issue 007, 2017 q2

Right data, right decisions, right results

BY Edward E. Canavan, AIC, ARM VP, Workers’ Compensation Practice and Compliance, Sedgwick

Without the right approach and resources to help the employee recover, even a minor back injury has the potential to become a costly, complex claim. Predicting the exact outcome of every claim is difficult, but certain factors and characteristics can be used to help identify complex cases early and achieve the best possible outcomes.

With rare, catastrophic cases that result in life-altering injuries, engaging the right resources from day one can help improve the patient’s recovery. Most complex claims are not initially defined as catastrophic; it is the claim’s path that can lead to the complexity and increased cost. This may include comorbidities impacting the employee’s recovery, the use or misuse of opioids, psychosocial issues or other concerns. Successful claim resolution hinges on identifying these characteristics and working to ensure the employee gets the right medical care.

Being able to recognize warning signs and effectively address claim issues in real time can have a positive impact on the claim’s outcome. A decision optimization platform provides the technology needed to detect workplace injury claims that have a high likelihood of becoming complex and costly by looking at factors such as comorbidities, opioid utilization, behavioral health issues and litigation. The system can also trigger claims to be reviewed when they reach certain cost levels. In addition to identifying these characteristics, decision optimization, also referred to as predictive analytics, uses existing data to determine patterns and predict future outcomes and trends based on those patterns. 

Important steps to prevent claims from becoming complex include identifying the key indicators above, and then deploying targeted strategies to mitigate the risk and address the cost drivers. It could prevent a simple strained wrist from turning into a claim with $100,000 in reserves.

When a complex case is detected, the claims and managed care teams must work closely together to engage the right resources to help improve the outcome. This may include connecting the injured employees with the right care to assist them on their path toward recovery or communicating with the employee to help reduce any potential litigation.

Critical steps for catastrophic cases include identifying the proper medical care early and establishing a plan for physical and occupational therapy. Being there from day one includes integrating expert advisors and clinical resources, and communicating with the claims team, clinicians, and the employee’s family and employer to ensure the employee is on the best possible path to recovery. Successful programs include experienced claims and managed care teams, medical treatment provided by specialized centers of excellence, and a proven process for developing customized care focused on the whole person – not just the injury. (See related article in this edition to learn more about the medical centers of excellence.)

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The path to a successful recovery goes beyond treating the injury

AVP, Managed Care Client Services, Sedgwick

Providing the right care is about being there for the injured person at every turn – throughout the medical treatment and rehabilitation process, and during their adjustment to life at home. The medical centers of excellence offer specialized care and the latest treatment options that can positively impact the employee’s recovery and help them achieve a better quality of life. They are designed for complex and catastrophic injuries such as burns and traumatic brain and spinal cord injuries. 

A colleague on our complex claims team visited one of the centers of excellence in our network and spoke to a patient who is among a group of people in the same situation. He explained that they have a support system of peers struggling with similar issues. They can talk about their experiences and when they feel depressed, they can lift each other up because they understand. There was a gentleman who had a spinal cord injury and they were teaching him how to text/voice command; he had only been there five days and that one thing gave him a first-time sense of some control over his situation. If a patient doesn’t have that ability to communicate or even just call a nurse, they can feel completely helpless and afraid. For a 40-year-old man with a severe spinal cord injury, the provider expertise and peer support at a center of excellence are significant advantages compared to a general rehabilitation center.

The specialty providers at the centers of excellence treat the whole person. The team is experienced in identifying the best treatment to help produce the best results, and avoid secondary or long-term issues. Secondary complications such as skin breakdowns, infections and pulmonary issues delay recovery and they could be life-threatening. Even a minor complication can lengthen the hospital stay and increase medical costs, so getting the injured employee the right care early on can help decrease the overall cost of the claim. In addition, staff members work closely with injured employees and family members to provide education on maintaining their health and well-being once discharged from the hospital. Nurse case managers work with the hospital team to ensure that a smooth transition to the home environment occurs along with the necessary specialty equipment and follow-up care.

In our industry, we can help ensure employees with severe injuries receive the right care by engaging expert resources early and being there to assist them every step of the way. Matching an employee with a severe injury with the specialized medical care they need can put them on the best path toward recovery – and ultimately help improve their quality of life.

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