Medical Case Management Guidelines
Formal medical case management has been evolving since the 1970's, and has been successfully applied in many sectors, including workers' compensation. Professional medical case management should be a collaborative and comprehensive process of evaluation, care coordination, and advocacy for medical services designed to meet an injured or disabled employee’s health and recovery needs in the safest and most effective method possible. The Workers' Compensation Agency realizes that medical management is an integral component in the overall process of returning injured employees to work. As with most professional fields of practice, it is also important to revisit the fundamental principles of the profession from time to time in order to stay within the defined scope of practice and established ethical boundaries. Therefore, we suggest following the list of medical case management guidelines below, which are based on The Michigan Quality Rehabilitation Service Delivery Guidelines. The central principle of these guidelines is an understanding that the primary obligation is the rehabilitation of the person with an injury or disability, who is your client.
Medical Case Management Services:
The following steps ARE recommended when implementing a medical management rehabilitation plan:
- Adhere to all state licensure requirements.
- 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 with an established critical pathway to determine variances.
- Support the stability of the client and family environment.
- Be inclusive of all parties involved in the medical recovery process, especially the injured employee and his/her family. The client should be an active participant in the development of the care plan, and/or the legal guardian when necessary.
- Include goals and timeframes when creating the care plan, and allow for updates as needed.
- Educate the involved parties on suggested treatment options to allow informed decision-making.
- Once a treatment plan is chosen, ensure that the client is following that plan.
- Validate the funding for case management services prior to proceeding.
- Verify the needs of all parties to ensure successful return-to-work, especially the employer.
- Provide client advocacy and support at all times, and provide input and guidance on treatment services…BE A LIAISON BETWEEN PARTIES.
- 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 participants 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.
The following steps are NOT recommended when implementing a medical management rehabilitation plan:
- Give legal advice at any time, including the signing or witnessing of legal documents.
- Question the physician or employee or make determinations regarding issues of claim compensability or work relatedness.
- Initiate cost services prior to obtaining carrier authorization.
- Schedule Independent Medical Examination (IME) appointments.
- Change or reschedule the client's medical appointments without first discussing the need for change with the client.
- Withhold information crucial to the return-to-work process.
- 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.
- Provide legal direction to the claims adjuster or engage in claim investigation and/or adversarial activities.
For further information contact the Workers' Compensation Agency, P.O. Box 30016, Lansing, MI 48909. Telephone: 517-284-8891 or 1-888-396-5041.