issue 011, 2019

Navigating the road to recovery

BY DR. TERESA BARTLETT SVP, Senior Medical Officer, Sedgwick

The array of managed care services that come together to help injured employees recover must be connected, collaborative and focused on the same goals to ensure the best possible care.

When an employee is injured on the job, there are multiple steps for the employer, the employee and their medical providers. It can be an overwhelming process. There are many elements for employers to consider to reduce costs and help injured employees recover. Having integrated, multi-disciplinary claims and managed care teams working together from the first report of injury to the moment the claim is closed helps employers control claim costs and ensures better care management for injured employees.

According to a study at Sedgwick, connecting managed care services, such as clinical consultation, medical bill review, case management, pharmacy management and utilization review on the same technology platform controls costs, and can help identify trends and create strategies to improve outcomes.

Determining the right level of care
Beginning with a 24/7 nurse line, the injured employee is triaged to determine if they need to be treated by a physician or whether self-care is more appropriate. If a physician is needed, the nurse will send the provider medical information such as where to send the employee for medication, imaging and therapy, which helps ensure the continuity of care going forward. Nurses answer questions, offer reassurance, evaluate the injury and use industry-proven guidelines to direct self-care, telemedicine or in-person care with a top-performing local provider.   

Collaborating for the best possible outcomes
With claims and managed care teams operating on the same system, they have total visibility and can take steps as needed to help move the claim forward such as suggesting peer-to-peer consultations, or requesting nurse case management, behavioral health or return-to-work services. System triggers can be set up for services such as utilization review, surgery nurse services and pharmacy review.

Having real-time connectivity built into the system allows examiners and nurses to quickly exchange information and collaborate effectively to help injured employees achieve the best possible outcomes.

Decision optimization technology and preemptive utilization review techniques can also be integrated, helping to quickly identify when nurse case managers should intervene. By using Sedgwick’s decision optimization rules, we have seen a 31% decrease in the average referral lag time and an 8% decrease in average incurred medical costs.

An integrated system also helps bill reviewers keep a close eye on medical expenses, and improves speed, accuracy, savings and regulatory compliance.

Improving performance results
Supportive, collaborative services focused on the individual are proven to be effective for injured employees and their employers. An integrated claims and managed care program under one administrator is good for the employee’s well-being and it can make a positive impact on claim outcomes. Sedgwick’s clients moving from an unbundled program to an integrated program see improved performance results. Integrated clients outperformed unbundled clients by 11% to 13% over each year of a three-year analysis, and they see a 4% decrease in pending claim volume after choosing an integrated program, compared to a 7% increase for clients that unbundle.

To ensure the best possible outcomes, claims and managed care teams must remember that at the center of all the important services they provide is a person facing an injury or illness. Delivering a streamlined, connected solution ensures injured employees get the care they need to help them recover and return to work as quickly and safely and possible.

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Innovations in connected care

SVP, Clinically Integrated Medical Programs, Sedgwick

After an employee is injured at work, they may be feeling uncertain about their job, their health, their future and their ability to pay their bills. There are several self-service tools and specialized technology options that can provide valuable resources for employees. Coupled with communications from the claims and managed care teams, these tools can help improve the employee’s recovery and their overall claims experience.

Road to recovery innovations

We offer several options to help employees manage their care more effectively and keep the process moving forward including:

  • mySedgwick – Employees can log in to mySedgwick, our self-service tool, from their smartphone, tablet, laptop or web-enabled device and confirm return-to-work dates, securely interact with their claims professional, request a call from their assigned nurse case manager, report new claims or intermittent absences, sign up for direct deposit, opt in for push communications, search for a medical provider specializing in occupational injuries in select states, securely upload claim or medical documents, and much more. The claims process can be complicated and mySedgwick has several resources to assist employees every step of the way. In the learning center, they will find frequently asked questions, helpful links and workers’ compensation explainer videos to help guide them through the claims process; video options include English, Spanish and English with subtitles.
  • Telemedicine – Through Sedgwick’s clinical consultation service, our nurses guide employees to telemedicine through careful triage of their treatment needs and technology access. It includes on-screen care provided by an occupational medicine physician who is specially trained in telemedicine.
  • TelePT – With our telePT service, injured employees who are prescribed physical therapy receive on-screen care and learn correct exercises and appropriate muscle use from licensed physical therapists who are specially trained in telePT.
  • Surgery nurse services – This unique solution provides dedicated nurse resources and technology to help injured employees take steps to prepare for surgery and improve their recovery. For more information, see the article on surgery nurse services in this issue.
  • Rideshare – Our rideshare service provides easy access to reliable transportation and ensures injured employees keep their appointments. After a Sedgwick colleague makes a referral, the active trip can be monitored in real time and the injured employee receives automated ride status updates.

These tools make many of the steps in the claims process easier and more convenient. They also work together to help employees stay engaged in their recovery while they are away from work.

 Road to Recovery Innovations

Surgery nurse services help patients steer themselves toward a faster recovery

SVP, Clinically Integrated Medical Programs, Sedgwick

Sedgwick’s surgery nurse solution, one of the first in the industry, helps injured employees prepare their mind and body before surgery and provides them with educational tools and guidance to improve their recovery.

When an operation is authorized, a surgery nurse will contact the injured employee to assess their health literacy, set expectations and identify any red flags that could impact their recovery. The nurse will also send the employee’s treating physician a letter to introduce the program and notify them about the daily exercises and well-being guidance.

Using their computer or mobile device, the patient can receive brief daily lessons carefully selected to improve pre-operative physical strength, nutrition and well-being, and address issues related to smoking cessation and home readiness. Movements such as steps and range of motion are measured using a specialized app developed by PeerWell. The patient’s progress is monitored and encouraged by an experienced surgery nurse who holds a certification as a case manager. As a part of the rehabilitation process, the nurse documents strengthening exercises and improvements, and keeps the claims examiner informed about the employee’s progress and compliance. The nurse also screens the employee for risks in areas such as opioid use, delayed recovery and the perception of serious pain. The daily exercises and well-being guidance continue after surgery to support recovery efforts.

Key results
When an injured employee is engaged in the process, before and after surgery, it helps control costs while improving the outcome. After comparing surgical claims with and without our surgery nurse program, claims where these services were used achieved the following results for our clients:

Road To Nurse