Welcome to the Worker in the Workplace, Coordination and Case Management for the Worker. I'm Dr. Tiffany Gleason, the Chief Medical Officer at Managed Care Advisors. I have no financial conflicts to disclose. I would like to express appreciation to Heather Burrell, the Manager of our Case Management Care Unit at Managed Care Advisors. Our objectives today are to review background information on work-related injuries and illnesses, discuss techniques to facilitate effective communication and overcome obstacles in workers' compensation case management, demonstrate care coordination and case management approaches through case studies, and incorporate best practices and guidelines by identifying resources. We'll begin with some background information on work suitability and disability. Just a reminder on personal injuries and illnesses. Employees may incur a personal illness or injury that impacts their ability to work at full duty. These employees have access to protections under FMLA and ADA. There's more information on these federal regulations at the end of the presentation. Employees that have personal injuries and illnesses may choose to use short- or long-term disability insurance to cover costs associated with these conditions. These conditions are considered non-work-related. Just a reminder that experiencing symptoms of a personal condition while at work does not establish work as a causal factor. An example of a personal illness would be our analyst, Joe. He has a history of childhood asthma. He takes daily medications for control, and he uses albuterol as needed. He also has seasonal allergies, which tend to aggravate his asthma. While at work in April, he needed to use his albuterol twice during the workday due to wheezing, which controlled his symptoms. In this example, Joe experienced symptoms of his personal illness while at work. Specific work factors were not identified to establish this as a work-related illness. Therefore, this would be a non-work-related personal medical condition. Another reminder on workers' compensation. These programs are no fault and provide medical benefits and compensation to employees who are injured or develop an illness due to specific work factors. The detailed processes vary under the programs. Programs can be administered through state or federal administrators. Employees in all these programs should report their injury or illness to their employer, usually through their supervisor, and seek necessary medical care. They'll file a claim according to their program's requirements, and then the claim must be adjudicated. The claim would then be accepted or denied. And now, just a brief overview of the workers' compensation process. Again, the details are different under each program. The employee must report their injury or illness to the employer and seek the necessary medical care. They'll file a claim on the appropriate forms, and the claims adjuster will adjudicate the claim. The claim will either be accepted, denied, or possibly put in appended status while they await more documentation. Programs offer limited benefits until the claim has been accepted. This usually involves coverage for urgent care-type services. If a claim is denied, there are appeal processes that vary across the different programs. There are some similarities across workers' compensation programs. The employee must be an employee of the employer. If they're a contractor or visiting the premises, they would not be eligible for that employer-based program. All programs have the ability to assess the fact of injury. This could include video surveillance, witness statements, supervisor statements, and also an assessment as the employee was in the line of duty while the injury or illness occurred. Medical evidence is then required to confirm the diagnosis and support causality and that work relation. Here's some information on work-related illnesses and injury, as well as fatality data in private industry in the United States. If you're interested in more statistics along these lines, the Bureau of Labor and Statistics is the best resource, and the website is available here. As you can see, there are quite a few work-related injuries and illnesses in private industry. This data is from 2021, and it shows that there's over 2.6 million recordable cases, with the median days away from work being 12. That data is from 2020. And then there's some information regarding the types of injuries that occur. We see most commonly sprained, strains, and tears, and that significant amount of injuries involve falls, slips, and trips. On the right, we have information on the cases across several years for non-fatal work injuries. So you can see rates have fortunately been fairly steady over the past five years. Now let's talk about causal relationships. The easiest relationship to describe is the direct causation. This is the relationship that occurs when a distinct injury results from a distinct work event. The easiest example is a slip, trip, and fall, like we just talked about, that happened frequently in the work environment. When someone has a slip, trip, or fall at work, and then they have a musculoskeletal condition, an ankle sprain is a common injury that results from a slip and fall. That would be directly caused by the work accident. Underlying conditions can also be aggravated by a work injury. So if the individual previously discussed had underlying arthritis of their ankle that now has become more symptomatic due to the ankle sprain, that underlying osteoarthritis could be considered temporarily aggravated. It's only with time we'll know if this becomes a permanent aggravation. The hope is that they can return to their baseline and the temporary aggravation can resolve. Underlying conditions can also be accelerated. This is when the rate of progression of an active condition is impacted by the work injury. This is very similar to an aggravation. Conditions that were previously asymptomatic can be precipitated by the injury or illness. Perhaps the individual did not have any symptoms of any ankle pathology, but on the diagnostic imaging, it's noticed that they have a bone cyst and that because of the inflammation and the altered biomechanics due to the sprain, the area where the bone cyst is now becoming painful. And this would be where an injury precipitated symptoms from a condition that was present but asymptomatic at the time of the injury. Consequential conditions arise as a result of the original conditions under the claim. We sometimes see this when, again, going back to altered biomechanics. Perhaps they have a left ankle injury and they're in a walking boot and their biomechanics are altered and they start to experience lower back pain or sacroiliac dysfunction because of their altered gait patterns. This would be a consequential condition. Now I'd like to share with you a work-related illness example. We have Dan, who is also an analyst with a history of childhood asthma. He also takes controller medications and uses albuterol as needed. While he is at work in his cubicle one day, the facility's crews are in the area painting the workspace walls. Several co-workers, including Dan, are irritated by the paint fumes and report headaches and coughing. In addition to these symptoms, Dan experiences wheezing. He takes his albuterol, but he's not gaining control and feels very short of breath. So he actually leaves and goes to urgent care. So unlike Joe, Dan had clearly identified factors at work that aggravated his asthma. Dan could file a worker's compensation claim. I'd like to mention fitness for duty. Fitness for duty is an assessment to determine if an employee is cleared physically and mentally to carry out the assigned duties of their usual job. If there's concerns from the employer that the employee is not able to carry out their duties, they can order a fitness for duty exam. This is requested and paid for by the employer. This is an administrative function that usually lives in colleague resources or human resources and is a separate process from worker's compensation. Modified duty is a term that encompasses any modifications to the usual work assignments. This could be location. This could be duration. It could be the duties that are assigned. Often people will say light duty, restricted duty, and use these terms interchangeably. I like the term modified duty as it is more encompassing and doesn't specify a demand level. Any offer for modified duty should be in writing, specifying the physical demands and the requirements of the position that is being offered and the time the position will be available. This should be signed by the employer and the employee. Now I'd like to shift gears and talk about case management and worker's compensation. What is case management in occupational medicine? It is a cyclical process. Initially, the needs of the employee need to be assessed. A plan needs to be developed and implemented with care coordination and workplace collaboration. The clinical status, employment status, treatment plan should all be monitored with an evaluation of that progress, which would then lead to a reassessment of the needs and the plans. There are some key factors to consider in occupational medicine case management. Professionalism and ethics are an important one to highlight because oftentimes the case management team is employed or contracted by the employer to assist employees. This can be seen as a conflict of interest. Also, what needs to be considered is health equity. This includes not giving certain employees different treatment than other employees and also assessing their social determinants of health to navigate access to resources that are available through worker's compensation, the employer and the community. It is important to have effective communication. Even more so, this is becoming important when we're thinking about telephonic and remote connections with the injured employee. With that in mind, case management services can be delivered by the employer. These could be on-site services. These could be telephonic. Again, the case management team could be employed by the agency. They could be contracted. They also could work with health care facilities that support the employer. Both the employer and the case management provider have very similar goals. The strategy for case management includes providing support to injured workers to restore their health and well-being to return them to work. The responsibility of the employer includes reporting the accident, supporting claim filing for worker's compensation. The different worker's compensation programs have different requirements for rights and responsibilities and privacy, and those should all be taken care of by the employer. The employer also has the responsibility for job offers and offering modified duty and keeping track of any time and attendance and modifications to compensation. The case management team is going to focus on access to care, collecting medical documentation, communicating with the providers, tracking outcomes, obtaining those medically recommended work restrictions and clarifying them when necessary. We'll take a few moments to talk about some communication best practices in case management. It's really important to start off on the right foot when communicating with an injured employee. Remember that the employee is in a new situation oftentimes. Perhaps they've never had an injury at work, and perhaps they've never had to navigate the health care system, particularly the health care system that is allowed under worker's compensation, which may have them using providers they're not familiar with. So in introducing yourself to the injured worker, you want to make sure you explain your role and be courteous. Speak slowly, ask open-ended questions so that you can gain information about their concerns. Listen, act with empathy, and manage expectations. And we'll talk about all of these in a little more detail. The results of good rapport are very meaningful. It's much easier to de-escalate situations. It's easier for the employee to stay motivated and, quite frankly, for the case manager to stay motivated and engaged as well, if you all are getting along. There's increased cooperation across all parties, not just the case manager and the injured worker. But if there's good rapport with the case management team, the employee is much more likely to cooperate with their treating providers, to be cooperative with the employer. And this saves everybody's time and results in fewer complaints. It's important to have that trust between the case manager and the employee, and that really does trickle down to the other stakeholders as well. We know that this results in better outcomes, less lawsuits, better follow-through, because there's an investment both on the side of the case manager and the employee. So some tips for communicating effectively. I'll start with listening and really active listening, making sure that you are not multitasking. Obviously, it's important to take notes to make sure that you are able to remember what they're sharing with you. But we really want to make sure we're focused on that injured worker. Again, this is a stressful time for many of them. So we want to ask clarifying questions. Use the repeat and rephrase method to show that you understand that there's areas you need more clarity on. This can be very effective. And, of course, being empathetic so that they know you are trying to understand their situation is very important. Nonverbal communications can be a challenge if you're working with an employee remotely. You may be only on the phone, or you may be using video conferencing. So some of these are more difficult when you are not face-to-face. When you are face-to-face, using eye contact to let them know you're staying engaged, welcoming body language, exerting confidence so that they have faith in your abilities to support them. And the tone of voice, while not necessarily nonverbal, can contribute to them feeling that you are being empathetic. Showing them respect. Again, being open-minded into your approach and learning about their situation and not prejudging or placing blame. It's not our decision to make those final determinations on causality and claim acceptance. If the claims examiner who does make those decisions feels that the facts of injury and the medical evidence support the claim being accepted, then that is their decision. Sometimes we don't understand how an employee injured themselves in that way, and it's really not the time to be critical or ask them why they didn't take more precautions. That's not really our role. We want to be respectful and supportive and not judgmental about the situation regarding the injury. We want to have awareness into how much we talk so that we can make sure we're listening. We want to deliver clear, concise information. Again, we're going to be working with employees that have various levels of health literacy and also have somewhat amount of stress because they did just sustain an injury or an illness. So we want to be as clear and concise as possible to make sure our message is conveyed effectively. There are some challenging scenarios that come up. And unfortunately, depending on your employee population, they may come up more frequently than others. When the employee is angry or hostile, they may be directing their anger towards you or speaking with anger towards their employer or supervisor or coworker. This can be disconcerting. If they're crying or distressed, if they're threatening legal involvement, reporting that they will file grievance against the employer or, again, a coworker or supervisor, if they're belittling to you and asking to speak with your supervisor, these can be very challenging. So I would like to suggest some verbal de-escalation techniques. And these can be used whether you're in person or remotely interacting with the employee. First off, remain calm and professional. Take a deep breath. Make sure your tone is coming across as peaceful. And listen, really listen. Sometimes they just need to vent. So avoid overreacting. You can validate. While this does not necessarily indicate you agree with them, you can voice that you understand why they would be upset. You might want to reframe the request that they're making, not necessarily repeating it, but restating it in a way to make sure you understand. This also gives the employee time to think when they hear it back in a slightly different way. If you need to, bring in another trained person to assist. This might just be accessing a supervisor or colleague via chat while you're on the phone with the employee, trying to get some advice that way. But if you need to, get another person on the phone or into the room. Again, be empathetic and not judgmental. This is, again, really important. Sometimes the employee knows they were partially at fault. Maybe they did not check the area before they stepped into the room and they should have realized that it was wet and a dangerous environment, but they didn't. We don't need to make them feel any worse than they already do. So we wanna listen again to what they're saying and try to establish that rapport. Some additional techniques are really focusing on your tone. Having that calm tone, not raising your volume and remember to breathe yourself, but slow your pace. Typically, when you're in a conversation with someone, subconsciously, they will start matching your pace. So if they're angry and speaking loudly and quickly, the slower and lower volume you speak, they'll actually naturally come down to somewhere meet you closer to your volume and your speed. So they probably won't get to where you are, but it'll bring them down to a calmer place. You also wanna make sure you sound confident that you can help them. And it's okay to admit that you don't have all the information. It's better to do that than to give them misinformation, but you can let them know that you know where to go to find it and that you'll get back to them. Do you wanna have a positive, reassuring attitude in your conversations to make sure the employee knows that you have time for them and that you want them to talk about it? It conveys to them that they are an important person and that you really want it to help things become better for them, but be careful not to make promises you cannot keep. That can be difficult to do when you're dealing with someone who's difficult and pressuring you for a lot of information or to take a lot of action. Next, I'd like to talk about some ways we can identify and overcome obstacles that are common in workers' compensation case management. First, let's talk about some key factors that impact case management. The availability of modified duty is very important. If the employer doesn't offer modified duty, then the employee would need to be cleared for their regular duty position before they can get back to work. So the more flexibility the employer has in offering modified duty positions, the more successful we can be with an early return to duty. The employee's mindset and social determinants of health are also key factors. This can include their optimism and goals for return to work, and also their health support system and their health literacy. And we'll talk more about these. The work-related conditions also impact case management. Injuries could be very simple, such as a very mild sprain or strain of the ankle that we've talked about before. And then we can get very complex injuries, especially those that involve motor vehicle accidents, involve head traumas, whereas we're seeing more and more if an employee had an accepted claim for workers' compensation for COVID infection, we're seeing long COVID cases that can be very complicated. So that obviously is going to impact the case management approach and the return to work plan. Providers that are open to communication and understand the importance of return to work and gradual advancement of duty, participate in the process can be very beneficial, but we have some providers, unfortunately, that don't participate as actively with the process. The availability of care. We have some geographic areas of the country that don't have the specialists that are needed, and this can be very challenging. Also, depending on the workers' compensation program, there may be difficulty finding providers that accept that program. So these can be challenges. Also lifestyle and personal conditions. If the person that is injured has some personal conditions at the time of their injury, this can further complicate their recovery. Also, if they were not very physically active to begin with, and now they have an injury and they are even less mobile, they're more likely to get deconditioned and that can impact their recovery and return to work as well. So when we think about those factors that we just discussed there on the left, there's a lot of impacts for the progression of the claim. So some actions we can take to address these factors are on the right in the blue boxes. So this starts with just supporting the employee from the beginning of the process with prompt filing of claims and notifying the supervisor so that the workplace can be supportive. And again, facilitation of timely and appropriate medical care. And that typically where the case manager can come in and be very supportive there. And that communication with the provider's office, letting them know that modified duty is available if it is, working with the provider to get appropriate treatment and progression of that return to work plan. Also identifying any community resources that may be available when we think about some of those lifestyle, personal health conditions, or social determinants of health that can be impacting recovery. So oftentimes transportation might be an issue. So helping an individual who's never relied on public transportation before, navigate the public transportation system so that they can get to their appointments or perhaps even get to a modified duty position if they're not able to drive themselves while injured. Verification of the availability of work and work status is really important. Again, just going back to the more flexible the employee can be with their options in return to work can be really helpful. So with the employer offering a multitude of modified duty positions that can help us overcome some of these obstacles. Just want to take a moment and talk about health literacy. Knowledge really is power and research has shown that the more the employee understands their medical condition and the treatment plan, the more likely they are to engage and adapt. And this is where the case manager can really have a key role in gaining insight into the employee's understanding of their condition and the treatment plan. So even just asking about what the doctor told them at their visit, what their understanding of the plan is and of the condition and the expectations for recovery, clarifying from a clinical standpoint, any misunderstandings or providing additional resources or linking them back up with the provider's office to fill in any gaps can be really critical to help the employee understand what's going on. It also, if they understand, they have less fear and anxiety over the situation. And that again, can just help with their recovery and their return to work. I've included a couple of links to some resources that dive more in to the importance of health literacy and health literacy aspects here on this slide. So feel free to explore those if this is something that interests you. And when we think about some of the difficulties we can experience in case management when we're trying to get the employee the access to care they need, trying to get them recovered and trying to get them back to work, we really wanna empower the employee. Again, this goes back, starts off with their knowledge, but we want them to have self-efficacy. And I think this is a great role for the case manager and it can even start with encouraging them to understand their situation and helping them get the resources and information they need in a digestible fashion. Remember, some folks are good learners by listening, some by reading. If they have limited health literacy or even literacy in general, it may be very important to get a copy of anything, any information or instructions that their physician or physical therapist has given them so you can read them back to the employee and answer any questions verbally if reading is not a good way for them to learn. Because self-efficacy is not really static, they may come into their initial injury and not feel very self-sufficient in navigating the healthcare system or their ability to understand the process, the healthcare system and the aspects with their supervisor in the worksite, but that's where you have the opportunity to provide that education which will increase their self-efficacy. This is really powerful. And that way, when the employee has the information and then they believe in themselves that they can act on that information, that really does create a more self-sufficient, engaged employee. And we have to think about this on kind of a scaled model. We can't expect them to go from not understanding any of these systems to having a full grasp on it. So it's a learning process. And just like that they're modified duty, we want them to gradually increase their activities as they rehabilitate and improve their functionality. We want them to gradually get more comfortable with interacting with their providers, interacting with their supervisors or their HR team about the process. And the language really does influence the expectations. And you've heard me say injured worker. I really prefer to say employee, recovering employee, or even claimant. When we say injured worker, it has somewhat of a negative connotation. An employee can start to categorize themselves as injured. This also tends to make them feel kind of subconsciously victimized when they lead off with calling themselves injured. So I would find a terminology that you feel comfortable with that has a more optimistic meaning. And whether that's employee or recovering employee, rehabilitating employee, that you may want to use in place of injured worker. We'd also avoid using the term disabled. We really want to focus on what people are able to do and not what they're disabled from. Again, it's just that mindset and language that can really frame the situation in folks' minds. So again, we really want them to have the information so they can act on it and think about the terminology we're using to create a positive mindset. A big piece of case management, as you've heard me discuss, is that collaboration. The collaboration between the employer, the employee, the case management team, and the clinical team. If everyone is able to share information, then you're more likely to be able to identify barriers to their clinical recovery and to their advancement in their work status, because you're all going to be getting information from different sources. And if you're able to share information, you'll be able to have the complete picture. This will also help put a plan together to overcome the barriers when you have an understanding of what they all are. And then next, we'll be talking more specifically about what some of those barriers may be. So we think about barriers to recovery. There's several different factors, but they all overlap. Start at the top with medical. And of course, this relates to the actual condition that has been endured from the incident. So the more severe the injuries are, then they can, in and of themselves, just be insurmountable to ever return to work. However, we hope that's not the case. Also, if people have had complications or have issues with access to care, those are medical factors, but some of these can be addressed and overcome, especially access to care and prevention of complications. The physician practice barriers, again, this is where case management can play a key role. Some providers who aren't educated in occupational medicine may let the employee determine their work disposition. They may not understand that light or modified duty is available and it's important to actually have the employee re-engage in the workplace as soon as possible because it can help with their functional recovery, can minimize unnecessary deconditioning, but also from a psychosocial component, that re-engagement early on has shown that they're more likely to stay out of work the longer they stay out of work. So we wanna get them back in and re-engaged as soon as it's safe to do so. So this is where the provider education from the case management team can be very valuable and sharing that information, especially the availability of light duty and the importance of early return to work. Again, the employee beliefs, their fears, their attitudes, their understanding of health literacy, this is where the case manager can have a big impact because they can provide that education. They can meet the employee where they are in their knowledge and understanding and help fill in those gaps. And I think that knowledge can really help dispel some of these other negative beliefs that we see here. So that can help dispel that fear. It can help prevent them from catastrophizing, which is just thinking that now that they've sprained their ankle, they're never gonna be able to run again. They're really making sure we're not exaggerating the situation because we're providing them with clear, comprehensible information so that they feel empowered. The job return to work barriers on the right, again, this is really important for the employer to offer modified duty. If there's no opportunity for modified duty, this can really be problematic. So if you're in the position where you're working with the employer, definitely wanna encourage as much as possible a very flexible, progressive return to work program that can support a variety of job duties while someone continues their rehabilitation. And then people just have other agendas. Now that they've been off work, maybe they realize they can save a lot of money so they've canceled their afterschool care and now they don't wanna restart it because that's an expense they don't wanna pay anymore. They may just really not have a goal of returning to work. They may feel that they've been wronged and that they have no intention of coming back even if they have a very mild injury. So again, this is where the case management team can, in their communications with the employee, try to figure out if there's any of these other agendas going on so we can get to the root of it and try to solve for that if that's feasible. So we talked through some of the techniques to overcome barriers as we were going through those obstacles. However, really wanna focus on the education piece. Providing that education and making sure the employee understands is really valuable, but also the employer, remember the employer may not have a true understanding of the importance of early return to work. They may not understand the work restrictions and they may ask for guidance to make sure that they are providing a safe modified duty position. So really in the case management role, you have an amazing opportunity to educate everyone. And as part of this, kind of an obligation to keep yourself up to date on the education materials that would be helpful to share or the clinical situations you're dealing with. So it's one of, I think the perks of being in case management because you do constantly need to learn yourself. And I think that's really, really valuable. So you wanna collaborate with the other stakeholders. So obviously the providers and the work site, but also with others on your case management team. Case management round tables or medical management meetings can be really helpful because every case manager is gonna have a different approach. Maybe somebody figured out something that works really well for them in a similar situation. So collaborating with your fellow case managers, your supervisor can really be a good opportunity to share best practices and learn from each other. Going back to the very beginning when we talked about building rapport, maintaining that rapport and maintaining that connection with the employee is really helpful. Research has shown that when the employee becomes more isolated from the workplace and from even the clinical team, we lose that engagement and we typically lose progress towards engagement in care and the success of return to work. Definitely facilitating quality health care. And this is gonna be more of a challenge, again, depending on what resources are available in your geographic area, but very important that folks are getting the care they need, but also aren't getting any unnecessary medical procedures. And sometimes in workers' compensation, that can be a concern if a provider just thinks that something will be covered, but perhaps they haven't explored all the conservative therapies, but they know that that healthcare payer will pay for certain procedures. They may move to those too early. So that's where your clinical expertise can be incredibly valuable to make sure they're getting quality healthcare, but not overusing or misusing healthcare resources as well. And as we spoke about before, maintaining that objectivity and professional detachment for those cases where you see that other agendas are at issue or the employee is catastrophizing or they're having some fear behavior. So maintaining that objectivity and going back to number one, we're just focusing on that education to try to get that employee to engage and overcome any negative mindsets that are creating an obstacle to them getting the care they need or participating in the return to work process. Now I have a few case studies I'd like to go over with you really to highlight the value of case management. So first we'll talk about Joe. He's a 42-year-old office manager who was carrying some boxes down the stairs in Slips and Falls. So he goes to the ER because he's having trouble bearing weight. The x-ray shows there's no fracture. He's diagnosed with an ankle sprain and bursitis in the emergency room and he's splinted. He's given crutches and advised to stay off work until he is cleared by an orthopedist. Joe's supervisor calls the next day to check in. Joe gives him the update and says he needs to find an orthopedist. Joe's supervisor calls the injury into their reporting hotline, which is through their safety department. This triggers a notification for a case manager who's assigned and calls Joe that same day. She introduces herself, starts building rapport and finds out what Joe's needs are. His immediate need is to find an orthopedist. So she finds one and is actually able to get him an appointment the next day. She does remind Joe that light duty is available and contacts the provider's office to supply all the necessary forms, request records when they are available, and offer support. She does make sure that the provider's office also knows that modified duty is available. So when Joe sees the orthopedist, there is some concern that he might have torn the ligament. So he is put in a walking boot and told he can work sedentary duty, four hours a day but no driving, and he wants to get an MRI before he decides what's next. The employer is able to offer Joe this part-time sedentary position, so he goes back to work the next day. The case manager is able to facilitate the MRI, so he obtains that, and he actually only ends up having a grade 2 sprain, which is very fortunate, so he is advised to transition to an ankle brace. He's advanced to a full shift, still just doing sedentary duties, and he is prescribed a short course of physical therapy to help get back his strength and range of motion. He participates in two weeks of therapy, and then he is advanced to his regular duty position, which is actually a light-demand job, so at this time, it's under four weeks, and he's back at full duty, so after 12 sessions, he wraps up his physical therapy, and he's released from care, and the case management actually concludes because Joe has no further needs. He has wrapped up his clinical care, and he is back to full duty. So now let's talk about Jim, who is also a 42-year-old office manager and has an ankle sprain when he is carrying boxes down the stairs and slips and falls, so he also goes to the ER and is diagnosed with the same thing as Joe, and he's advised to stay home until he sees an orthopedist, so Jim goes home, and he doesn't know how to find an orthopedist. He doesn't really know what to do. His ankle hurts, so he just stays home, and after three days, HR calls and asks why he's not at work, and they say he needs to submit documentation as to why he's not there. So then Jim tells them that he got hurt at work, and so the supervisor calls and calls them the Injury Reporting Hotline, but now it's been four days later. The case manager is assigned and calls Jim that day, but Jim doesn't really want to talk to her because he's pretty upset because now he feels like HR is mad at him because he didn't have the paperwork in on time. So the case manager can tell he's pretty stressed already about this, and he's still in pain with his ankle and doesn't know what he's supposed to be doing. The case manager is able to de-escalate the situation and locates an orthopedist but is not able to get an appointment until three days later. When Jim does go to the orthopedist, it's very similar. There's concern for a higher-grade sprain, so an MRI is ordered, but Jim is complaining of so much pain the orthopedist does give him opioids. So the case manager, again, was able to get an MRI scheduled, but Jim actually was taking the opioids and he slept through the appointment, so he missed the appointment, and they had to reschedule that, so it delayed the MRI, and the orthopedist was keeping him out of work until he got the MRI back. So when they do get the MRI back, same as Joe, lower-grade sprain, so he's able to advance to the ankle brace and start PT, and he was released to sedentary duty. Jim goes back to work, but he calls the orthopedist's office and he says, I'm having way too much pain. There's no way I can work. I need more pain medicine. There's no way I can do this. So they take him back off of work and give him more opioids. So after two weeks of PT, Jim is still complaining of pain and limited motion and weakness, so they keep him off two more weeks while he has more PT. After four weeks of PT, now he's still complaining of all of this. He says he's not getting any better, so they give him a steroid injection and give him two more weeks of PT. That follow-up, now nine weeks after the injury, he is released to sedentary duty. So let's do some comparison of Jim and Joe. They had the same injury and the same pathology. Joe's supervisor made early contact with early case manager involvement. The case manager was able to facilitate care, facilitate late duty, communicate with the provider and the work site. The employer was able to accommodate the modified duty, and this resulted in minimal lost time and a really good clinical outcome. So Joe had a really good experience. Jim, however, did not understand what to do, and he did not hear from the employer for a few days. There was delayed involvement from the case manager. Opioids were prescribed, which as we know, for an injury like this, really non-opioid medication would have been preferred because we saw some complications from side effects from the opioids in this case. This resulted in missed appointments, and it seemed to impact Jim's mindset towards the injury, and he had more time off work, which was unsubstantiated, and he did not even return to a sedentary position for nine weeks after sustaining really only a low-grade ankle sprain. So we want to focus on the opportunities that Joe had, but especially that early workplace involvement and case manager involvement and the coordination across those stakeholders, we saw that Joe had a really optimal experience, whereas unfortunately Jim did not. Now let's talk about Jill. Jill is a 26-year-old assembly line worker for a small manufacturing company. She was moving boxes of materials and injured her back and does not report the incident. But she wakes up the next day and she's in a lot of pain, so she calls in sick to work and goes to the ER and does not share with work that or that. So some x-rays are taken, there was no fracture, but she has a lot of paraspinal muscle spasms, reduced motion, and she's reporting some pain and tingling into her left leg. She's prescribed muscle relaxers and opioids and advised to follow up with orthopedics, and she was advised to stay off work. As the ER nurse is talking to her, she realizes that this is related to work, and so before she leaves, she says, you might want to call your job site. This could be a worker's comp issue. But Jill gets home, she can't remember exactly what the medication instructions were. She has poor literacy skills, so she can't remember the ER discharge instructions and what she's reading. She's just not able to really comprehend the paperwork she was given. So she just decides to take two of each of the pills because she remembers hearing something about two or twice a day. So she just decides to take two, but this caused her to oversleep and she misses work again. So work calls and says she's in trouble because she was supposed to call in if she's going to be out, but she tries to explain what's going on, but she's very groggy from the medications. She finally makes it into work, but she doesn't feel well from the medications and the pain. So she goes to the HR office when she gets in there, but, and she again tries to explain the situation, but at this point she's just really upset. So she becomes tearful and it takes a while for the HR person to try to piece everything together, but they finally realized it started with a work injury and that they call in the supervisor to start the process. But now at this point, Jill is just very upset. She says her pain is getting bad. She needs to take more medicine. So she just leaves work again and goes back to the ER. So that is Jill. Talk about Jane, who's also a 26-year-old assembly line worker for a large manufacturing company, and she also injures her back at work moving materials, but she notifies her supervisor at the end of the shift when she realized that this is really not a normal injury for her and the pain keeps getting worse. So her supervisor reports the injury to safety and directs her to the contracted occupational health clinic that's nearby. So they have a relationship with this clinic for on-site work injuries. So she's able to do a walk-in acute care visit with a clinic that is very familiar with the employer and their practices. The exam is identical to Jill's and same diagnosis. She is prescribed muscle relaxers and nonsteroidal anti-inflammatory medications. She's advised she can return to sedentary duty until she's seen by orthopedics to make sure that there's nothing else going on. So this clinic has a case manager for this employer's workers' compensation. So they actually, as part of their checkout process, the employee goes and visits with the case manager who's on-site at this clinic. So this is a different model, and the case manager realizes that Jane isn't really understanding what the provider told her. So she goes back through the instructions and then offers assistance in scheduling the orthopedics evaluation. So the case manager was able to get her in to see ortho two days later, and the case manager confirms that the sedentary duty is available and provides the instructions from the work site back to the employee so she knows what's to be expected the next day when she returns to her modified duty position. Jane does go back to work the next day. Her normal supervisor stops by to check in on her. The case manager calls to check in as well and reminds her of her appointments and reminds her of her medication instructions and see if she has any other questions. Jane was able to see the orthopedist who confirmed that it was just a lumbar strain, and they did order a short course of physical therapy and continued modified duty for 10 days. The case manager was able to assist with the physical therapy as she recovered and ended up returning to full duty in just over two weeks. So let's compare Jane and Jill. So unfortunately, Jill didn't even know her employer had a workers' compensation program or how she should report her injury. So while it was a small company, it is large enough that they should be providing these benefits to the employees. So there was not early supervisor notification, and there was no case management involvement at all. She ended up taking personal time off. She had opioid medications, side effects from those medications, and then because of all of this, things got escalated through HR, which made her feel she was in trouble or had done something wrong and increased her stress and anxiety over the situation, which made the pain worse. And we didn't even have a resolution at the end of the case with Jill. Jane, on the other hand, had been educated on her benefits and her workers' compensation and the notification requirements. So she was able to not only notify her supervisor, but be seen and have case management involvement within the first day, which is really remarkable. They were able to coordinate between the work site, the provider, and the case management team to get her access to the care she needs. The case manager was able to assess her health literacy and educate and empower the employee by providing the education gaps. The supervisor was engaged in checking in on her, which can be very meaningful, and this all led to a very positive outcome with both clinically and return to work. Really avoided a lot of the undue stressors that we were seeing with Jill. Follow up with some best practice takeaways. Key interventions with the employee are early supervisor contact. That has been shown to be very valuable, not just for reporting and claims filing, but for the employee to feel like they are supported from the work site. We do want to assist with necessary care, and this often falls to the case management team. And across the board, establishing that return to work is the goal. Emphasize maintenance of current activities in the discussions with the employee. And when we're working with our employers, we try to remind them of this as well, that if they are able to do certain activities, we want them in a position where they're doing those. So we don't want them just sitting all day if they actually are able to do certain walking or standing because we don't want them to get further deconditioned. And we want to do that incremental increase in activity as they progress in their rehabilitation. Really focusing on the goal of preserving function in our interactions with the employee, not necessarily elimination of pain or that focus on pain, focusing on function. Again, focusing on what they are able to do, not what they are disabled from. Key interventions at work are offering modified duty. I know I've said that several times, but it's really important to get that employee back to work as soon as possible and advance the duties as they are tolerated. So this really falls on the employer. And again, if you have the opportunity to work with employing agencies or companies that don't have programs for return to work to help them build that, it would be phenomenal. Focusing again on what they're able to do so that they are participating in the activities that they can safely perform and involve the recovering worker as much as possible in helping determine what they can do. So if they're crafting a modified duty position, engaging the employee to say, what do you feel you are able to do here? The restrictions from your doctor, but as far as translating that into this worksite, how do you feel that translates? What do you think those tasks would look like here at this worksite? That can be very empowering to the employee to engage them in that process. Just a quick note on urgent and rapid response case management. The examples I've shared have been injuries that have occurred at the worksite that really have only impacted one person. And most often that is what we see. Sometimes we'll see where a few people are injured due to a lot of times it's construction or something on a worksite and that we have several people slip and fall in an area. But if there is more of a mass casualty situation, and we think about this more in an industrial, like a plant, where we would need a rapid response of support for these employees that are impacted, that team may not be the case management team. The best practice is to have case managers available during working hours so that employees can have access to case managers during their work shift. If there's a rapid response team, case management may be on that team or may be available to support that team kind of in the background. So it's just something to think about if you're working with an employer that may have such a rapid response team to make sure you understand the case manager's role in that team. I've provided some clinical resources here for you. Both ACOM and the American Association of Nurse Practitioners, of course, have an abundance of information. I like to use up-to-date. I think it's very helpful when evaluating the conditions and looking at what treatment is appropriate. There are multiple evidence-based care guidelines as well. MCG Health is one I like to use. A lot of these are subscription-based, but just resources I did want to share with you that are available. CDC is always a good reference point for opioids. We talked about in two of those case studies where opioids created an obstacle. And so fortunately, while not as much of an issue as it was a decade ago, opioids still impact progression of workers' compensation cases. So always my first stop for opioid questions is back to the CDC. Other questions about medications, FDA is always a good resource. SAMHSA is a great resource for anything related to substance abuse or mental health. There is also a hotline through SAMHSA that is available for cases where there is any sort of mass disaster, and that can be shared with employees. So if you're not familiar with that site and all the resources available, I would encourage you to go there. Fortunately, we don't see a lot of cancer claims in workers' compensation, but if you do, the National Cancer Care Alliance is a good resource. It is a return-to-work tool. It provides estimates of when someone should be able to return to their normal duty position based upon the diagnosis, and you can put in multiple diagnoses into the tool, which is neat, but then also based upon the physical demands of their position. So it really helps employers understand when they might expect an employee to be back to their regular duty position, and it can help the case manager monitor progress towards that goal. But every employee is individual. Every injury is unique, and every treatment is unique. So it is just a guide, but it can be very helpful. But it can be very helpful. And just the purpose is to help, from the case management standpoint, offer timelines to help you have expectations, but that can also then help the employer with their expectations for the ultimate return-to-work status. As I mentioned, a few other regulations that can be available for employees with personal medical conditions, the Family Medical Leave Act, and the American with Disabilities Act. Just a note about ADA and employment. It does apply to any company that employs more than 15 folks, and the accommodations that are allowed under ADA depend on the employer's resources. So that is something to keep in mind where a smaller company, even though they might meet this, may not have as many resources to supply the accommodation, whereas a larger company may be able to add a ramp or add an elevator or move them to a different building that is ground level. Smaller companies may not be able to accommodate those requests. I have the links coming up, so you can go to those for more detail if you're not familiar with those regulations and are interested in learning more. As mentioned, the accommodation must be reasonable, and so it must be related to the medical condition, but it cannot jeopardize the safety of others or cause undue hardship for the employer, and that is where the size and resources available to the employer come into play. Here's more information on those regulations, on accommodations, and also a link to the statistics website, which can be very helpful if you're interested in more data. Thank you so much for joining us. I hope this has been a helpful session.

worker coordination

case management

work-related injuries

workers' compensation

communication techniques

care coordination

best practices

health literacy

return to work