she will continue to be available during the course of the claim.

Inquiry provides information essential to the initial assessment, subsequent planning, coordination, and evaluation stages. This interview helps the nurse and others involved understand the injury, formulate a treatment plan, and research return-to-work policies and barriers that might hinder a return to work. Later contact, telephonic or on-site, is done to evaluate the success of the treatment plans. This contact is necessary to continue to assess the worker’s progress toward recovery and offers an avenue to continue to monitor status. The case management functions of assessor, planner, facilitator, and advocate continue throughout the nurse’s involvement with the injured worker regardless of prognosis and medical end point.

When Allison became a workers’ compensation case manager, she was introduced to a host of new acronyms. ER no longer meant emergency room. Depending on the circumstances, WC could relate to workers’ comp or work capacity. In addition, each employer may have its own set of abbreviations to learn. (See chart for help.)

Many case managers new to a workers’ comp insurer have experience and skills directly relating to this position. New case managers often are placed with a mentor. Whether it is called orientation, mentoring, or even probation, a seasoned case manager usually is responsible for a successful adjustment to a new environment. This is the first opportunity to learn the basics of the company and workflow. A positive relationship with a mentor offers support and collegial assistance.

Other sources of information are available. The most prominent national professional organization is the Case Management Society of America (www.cmsa.org). Regional chapters hold meetings and offer CE presentations, conferences, and networking opportunities. Certification programs can offer professional advancement; many workers’ compensation employers desire nurses to be certified in case management. Journals, newsletters, and reference materials are also available. It’s important to become familiar with industry standards. The Medical Disability Advisor: Workplace Guidelines for Disability Duration covers a wide range of illnesses and injuries, and duration guidelines to allow for individual differences in response to illness or injury.⁸

Anytime nurses change career paths, they must acquire new knowledge. Getting a jump on the learning curve before your first day on the job can be essential to your success.