How Nurse Case Managers Add Value to Workers’ Compensation Claims

At the 2015 National Workers’ Compensation & Disability Conference, Mary O’Donoghue, Vice President, Medical Services, Helmsman Management Services and Stephanie Perilli, Senior Director, Medical & Health Management, The Home Depot discussed how nurse case managers can add value to your data and to create a successful strategy to improve return-to-work outcomes, lower costs and deliver the best care possible.

Some major healthcare challenges are high costs. Global healthcare is slowing but not in the US, 5.4% increase in US health spending, about $8000 a year per person. The environment is dynamic, technology is advancing but the people who are using this technology is more unhealthy than ever. US currently has the poorest ROI. Obesity is the biggest concern right now for work comp claims.

There have been some major medical advances in the past few years:

• Ortho-biologics – lots of promise but little evidence
• Procedures – multi-billion dollar industry with no shortage of “advances”
• Testing – constantly expanding into many areas

Pharmacy costs:

• 70% of americans take atleast one prescription
• $2.4 billion in big pharma advertising to drs
• 50% of americans take 2 prescriptions
• $392 billions spent on prescriptions in U.S. in 2014

Challenge and Solution: Building a Model

Objective: measuring impact of nurses

Target measures are: number of days, paid loss dollars and paid medical dollars

Solution: we overcame problem with two predictive models

Matching model: matches claims with appropriate peer

Impact model: measures impact of nurses

Multiple indicators:

• Claim demographics
• claimant behavioral characteristics
• diagnostic and medical treatment
• injury related characteristics

Measuring results – nurses positively impacts quality and cost of claim outcomes

Why not put a nurse on every claim? That’s simple – they don’t necessarily need a nurse on every claim. Important to dig deep into the claim to see where they will add the most valu

Evolution: Decision Support Model – applying insights by targeting specific claims for maximum nurse value

Nurses add the most value when care starts in the hospital, weight loss or increase, significant work loss, employer/employee relationship is damaged, no college education, over the age of 35, hypertension, and high level of pain.

A study was conducted that compared shoulder surgery claims with nurses to similar claims from 31 other companies that did not have a nurse assigned. The findings included claims with a nurse assigned had 57% fewer disability days, despite other variables. The future potential savings include 18% medical dollars, 26% loss dollars and 15% number of workdays lost.

The hard facts about soft skills (skills and attributes rates as most important by return-to-work coordinators):

• respecting and maintaining confidentiality
• listening and negotiating
• communicating well in person and written
• effective problem solving with focus on return to work
• relating well to a wide range of personalities

Research to Reality

• employee selection-find those key attributes and innate qualities that set employees apart
• training and mentorship-ongoing training on emerging trends and evidence based medicine
• focus on RTW-return to work drives better medical outcomes

Home Depot: Our Experience

Core values drives their strategy. They use nurses for unique intervention based on assessed needs of our population, targeted case management strategy beyond catastrophic cases, clear and concise integration of all medical resources. Nurses work in the Home Depot locations and with the workers so they know exactly what the employees are working with each day. Not only are the nurses trained to know the medical assistance but also other employee benefits.

Regarding paid medical dollars for Home Depot, they were able to save about 12% on average when a nurse case manager was involved. For paid loss dollars, nurse involvement reduces paid medical by 28%. Home Depot’s study included shoulder surgeries. The median lost working days were 50 (Home Depot with nurse) compared to 115 (31 national market customers without nurse). The median medical cost was $19,300 (Home Depot with nurse) compared to $22,008 (31 national market customers without nurse). Data has helped Home Depot know when to add a nurse to a claim and use data to find connections between resources, claim characteristics, and outcomes. The nurse’s talent and skills drive benefits, including faster return to work at a lower cost. Nurses are able to use the connections to facilitate innovation and guide decisions that lead to better outcomes for injured workers and businesses.