photo credit: Josh Liba

The most important role of the case manager is to advocate while educating. Case managers must advocate on the client’s behalf to get each client the right resources and the right care at the right time and by the right provider–all while considering the patient’s own resources and abilities. Clients need to understand the information they have been given and the implications for their future, while learning how to manage and navigate the landscape on their own. The workers compensation patient has an additional learning curve as they navigate the legal system and employment issues all while recovering from an injury.

Jo Carter, a Commissioner with CCMC explains, “The workers’ compensation setting is a highly regulated area of practice, with both health care regulations to follow and state-by-state reimbursement systems and laws. When you’re providing case management services, you have to be aware of how those regulations affect the process. There is also the interdependence of many other stakeholders, including attorneys–an attorney who may be giving the worker specific advice based not necessarily on returning them back to health and the highest level of independent function, but on the legal and financial aspects of the claim. That can create conflicting goals and dynamics. There can be additional pull for case managers who are employees of the insurance company in workers’ compensation cases. Their struggle is to advocate for the client while evaluating for fraud and abuse. With all these factors in play, it’s not surprising that the workers’ compensation industry has much more experience using case management and has led the way in identification of ethical dilemmas and state regulations that require case manager certification to manage these complex cases.”

In order to be a successful case manager working within the confines of the workers compensation arena, one must possess a distinct knowledge and skill set.  The nurse case manager should be a master communicator, negotiator and facilitator, as well as technologically savvy enough to maximize time; working smarter within the confines of the clock.  Here at VP Medical Consulting, we do not want nurses who can simply attend an appointment and report back the findings.  We want nurses who are engaged, critical thinkers, and able to think outside the box.  Our nurses must be willing to stand on their principles and rally for what the patient needs while functioning within the confines of the payor source.  Our nurses are either certified by CCMC or are working toward certification.

If you need an experienced workers compensation case manager, consider VP Medical Consulting.

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In a recent article by Dr. Catherine Garner, she reports that the Bureau of Labor Statistics identifies case management as a field projected to grow faster than other job categories.  She explains that traditionally,case management has been a tool reserved for complex cases, but this may soon change as accountable care organizations take center stage next year.  Case managers will be needed to strategically manage services for all patients, even those in ambulatory care.

It’s been said that case management, with its current emphasis on complicated cases, needs to evolve into care management, with a focus on wellness, prevention, and efficient care for entire populations of patients – both inside and outside the hospital. Tomorrow’s case managers will have to consider clinical, financial, and patient advocacy functions simultaneously, as they balance competing interests.  For nurses looking to be more competitive within the evolving marketplace of professional nursing practice, case management can be an excellent career choice. This “marketability” in the case management field will depend upon obtaining the credentials, education, and on-the-job experience that tomorrow’s employers will be seeking – so it’s crucial to identify the knowledge and skills needed now, and begin planning strategically to achieve them.

As a case manager, it is important to become certified.  More employers are requiring certification of their case managers and some offer additional compensation.  Requirements for case management certification include:

• Nursing degree
• An unencumbered RN license
• At least 12 months of qualified job experience
• A passing score on the credentialing exam

To learn more about the CCM certification, head over to the Commission for Case Manager Certification. Because case management encompasses so many areas, it is important to study a variety of areas in preparation for the exam.

Not only do hospitals employee case managers, but insurers do as well.  Aetna pioneered the practice of embedding case managers into large physician practices that had at least 1500 patients enrolled in their Medicare Advantage plan in a 2010 case study.  Many of my clients are insurance companies and I have several colleagues who are employed with insurers such as Blue Cross and Blue Shield.

Case managers work side by side with healthcare providers to help manager patients with multiple or complex medical issues or disabilities or catastrophic injuries.  The face-to-face interaction enhances our ability to collaborate and establish rapport with the patients and providers. Aetna found they were able to control costs by avoiding unnecessary hospitalization and complications related for chronic diseases.  In my experience, field case management nearly always exceeds the outcomes in comparison with telephonic case management.

As case managers find themselves to be more in demand, we also must be accountable to deliver.  We are expected to know the specific clinical and financial goals and plan strategically to help reach those goals. As the central coordinator of many health related activities, we much be ready to assume authority.

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The most important thing a professional case manager does for a client is form a relationship. Through that relationship, we help patients move across the continuum of care to obtain as healthy an outcome as they can reasonably achieve.

Such relationships require a foundation of respect and integrity. Without a good foundation, it doesn’t matter how much knowledge the case manager has–the patient isn’t going to buy into it. The relationship is vital: listening and sharing so we can work together to get the best outcome. A professional case manager is willing to listen and is willing to cultivate that relationship. Drawing on my psychiatric nursing background, I’d call it “the effective use of self”–something professional case managers develop over time.

Today, the board-certified case manager plays a more important role than ever before. There is so much information out there. Patients can Google anything. They are bombarded with information. It gets to be overwhelming and they get overloaded. The board-certified case manager helps educate them, helps them make better choices.

Because of technology and social media, patients often don’t know what valid information is on a website. I never discourage them from searching. Instead, I encourage them to be savvy surfers. I give them resources and options. When they find information, they bring it back to me. We dialogue.

We are the resource, the safe place to talk about barriers to reaching a patient’s maximum health potential.

And it’s not just the relationship with the client, but also with the health care team, that matters. The professional case manager educates others about the client. Because we have a dynamic relationship with each patient, professional case managers have an important role to play in informing the care team about the client’s needs–helping clarify the client’s barriers, barriers the patient may not express to the primary care provider or even the RN.

I’m a lifelong learner, and I believe it’s essential for our [case manager] certificants to be committed to knowledge, too. We want our board-certified case managers, like our clients, to be savvy surfers.

Kathryn M. Serbin, BSN, MS, CCM

Chair-Elect, CCMC

Section Chief, Women’s Health Clinic
Senior Nurse, Surgical Clinics, Ambulatory Care Center

James A. Lovell Federal Healthcare Facility

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A class-action lawsuit has been filed against DePuy Orthopaedics, Inc. a subsidiary of Johnson & Johnson over a hip replacement implant that was recalled earlier this year due to a high failure rate. According to a study published in Britain, 13 percent of patients that received the ASR XL Acetabular System hip replacement had to have revision surgery within five years.   This recall of the faulty hip replacement devices has affected around 93,000 people. The suit claims the company, DePuy Orthopaedics, misled patients to believe they were going to be reimbursed for the costs of their “revision surgeries.” Patients released their medical records to DePuy under that assumption, the lawsuit states.  The lawsuit contends that the company should have known the device was defective prior its sale to patients. The suit will potentially cover any patient who received a DePuy hip replacement in the last seven years.

DePuy is owned by Johnson and Johnson, whose slogan is:  “A family company.”  Reading these articles makes one wonder if any of the Johnson family was ever implanted with one of these faulty hip replacements.  Guessing the answer would be no.

We are talking 93,000 possible patients affected, worldwide.  Most of these individuals are older folks, who are more affected by anesthesia, less tolerant of the excruciating pain involved in hip replacement surgery, have longer duration of physical therapy treatment and are most likely have other conditions that affected the need for the surgery, which will further complicate matters.  In addition, for many of these patients, nursing home care will be required, with the attendant risks for the patient of being in that environment.

According to one of the law firms involved:

“Hip replacement surgery is among the most painful and disruptive surgeries an individual may have to endure. Once is certainly enough, but to undergo the procedure twice, and as a result of a defective implant is almost unimaginable,” said Seth A. Katz, Burg Simpson shareholder, and one of several attorneys working on this case.

Mr. Katz continues, “When medical devices such as DePuy’s ASR XL Acetabular System fail, the impact on a patient’s life can be devastating. Given the large number of devices recalled, it is conceivable that thousands of individuals across the United States may unknowingly need revision surgery, even if they are currently not experiencing any pain or discomfort…”

Added to that is the duplicity of DePuy in giving the impression that by the patients’ sending their medical records, the company would cover the expense of revision surgery, when it appears that the primary purpose of that request was to get their “ducks in a row” for the lawsuits they saw looming over them.

As a Nurse Life Care Planner, there are any number of considerations that will need to be evaluated in order to assess the ongoing damages to these patients:

• Overall status of these patient’s general health both for patients who have had revision surgery and those who will have to undergo the surgery again.  Including co-morbidities brought about by additional surgery and the resultant hospitalizations.
• What will be required for them to return to work and activities of daily living?  Physical therapy, assistive devices, nursing home care, home health care, etc.
• They could require a pain management specialist as this surgery and recovery is painful.  The effects of these medications should be reviewed.
• Particularly for the elderly patients, the services of a Case Manager will be needed to ensure continuity of care.

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Generally, a Life Care Plan is written by a medical professional on behalf of a patient who is catastrophically injured or has a life altering illness.  It is often used in litigation.  A life care plan is a dynamic and ever changing document that describes the needs, both medical and non-medical, for the injured or disabled individual.  It includes the costs for items and the replacement value of each item.  The Life Care Plan takes into consideration the home environment, resources available, warranties and maintenance, specialized devices to improve activities of daily living, and so much more.  In recent years, this term has been used to describe a different service altogether.

Many attorneys who provide elder care, trusts and estate planning have begun using “Life Care Planning” as a term to describe their services which are not the same as the term has been typically defined.  Most of the time these services are provided by a member of the staff who does not necessarily have any medical training.  The attorney uses the term Life Care Planning to describe the service that consists of an individual who evaluates circumstances and needs of an individual—usually elderly, for a plan to help the individual be able to remain in their homes as they age.  (This is actually long term planning or case management, not life care planning).

These specialized attorneys now have their own life care planning association.  They advocate wills, trusts, guardianship, eligibility for Social Security Income and Medicaid.  They employee “Care Coordinators” to locate and coordinate care and community services and serve as an advocate.  This is also known as case management or geriatric care management.

A Nurse Life Care Planner working for an attorney in a litigation matter, does not consider collateral sources of income or medical services.  We have no standard expertise in these matters.  We would not typically have any training in Social Security or Medicaid nor developing wills, trusts or handling guardianship issues.

A search for “life care planning” reveals every other result related to this elder care service now.  This is a great service and would recommend that adult offspring of aging parents consider some form of this type service before a situation becomes critical.  As a Certified Nurse Life Care Planner and Certified Case Manager, I just wish they would call it something else.  :sigh:

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Many workers compensation injuries involve the musculoskeletal system.  Strains and sprains are common and sometimes result in longer claims than those who suffer fractures or tears which require surgical intervention.  The treating physicians will often use physical therapy or physiotherapy to develop, maintain, or restore the body’s normal motion.

Signs that physical therapy may be in order include:

• decreased range of motion
• pain
• decreased strength
• gait disturbances

When range of motion is limited, function of the limb or joint is decreased which in turn makes it difficult for one to perform tasks in a normal fashion.  This decrease in range of motion often occurs secondary to pain.  The patient limits their motion because the motion causes pain and soon their overall range is diminished resulting in a vicious cycle.

Physical therapists specialize in working with the body’s muscle, tendons, ligaments, bones and joints.  Some therapists work with skin secondary to burns, or wounds.  Others work with breathing and lung problems secondary to respiratory issues.

A case manager typically has relationships with different therapy providers in the area and may be knowledgeable about the best facility for the particular body part or condition involved.  Therapy is typically performed in an outpatient setting for the workers compensation patient.  The physician will indicate the frequency and duration of the therapy.  The case manager stays in touch with the therapist and reviews the records to determine if the patient is compliant with therapy and making progress.

The initial visit with the therapist will be an evaluation to determine what treatment plan would be best for the individual.  Measurements are taken and pain level identified.  The treatment plan can include items for improving flexibility, endurance, strength, coordination and balance.  Other treatments are used to reduce swelling, stiffness, and pain.

The treatments by the therapist include multiple modalities.  These include items such as:

• ultrasound
• hot/cold packs
• aqua therapy
• hydrotherapy
• electrical stimulation
• stretching
• walking
• weight lifting
• exercises

The therapist is also responsible for educating the patient.  Education is directed at proper body mechanics, avoiding re-injury, minimizing the effects of repetitive motion, etc.  Therapy a couple of times per week is not enough.  The patient must take some responsibility for their own musculoskeletal health.  Many therapists will provide the patient with a home exercise plan.

Physical therapy treatments couple with rest and medication are considered conservative care.  This conservative care is traditionally less expensive than the surgical alternative.  By educating the patient, future injury might be avoided as well.

I promote the use of formal physical therapy in my practice.  However as a case manager my job also consists of reserving resources.  I evaluate therapy on a frequent and on-going basis.  If my client fails to make progress with multiple therapy attempts, I do not continue to authorize the treatment.  Staying in touch with the patient and their therapist as well as reviewing the medical records is key to determining if additional therapy is warranted.

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The 17 year old, Case Management Society of America (CMSA), has announced the celebration of National Case Management Week.  This special week-long event seeks to unify case management professionals, educate the public about case management, and increase awareness and recognition of the significant contributions case managers make the quality healthcare for patients, healthcare providers, and payers.  This week is celebrated nationally during the second full week of October each year.

CMSA is an international organization of case managers and healthcare professionals, committed to promoting the growth and value of case management, and to support the evolving needs of the case management professional.  Founded in 1990, CMSA now has over 11,000 members and over 70 affiliated and pending chapters. I am one such member and proud to be a part of the Little Rock Chapter.

For those who are unfamiliar, Case Management is a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individuals heath needs through communication and available resources to promote quality cost-effective outcomes.  My case management practice is primarily associated with workers compensation clients.  Injured workers need prompt assistance in finding the appropriate healthcare provider who will diagnose them quickly and provide the treatment plan to help get them back on their feet and productive again.  My job is to first assess the situation which includes not only the injury itself, but also the claimant’s situation at home, emotionally, mentally, physically, socially, etc.  The next step involves locating the provider, arranging the appointments; all while educating those involved.  The plan is ever changing as the situation changes.  I am advocating for my patients to help them get their needs met all the while working to save the insurance carrier money by preventing unnecessary testing, negotiating reduced rates for services, limiting loss time wages, and eliminating waste.

Establishing a nationally recognized Case Management Week is vitally important as the field of case management becomes an increasingly recognized as a strategy of great significance across the continuum of care.  Not only does case management support patients and their families in navigating the healthcare system, it decreases the fragmentation of services, encourages health team communication, and contributes significantly to patient safety, quality of life, and cost-effective management of limited resources.  It should be recognized by the healthcare industry as a crucial element of giving.

If you wish to learn more about Case Management or CMSA, contact Cheri Lattimer, Executive Director or visit www.cmsa.org.  The association headquarters are located right here in Arkansas at 6301 Ranch Drive, Little Rock, AR 72223.  501-225-2229

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I am so proud to be a nurse case manager.  I have worked in this industry since 1999 and became certified in 2003.  October 10-16, 2010 marks National Case Management Week, recognizing the contributions and commitments case managers make and educating the public about the significant work we perform. When employed by an agency or hospital, activities typically include banquets and recognition dinners, state and city proclamations, continuing education seminars, and other community events. Case Managers are typically honored with gifts, dinners, and flowers coworkers such as doctors and administrators, and patients who want to show their appreciation.

As an independent case manager, I do not get to participate in such activities, but I can still celebrate.  Here are a few ways each of us can participate in National Case Management Week.

• Tell 10 other professionals you are a case manager
• Offer to speak at community events on case management
• Wear your CMSA Member Pin
• Promote case management by sponsoring or volunteering at a health fair, preventive screening or organizing services in your community
• Host a reception in your community
• Host a professional seminar for health professionals in your community
• Highlight a different case management practice setting each day of the special week in your newsletter or blog
• Encourage your mayor, county executive or governor to issue a local proclamation establishing October 10-1th as National Case Management Week
• Invite a politician to accompany a case manager at their place of business for a day
• Decorate with banners, posters, or flyers
• Publish newsletters focusing on CM week
• Speak to nursing organizations about case management careers
• Create a publication of case management stories
• Write a letter to your local paper
• Contact radio and TV stations to let them know about CM week
• Write a guest editorial to newspapers, journals or magazines regarding the positive impact of case management
• Distribute a press release announcing CM week

I am committing to several of these activities this year.  (I just completed one by posting this!)  I am glad I have an opportunity to impact my patient’s lives everyday.  The very things that seem so simple to me, make a big difference in the lives of others.  I just hope I can continue this for many years to come.

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I recently read an article by Chris Moranda in The Rehabilitation Professional on getting managers to buy-in to the concept of return to work and its benefits.  He states the best measure of the effectiveness of any case management program is job placement which is accomplished through various tools such as…

• up-to-date assessments of job descriptions and analysis with essential functions
• ergonomic evaluations
• reasonable accommodation assessments including identifying adaptive equipment.

Most importantly is the understanding and support of managers.  Though managers and supervisors may be highly trained there remains a great need for awareness of the requirements of the Americans with Disabilities Act (ADA) and the recent ADA Amendments.

In my role as a case manager I can further the company’s understanding to move managers and supervisors beyond an attitude of compliance to one of being a champion for those they represent.  In order to accomplish this, the case manager must begin by forming relationships with those employers to gain their trust, hear their concerns and help pursue solutions.  Creativity is the key.  A case manager and manager working together can often make adaptations that benefit everyone.

One goal for case managers is to support the employer to become more comfortable in taking back an employee on light duty restrictions through a transitional work duty program.  A manger who sees how accommodations work will more likely be willing in the future to consider hiring other people with restrictions and disabilities.

A case manager can forge these relationships with the human resource person.  Through this relationship the case manager could attend managers meetings as a consultant to represent and inform about transitional work programs, the ADA and demystify reasonable accommodations.

With this in mind the case manager must understand the company’s attitude regarding return-to-work (RTW).  If the employer is only focused on production the reduced work capacity of the individual will make fora difficult course.  The company’s goal should be to champion employees on the job and working.  If the concern is focused on decreased productivity, one option would be to have the patient to function as an extra staff and not impact the productivity of the department or even move them to a non-production position temporarily.  The most important matter for managers to understand is the value the employee brings to the job through knowledge and experience.

As both a case manager and an ergonomics assessment specialist, VP Medical Consulting can provide employers with the assistance they need to develop cost effective transitional duty programs.  This results in a win-win situation for the employer, the injured worker, and the carrier.  Let us help you get started today.

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Working as a case manager in the area of workers compensation, I heard the term life care planner, but didn’t really understand the term.  Later, while working as a legal nurse consultant, I began to hear the term more frequently.  Finally an attorney client mentioned that he needed a new life care planner and my ears finally perked up.  If my client needed it, perhaps I needed to find out just exactly what this was all about.

I am proud to say that I have been providing nurse life care planning services for several years.  It was a great move for me and something I enjoy.  I have people ask me frequently to explain life care planning and felt it was time for a post to address some of these frequently asked questions.

1.  What exactly is a life care plan?

A life care plan is just like any other care plan we would write as a nurse only it covers the individual for life.  It is dynamic just as our bedside care plans change as our patient’s condition changes.  The plan is based on the author’s standards of practice coupled with nursing assessment, analysis of the medical records and other data, as well as research and collaboration with providers.  The plan provides an organized and concise outline of the current and future needs along with the costs of those needs.  Careful consideration is given to the patient’s goals, needs and interests as well as their geographic area and the types of care to be found in the area.

2.  How does this plan benefit the patient?

The life care plan is a tool.  It is used for education, budgeting, case management, rehabilitation, and has application both in and outside of the judicial system.

3.  What is the role of the nurse life care planner in a litigated case?

The role is one of an educator rather than an advocate.  The author must maintain objectivity and base his or her recommendations on the medical records, assessment and interview as well as the history of care.  The author should is to set forth rehabilitation goals that are attainable, which include how and when services should be provided, how to implement the plan and it must be clearly communicated.  The author of the plan is considered an expert in life care planning and will be asked to testify as such to explain the plan and how he or she derived at the recommendations put forth in the plan.

4. What is the difference in a plan written for the defense versus one written for the plaintiff?

There are no differences.  A life care plan is to address the needs of the individual and should be created in a systematic approach.  The life care plans are individualized to the patient, but should not vary based on the requesting attorney.  It is not unusual to be prevented from in home assessment and interview when writing a plan for the defense, however that does not mean that the approach to the plan is any different.  This only means that some portions of the standard approach may be missing.

5.  What do you do about collateral funding sources when writing the plan?

Life Care Plans are to be needs based rather than funding based.  If the item is needed, it is included in the plan regardless of funding for that particular item(s).  Needs and the associated recommendations are not to be restricted to only those items covered by insurance.  Costs associated with the care recommendations are cited according to the prevailing charges within the community in which the patient resides.  The plan covers the individual’s life expectancy and funding sources change and even disappear.

6.  Can I become certified as a nurse life care planner?

YES!  There is a Certified Nurse Life Care Planner certification board which certifies only nurses as life care planners (CNLCP).  They provide three routes for one to become certified and information about each can be found on their website.  There is also a certification (CLCP), not specific to nurses, which is granted by the Commission on Health Care Certification.

7.  I am interested!  Where can I find more information?

The American Association of Nurse Life Care Planners is the association for nurses in this exciting field.  The have a website that includes the mission of nurse life care planners, member lists, conference information, and resources.  The annual conference is an excellent way to obtain additional information as well as to network with other like minded individuals.  The International Association of Rehabilitation Professionals also provides information for life care planners and includes a section specific to life care planning entitled International Academy of Life Care Planners.  This association hosts multiple educational events throughout the year.  The Care Planner Network is dedicated to the community of life care planners and hosts a directory as well as a forum.

If all of this sounds interesting, but you are afraid to take the plunge, join me on October 8th in Boston for a conference on nurse consultants in business.  We will discuss how to get started, marketing, technology, the logistics of doing business, and much more.  Then, if you stay for another day or so, you will meet a host of individuals in all stages of their business.  Learn the pros and cons.  Find your local guru.  Surround yourself with support and encouragement.  You can do it!

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