Disability Case Management Flashcards
0
Q
Disability case management
A
The coordination and management of work related and nonwork-related injury and illness
1
Q
Case management
A
A process of coordinating a workers health care services to deliver optimal, quality care in a cost-effective manner
2
Q
Disability case management includes aspects related to the following types of benefits
A
- Group health
- Workers’ compensation
- Short term disability
- FMLA
- Long term disability
3
Q
Purpose of case management
A
- Prevent fragmented care and delayed recovery
- Manage associated benefits
- Facilitate workers return to work to appropriate transitional or full duty assignment or to an optimal alternative
4
Q
Primary goal of case management
A
Justify the health care provided with a clear measurement of outcomes
5
Q
Benefits
A
Services owed to an individual, as defined by law (employment or workers compensation benefits) or based on criteria established in a policy or summary plan description ( rehabilitation, restraining)
6
Q
Cash benefits
A
Cash that is paid either as part of workers compensation benefits or according to an employers defined disability plan or negotiated in a union contract to replace a workers loss of income or earning capacity due to disability resulting from an occupational or nonoccupational injury or illness
7
Q
Four classifications to describe monetary workers compensation disability benefits
A
- Temporary total disability (TTD)
- Temporary partial disability (TPD)
- Permanent total disability (PTD)
- Permanent partial disability (PPD)
8
Q
Temporary total disability
A
- TTD
- Tax free reimbursement for partial wages when a worker is temporarily totally disabled
9
Q
Temporary partial disability
A
- TPD
- Tax free reimbursement for partial wages when a worker is temporarily partially disabled
10
Q
Permanent total disability
A
- PTD
- Tax free reimbursement for partial wages when a worker is permanently totally disabled
11
Q
Permanent partial disability
A
- PPD
- Tax free reimbursement for partial wages when a worker is permanently partially disabled
12
Q
Workers compensation benefits are determined and allocated according to…
A
State jurisdictional rules
13
Q
Other disability benefits (STD and LTD) can be either tax free when——- or after tax in ———
A
Worker pays for these plans
Employer paid or employer self funded programs
14
Q
Other disability benefits (STD or LTD) are determined and allocated according to…
A
Language in the employers disability plan descriptions or policy statement
15
Q
Deductible
A
The amount that a member of the health care plan must pay for covered services per specified period (usually the policy year) before the insurer will pay benefits (ie health care/ prescriptions)
16
Q
Earning capacity
A
The potential wages a worker could achieve, given his or her education, training, skill level, previous experience, medical condition, proximity to available work and other factors
17
Q
Exclusive remedy
A
The legal concept that receipt of workers compensation benefits is the sole benefit (remedy) for the occupational condition incurred and leaves the worker without an additional course of action against the employer
18
Q
Functional capacity evaluation
A
- FCE
- A professional assessment to specifically determine a disabled persons residual physical abilities
19
Q
Gatekeeper
A
- The term commonly used to refer to a primary care provider (PCP) who is responsible for coordinating all of a members medical care.
- Also may refer to a type if managed care plan that required that all members have a formal referral from a PCP in order for other care to be covered by the plan
20
Q
Indemnity
A
In workers compensation language, generally refers to payments made for lost wages
21
Q
Indemnity plan
A
A traditional health insurance program in which the insured person is reimbursed for covered expenses after a deductible is met
22
Q
Independent medical examination
A
- IME
- A second medical opinion related to a workers health condition that can be legally binding in some jurisdictions and according to some plan designs
23
Q
Job analysis
A
A detailed description of a workers job duties and physical and mental activities that identifies the essential functions of the job
24
Managed care
A system of health care delivery that influences utilization of services, costs of services, channeling for services and measures of performance
25
Maximum medical improvement
Used in workers compensation to indicate the final level to which a person improves/recovers after sustaining a disabling medical condition (may or may not equate to pre-disability level)
26
Rehabilitation
Treatment or formal plan provided by multidisciplinary specialists intended to return the worker to optimal function
27
Reserves
Money set aside by a self-insured organization or an insurance carrier to pay the ultimate monetary cost of claims/losses
28
Residual functional capacity
- RFC
- The final determination of a persons physical capabilities or restrictions at the conclusion of recovery from an illness or injury, usually determined from a physical evaluation and review of a FCE test.
- The RFC determination is compared with the physical demands of the job activity to determine the appropriateness of vocational options or limitations in daily living.
29
Risk management
The process of making and implementing decisions that will minimize the adverse effects of accidental and business losses on an organization
30
Return to work
- RTW
| - The desired goal for all workers after an injury or illness (occupational or nonoccupational)
31
Transitional work
A temporary job that accommodates the workers restrictions for a limited period during recovery from an injury or illness
32
Options for transitional work assignments include the following:
1. Modified duty
| 2. Alternative duty
33
Modified duty
A workers original job is adjusted to accommodate restrictions
34
Alternative duty
The worker performs a different job because restrictions rule out continued performance of original job duties
35
Third party administrator
- TPA
- A company that handles all the administrative tasks involved in managing claims for self-insured employers who find their own benefit plans
36
Utilization review
A process that measures use and consumption of available resources (including professional staff, facilities and services) to determine medical necessity, cost effectiveness and conformity to criteria for optimal use
37
Wage loss
The actual amount of monetary losses sustained by a worker due to the inability to work
38
Case management has been used to describe a variety of strategies for managing health and social services for.....
1. Individuals
2. Families
3. Work force populations
39
------------, a forerunner to case management began at the turn or the 20th century in public health programs
Community service coordination
40
Case management is not a new process and its scope has.....
Expanded and become more sophisticated
41
The current trend in formalized case management began with......
Medicaid and Medicare demonstration projects in the early 1970s
42
--------- emerged as a strategy to contain health care costs
Managed care programs
43
Dual priorities of case management became.....
1. Meeting the workers needs
| 2. Making good use of community resources
44
Major shifts in the approach for disability case management
1. 1970s- work adjustment services
2. 1980s- work hardening
3. 1990s- rehabilitation in the workplace
45
In 2003 there were -------- reported injuries and illnesses in private industry; of these ------ were cases with days away from work, job transfer or restriction
4. 4 million
| 2. 3 million
46
On any given day ------ if workers in the US are absent from work
3.9%
47
More than ------- of employers are unaware of how their absence rates compare with competitors
Half
48
-------------- is one "best practice" for responding to economic and productivity problems
Keeping more workers at work more of the time
49
Focuses of occupational health case management are as follows:
1. Providing a safe and healthful workplace
2. Ensuring that ill or injured workers receive prompt, quality healthcare
3. Facilitating ill and injured workers return to work as soon as it is medically safe
4. Coordinating total absence management programs
50
Occupational and environmental health nurses help injured workers achieve optimal outcomes by using the following:
1. Expertise in health care delivery
2. Knowledge of the multitude of service options
3. Expertise in managing return to work programs
4. Understanding of workers relationships with their environments
51
Today case management requires an understanding of how the healthcare delivery system is affected by various......
Medical insurance, government and corporate mechanisms
52
In the practice setting, case management demands the following competencies/skills:
1. Critical thinking skills
2. Clinical knowledge
3. Experience within health care delivery systems
4. Ability to access quality, professional resources
5. Knowledge of the workplace
6. Knowledge of benefit plan designs and statutory requirements
53
----------- for healthcare services have historically had the greatest effect on access and delivery
Changes in the payment
54
Payment for health care services before World War II
Technology was simple and health care dollars were directed primarily toward the treatment of acute illnesses and injuries
55
Payment for health care services after World War II
Technology became more complex and health care expenses for the treatment of chronic, long term, expensive to treat illnesses and injuries increased dramatically
56
When did the health insurance industry and third party payment systems emerge?
After World War II
57
During postwar economic challenges it was very common for employers to offer ------------------- instead of salary increases
Benefits such as pensions, disability benefits and insurance plans
58
Health insurance payments rose as the insurance industry expanded from covering less than ---- of Americans before WWII to greater than ------ by the early 1960s
20%
60%
59
Third party payments rose from covering about ----- of all personal health costs in 1950 to almost ----- in the 1990s
33%
75%
60
Direct costs for workers health care expenses and lost wages resulting from occupational illnesses and injuries are generally paid......
Under a variety of workers compensation insurance arrangements at no cost to the worker
61
Costs for nonwork related health care expenses are generally paid.....
Under a variety of employer group health insurance arrangements that include copayment costs for workers
62
The critical need for effective case management has grown largely as a result of...
Uncontrolled and rising healthcare costs
63
By the ------, employers were paying for a larger portion of the nation's healthcare and could no longer tolerate increases in both -------- and ------- that had resulted in -------- increases for their group health and workers compensation premiums
1980s
Private
Public healthcare costs
Double digit
64
In the 1980s healthcare expenses were consuming approximately ----- of the gross domestic product
15%
65
Managed care as a cost containment strategy emerged first in the --------- arena and later in the -------- arena
Group health insurance
| Workers compensation
66
Managed care incorporates the use of:
1. Preferred provider networks
2. Health maintenance organizations (HMO)
3. Direct contracting
4. Bill audits
5. Utilization review
6. Pre admission authorization
7. Concurrent and retrospective review
8. Second surgical opinion
9. Independent medical exams
10. Targeted case management
67
In 1997, nearly ----- of workers who received health benefits from their employers were covered by some type of managed care plan
75%
68
It has been estimated that more than ------- Americans are enrolled in formal managed care plans
110 million
69
Managed care programs vs case management
- Managed care programs strive to reach all potential users of healthcare service
- Case management is a personalized process that focuses on certain high risk or high cost individuals
70
Some of the greatest cost savings are achieved when case management efforts are focused on the ------- of the worker population responsible for ------- of the expenditures in any health plan
3-5%
| 60-70%
71
Decision factors or triggers for case management are often developed based on....
The goals of the individual program
72
Disability management utilizes -------, -------, and ------- to minimize the cost of disability to employers and workers and encourages ------------
Services
People
Materials
Return to work for employees with disabilities
73
Disability management has a ------- side and a ----------- side
Business
| Financial
74
The business and financial side of disability management include.....
1. Designing return to work policies that are consistent with a company's operations
2. Promote a return to work culture
75
Using an effective disability case management process, workers get....
1. The treatment they need
| 2. Goal of returning them to work as soon as is medically feasible
76
Corporations can realize significant cost benefit from effectively integrating (1), (2), (3), (4) programs with occupational health and safety and worksite disease management programs
1. Workers compensation
2. FMLA
3. Short term disability
4. Long term disability
77
Supervisors must be shown how they can benefit from programs to (1) and from developing program evaluation strategies that link (2)
1. Keep valued workers on the job
| 2. Disability management with the corporate bottom line
78
Employers should be prompted to incorporate ---------- into strategic planning as part of creating a healthy organization.
Integrated disability management
79
Case managers are in a unique position to ------, -------, -------, or -------- disability
Define
Prevent
Create
Reinforce
80
Case managers define, prevent, create and reinforce disability by the following means:
1. Understanding the relationship among impairment, work and disability
2. Promoting return to work solutions for individuals and employers
3. Coordinating administration of the claim in a timely fashion
4. Partnering with the employer and the worker to ensure positive return to work outcomes
5. Utilizing basic return to work principles in disability management programming
81
The component level of practice in the case management category includes:
1. Identifying the need for case management
2. Conducting a thorough and objective assessment of the client's current status and case management needs
3. Using and evaluating available health care resources to achieve an optimal health care outcome
4. Collaborating with the client and others to use a multidisciplinary approach to achieve the desired outcomes
5. Using and maintaining an accurate, complete record keeping system while maintaining confidentiality
6. Identifying changes in case management practice to bring about appropriate care and cost effective outcomes
82
Case management practice at the proficient and expert levels includes
1. Developing and managing case management programs
| 2. Functioning as an expert to internal and external audiences
83
Practice settings for case management services
1. Workplaces/ corporations
2. Health care delivery systems (hospitals, clinics, rehabilitation facilities)
3. Provider agencies/facilities (mental health/ home health)
4. Managed care organizations
5. Public insurance providers (Medicaid, Medicare, Social Security Administration)
6. Private insurance providers (workers' compensation, health, long term care, disability, liability, casualty, auto and accident)
7. Independent case management companies and providers
84
The worker, who is the central player in the case management process, has the following main responsibilities:
1. Communicating promptly with the employer about an occupational or non-occupational injury or illness
2. Participating in the accident investigation process as appropriate
3. Maintaining contact with the occupational and environmental health nurse regarding medical care, treatment, prognosis, follow-up appointments and issues regarding return to work
4. Keeping appointments with all health care providers
5. Complying with treatment and medical protocols for recovery
85
The occupational and environmental health nurse is involved in all stages of the case management process and has the following responsibilities:
1. Serving as the first line of contact for the injured worker
2. Providing case management with an emphasis on return to pre-injury function
3. Acting as a liaison
4. Establishing a target return to work date based on disability guidelines
5. Working with the worker to establish recovery and rehabilitation goals
6. Jointly setting a date for return to work
7. Communicating with other health care professionals to negotiate care and assess social support resources
8. Working with the employer to determine if transitional work is available and monitoring worker's progress upon return to work
9. Researching sources of valuable information for developing specific job restrictions
10. Educating the worker about the benefits of workers compensation or disability system or referring further questions to the claims manager or HR
11. Maintaining confidentiality of the workers protected health information in accordance with professional codes, laws and regulations
86
The physician is usually the primary care provider for the seriously injured or ill worker. The physicians case management responsibilities include:
1. Providing timely information regarding diagnosis, treatment, prognosis, and expected return to work date
2. Clarifying by work limitations that may apply upon return to work, approving transitional duty work
3. Being aware of workplace issues, including types of work available and transitional work options
4. Conducting a workplace walk-through assessment as needed in coordination with the employer
5. Communicating with members of the return to work team before markings referrals to other specialists for persistent symptoms
87
The employer's support is critical in an effective case management program. Employer responsibilities include:
1. Investigating the accident or issues impacting illness and injury and reviewing workplace factors, which may need to be changed or modified
2. Maintains contact between supervisor and worker during the disability to promote good will and help maintain the link between the ill and injured worker and the workplace
3. Helping the occupational and environmental health nurse, HR professionals and the supervisor identify suitable transitional work
4. Establishing and supporting a return to work program for both occupational and non occupational injuries and illnesses
5. Facilitating the workers return to work as soon as is medically safe
88
The insurer or third party administrator (TPA), represented by the claims manager, acts as a consultant with all parties during all stages of the claim. Responsibilities of the insurer include:
1. Determining compensability and/or eligibility of the claim
2. Authorizing medical care and payments of bills to providers
3. Ensuring the payment of appropriate wages specified in workers compensation statues and/or disability plans
4. Communicating regularly and responding promptly and accurately to employer's and worker's questions regarding the claim
5. Coordinating the flow of information by requesting periodic health and medical information from health care providers when necessary
6. Consulting with attorneys, when necessary, regarding specific questions about worker's rights under state worker's compensation laws
89
Types of rehabilitation specialists
1. Rehabilitation nurses
2. Physical therapists
3. Occupational specialists
4. Vocational counselors
90
Rehabilitation specialists work with the injured worker during the rehabilitation phases of recovery. Their major responsibilities include:
1. Working with the injured worker so function and strength are regained to meet the goal of return to work as soon s medically possible.
2. Communicating with the team regarding the worker's progress and being aware of red flags and issues affecting return to work
3. Providing specialization programs to facilitate the workers return to work
4. Providing realistic expectations regarding recovery
5. Helping the injured worker manage chronic pain
91
Indicators of delayed recovery (red flags)
1. Poor job satisfaction
2. A change in the story of injury occurrence
3. Unresolved anger at employer about injury
4. Unwillingness to discuss or negotiate a return to work plan
5. Multiple failures to return to work
6. Perceived lack of support from supervisor
7. History of job performance problems
8. Time off without any change in symptoms
9. Income or temporary disability equal to or greater than regular wage scale
10. Double dipping between workers compensation, STD, LTD or SSDI
11. Other secondary gain issues: disabled partner at home, multiple demands, entitlement issues
12. Limited job offerings in the area
13. Doctor shopping
14. Involvement of an attorney
15. Requests for narcotics renewals
16. Close to retirement age
17. Undiagnosed or untreated depression
18. Time off from the date of injury exceeds six months
19. Continued subjective complaints without objective findings
20. Unavailable when case manager calls
92
The union is important in its support of the case management process and the injured or ill worker. Main responsibilities include the following:
1. Working with the employer and the occupational and environmental health nurse to understand and support objectives for the ill or injured worker
2. Helping the ill or injured worker understand his or her responsibilities for return to transitional work
3. Helping the ill or injured worker understand his or her benefits while disabled
93
The occupational and environmental health nurse acts as a liaison with the following parties:
1. Worker
2. Other health care professionals
3. Insurers
4. TPAs
5. The employer
6. The worker's compensation board
94
Example of source of information for developing job specific restrictions
Job Accommodation Network
95
Job Accomodation Network
Where health care professionals can speak directly with trained consultants about specific job restriction needs and modification solutions
96
Examples of workplace factors that might be changed or modified following a post-accident investigation
1. Machine modifications
| 2. Ergonomic improvements
97
Examples of specialized programs to facilitate worker's return to work performed by rehabilitation specialists
1. Functional capacity assessments
2. Ergonomic evaluations
3. Labor market surveys
4. Work hardening programs
