Medical Case Management Do's and Don'ts
September 24, 2004
All Agency Approved Rehabilitation Facilities
David R. Campbell, MA, CRC
Vocational Rehabilitation Consultant
Medical Case Management Do's and Don'ts
Formal medical case management has been evolving since the 1970's, and has been successfully applied in many sectors, including workers' compensation. Statistics on the activity of Approved Vocational Rehabilitation Providers kept by the Workers' Compensation Agency have proven that medically managed cases continue to dominate the workloads of many rehabilitation firms. In fact, approximately 75% of the cases sent in monthly are medical management cases vs. approximately 25% vocational rehabilitation. The Workers' Compensation Agency realizes that medical management is an integral component in the overall process of returning injured employees to work. However, as in any professional field it is important to remind ourselves of the fundamentals within the practice, to help us stay grounded in established ethical and professional boundaries that can become blurry at times. Therefore, we offer the following list of guidelines, or "Do's and Don'ts" for the field of medical case management.
In July 1998, representatives of the following organizations: MRA, MRCA, MASPPR, MiARP, CMSA-DC, AND DMAHON came together to form the Coalition for Quality Rehabilitation Performance. Coalition members include the Michigan Rehabilitation Association, the Case Management Society of America - Detroit Chapter, and the Detroit Michigan Association of Occupational Health Nurses. The objective of the Coalition was to develop guidelines for the promotion of measurable and appropriate delivery of rehabilitation services in the State of Michigan. The expressed desire of the committee was to have a positive end product that would help to facilitate a higher quality of service delivery. The result was the publishing of The Michigan Quality Rehabilitation Service Delivery Guidelines. The coalition guidelines have been formally adopted by five of the participating Coalition members. In addition, the Michigan Occupational Therapy Association and the Michigan Self Insurers' Association have endorsed the guidelines. In April 2001, the Workers' Compensation Section of the State Bar of Michigan endorsed the guidelines.
These Service Delivery Guidelines apply to two primary areas: Medical Case Management Services, and Vocational Rehabilitation Services. The integration of vocational services with medical case management can accelerate the return to work process, maximize outcomes and manage benefit expenditures.
Rehabilitation practitioners are to respect the integrity and protect the welfare of the people and groups with whom they work, with the primary obligation to the rehabilitation of the person with a disability, who is the client. Rehabilitation service providers are expected to adhere to all standards and ethical guidelines applicable to their professional discipline.
Medical Case Management Services:
The following steps are recommended when implementing a medical management rehabilitation plan:
· Coordinate activities of medical professionals, community agents, funding sources, client and family for the goal of achieving maximum functional outcomes.
· Facilitate inpatient, outpatient, and home services as well as medical evaluations and environmental modifications as needed.
· Assist in securing funding for medical equipment, supplies, medications and services in a cost effective manner.
· Provide information to the client to help facilitate timely and appropriate treatment.
· Guide client to self directed care, self-advocacy and decision making to the degree possible.
· Maintain a professional rapport and open communication with all members of the team so that the care plan can be discussed objectively, problems identified and adjustments made as needed.
· Make adjustments in the care plan to promote better outcomes, if the plan is static or regressive.
· Coordinate the care plan and disease course with an established critical pathway to determine variances.
· Support the stability of the client and family environment.
MEDICAL CASE MANAGEMENT DO'S AND DON'TS
· Be inclusive of all parties involved in the medical recovery process, especially the injured employee and their family.
· Include goals and timeframes when creating the care plan, and allow for updates as needed.
· Determine if treatment is appropriate.
· Determine if funding for case management services is secured before proceeding.
· Determine what is needed for successful return to work, especially from employer's perspective.
· Provide client advocacy and support at all times, and provide input and guidance on treatment services…BE A LIAISON BETWEEN PARTIES.
· Use valid disability duration guidelines, and use them as GUIDELINES.
· Educate all parties, especially employer, whenever possible on the positive and cost-effective aspects of return to work programs and processes.
· Always obtain and maintain appropriate releases of information prior to beginning case management services.
· Understand that there are many players in the case management process, but that your main client should always be the injured employee.
· Always identify clearly your role as a case manager to the employee at the start of the relationship.
· Give legal advice at any time.
· Schedule IME appointments.
· Change employee's doctor appointments just to fit YOUR schedule.
· Withhold information crucial to RTW success.
· Perpetuate disability by failing to address doctor recommendations, health concerns, or return-to-work issues in a timely fashion.
· Become personally and/or emotionally attached to the client.
· Assume that you have an absolute right to attend all doctors' appointments despite client wishes against it.
· Interfere with due process between employee and employer.
· Initiate cost services prior to obtaining carrier authorization.
· Provide legal direction to the claims adjuster, or engage in claims investigative or adversarial activities.
For further information contact the Workers' Compensation Agency, Vocational Rehabilitation Division, c/o General Office Building, 7150 Harris Drive, P.O. Box 30016, Lansing, MI 48909. Telephone 517-322-1721 (Voice) or 1-888-396-5041. You can find a copy of The Michigan Quality Rehabilitation Service Delivery Guidelines on our website at: www.michigan.gov/wca. They are in the Vocational Rehabilitation section.