And What Payers Should Expect from Rehabilitation
Clinical Care Managers
It is well understood that a spinal cord or traumatic brain injury is catastrophic and creates a lifetime of challenges and changes for the injured worker, their family, their employer, and their workers' compensation payer. Clinical Care Managers (CCMs) are integral to rehabilitation programs and play a vital role in patients' outcomes. What should payers expect in terms of accountability and service from CCMs? Below are our top five factors that lead to optimal outcomes with the support of CCMs.
1. Early Referral to Specialty Rehabilitation Programs: Early after injury, decisions are often made in acute care settings that have lifetime consequences for all parties. Acute care hospital case managers typically don’t understand workers compensation, and their main pressure is to discharge patients as quickly as possible to post-acute care facilities, often without regard to the quality of programs or long-term outcomes and expenses. Transfer decisions are usually made in the first two weeks, and patients and families are often not aware of their options and the life-time implications of those decisions. Payers are encouraged to educate acute care centers and to counsel injured workers and their families, helping them make the most informed decisions for rehabilitation. Rehabilitation programs that are specialized in catastrophic injuries and care have experienced physicians and interdisciplinary teams and offer the best chance of optimal outcomes and long-term cost savings. This includes specialized knowledge and treatment programs for bowel, bladder, skin, self-care, mobility, community re-integration, a large community of similar patients, and a proven track record of expertise. This fact has long been understood by the workers compensation literature and large loss “cat” team experience.
2. Clinical Care Managers Who Understand Workers' Compensation: Once an injured worker has been transferred to specialized rehabilitation, the designated Clinical Care Manager (CCM) is an essential member of the interdisciplinary team and is accountable for communication and problem-solving with carrier claims professionals and case managers, alignment of team expectations, coordination and discharge planning. CCMs should have masters degrees in social work, rehab counseling, educational psychology, or the like, or have nursing degrees. Payers are encouraged to ask any rehabilitation hospital being considered about their CCM department, their caseloads, their standards of practice and the average tenure and experience of their CCM staff.
3. Psychosocial Care for the Whole Person and Family: Every patient and family is unique, and it’s important that rehab programs treat the whole person and family. The medical, nursing, physical, occupational, and respiratory care are most obvious and critical. However, the entire team is also particularly concerned about the psychosocial treatment that has a large bearing on outcome. The psychosocial factors of mental health, family education and support, pre-injury personality and function, work and recreation have long been understood as critical to maximum independence and productivity. Psychosocial care includes individual counseling and family counseling, group support, education and empowerment, and meaningful recreational pursuits. The overall goals of psychosocial adjustment is for the individual to re-define themselves after injury, to become productive again in a meaningful way for them, and to financially, emotionally, and socially adjust to their “new normal.” This process of re-definition and adjustment can take months or years and is a continual lifetime challenge, but the foundation for successful adjustment begins in the first months within a powerful positive culture of specialized rehabilitation. CCMs are critical to the oversight and advocacy of this process.
4. Comprehensive Communication Between Case Managers and Payers: The standard of best practice is that CCMs fax records weekly to payers, speak by phone weekly, include payers in formal patient conferences (face to face or telephonically), and problem-solve the dozens of issues patients and families face regarding home preparation: bowel, bladder, skin and self-care management, finances, equipment, transportation, home care, home-town physician, pharmacy, supplies, outpatient treatment, etc. The complexities of these matters can require dozens of phone calls per week between the CCM and insurance case manager leading up to discharge home. For payers to have a knowledgeable “single point of contact” within the rehab hospital (a CCM) with whom they can closely work on these numerous and complex planning issues is invaluable. CCMs should have caseloads fewer than 15 patients to adequately do the job with newly catastrophically-injured patients and their families. There is no way a CCM can adequately manage the total scope of work with caseloads of 30 patients, which is typical in many rehabilitation facilities.
5. Appropriate Lengths of Stay to Achieve Highest Outcomes: Workers compensation professionals and specialized rehabilitation programs have long understood that two thirds of lifetime costs are associated with levels of functional independence and the need for long-term skilled and non-skilled attendant care. That is why workers compensation payers and specialized centers have focused for decades on long-term functional outcomes and medical stability, versus short-term length of stay considerations. This partnership of aggressively focusing on functional independence within inpatient and outpatient settings or post-acute residential settings can result in six-to-seven figure financial savings per patient over the injured worker’s lifetime. CCMs work closely with workers compensation case managers to ensure efficient care and avoid unnecessary delays, but together they co-advocate for adequate lengths of stay to achieve maximal outcomes.
By Stephanie Percival, Director of Clinical Care Management at Craig Hospital. Learn more about the work of CCMs here.