What is Nurse Case management, and why is it important to your workers’ comp cost containment?

Updated: Feb 19, 2019

Our Nurse case managers meet patients at the patients' home, in the Dr's office and in the hospital.

PDI’s Nurse Case Managers are committed to altering the injured workers life for the better. PDI’s case management philosophy focuses on the management and coordination of care through efficient use of resources. Cost containment, while essential, is not the only goal.

Quality and continuity of care, coupled with the assurance of appropriate and timely intervention, are crucial elements for recovery and promoting a stay at work/return to work philosophy. By approaching the case with these goals, our nurses facilitate treatment options and services focused on the identified health needs. This approach decreases the fragmentation and duplication of treatment, while ensuring the right treatment, at the right time, with the right provider.

PDI’s philosophy centers around the concept that the best opportunity to medically impact a claim and reduce days away from work is at the most critical stage, the beginning. PDI's Nurse Advice & Injury Reporting line allows employees, including those in a dispersed workforce, immediate access to a Registered Nurse to discuss the nature of their injury. This not only provides the employee an instant advocate and clinical advice to treat their injury it also provides the employer with:

  • Decreased lag time in injury reporting

  • One point of contact at the time of injury creates a streamlined process for both the employee and the employer

  • Reduces OSHA recordable and reportable claims by providing self-care advice when applicable

  • Increased penetration of in-network options

  • Reduction in lost time/days away from work

  • Provides employees with an advocate to address their physical or emotional concerns, promoting improved workplace moral

  • Recording (mp3) of the initial report

PDI’s Nurse Case Managers work as intermediaries between carriers, attorneys, medical care providers, employers and employees to ensure appropriate and cost-effective health care services. A recent PDI White-paper reviewed outcomes from a large California public entity client, the results are as follows:

  • After the first year of the program, the entity saw a 56% reduction in days away from work, including a 61% reduction in days away from work for the Department of Public works.

  • After 3 years, the average medical cost per claim was down 53%, from $5,526 per claim to $2,571, and the number of total disability cases were reduced 20%.

  • After five years of the program, the days away from work were reduced an average of 62% from the year prior to program implementation, 68% for the Department of Public Safety.

A claims analysis from a large insurance group (Zurich) of nearly 28,000 claims showed that the timing of nurse case manager referral can have significant impact on the total cost of a claim as well as the closing rate.

The analysis looked at three distinct referral time frames:

  • Early: 4-30 days

  • Late: 31-90 days

  • Extremely late: After 90 days

Ultimately, the analysis confirmed longstanding belief: Early referral of claims is optimal.

When nurses are engaged early, the result can be an average $6,000-$26,000 total savings per claim, with nearly 50% of that savings in medical spend.

Early Nurse Case Manager Referral Benefit

Source: Zurich Closed Claims Data 2012-2015

Should I use a Nurse Case manager for every injury?

There are many guidelines that can be applied with respect to evaluating if a case warrants advanced Nurse Case Management, Betti Anders, (RN and the CEO of PDI) strongly believes in the philosophy that the best way to impact the outcome of a case is at the beginning – ideally, at the time of injury. Implementing the 24/7 Nurse Injury Reporting program is the best way to start evaluating if a case will require Nurse Case Management intervention.

Unfortunately, there is a misconception among employers and carriers that often case management is brought in too soon, or for claims for which there is little value. As a result, there is a perception that case management is “just a commodity” without quantitative differentiation across vendors. Perhaps this is one of the reasons that, despite its proven value, use of nurse case management remains low, especially early

in the claim cycle. Only about 10 percent of all U.S. workers’ comp claims today use nurse case managers.

In an article published by Business Insurance, Boston-based Liberty Mutual Insurance Co. states:

“nurse case managers have shaved an average of $6,100 off medical and indemnity costs for the workers comp claims on which they were involved, producing a return on investment of 8-to-1.”

Also, from that article:

“Litigation rates dropped by one-third in a nurse case management pilot program administered by MEDSTAR Medical Management of Long Beach, Calif., said Pam Guiles, VP of operations. In addition, the duration of cases was halved, she added.”

The effectiveness of a case management program hinges on the outcomes the case management provider can produce. Click here to see PDI’s actual results with a large California Public Entity.

While many vendors offer commodity-level case management, which may include computerized data analytics, or a computer algorithm that segments outcomes based on trigger diagnoses or code, PDI believes that what employers and carriers need are business partners that have a human interaction with the injured worker, and with all parties involved in the case. Having a live nurse triage at the time of the injury provides a level of human interaction that can more accurately quantify the value of the case.

While PDI has served many large public and private entities, the human interaction and human touch has always been a keystone to PDI’s approach and philosophy. Maintaining the “boutique approach” even for large clients, is what separates PDI from all of the large multi-national conglomerates that have commoditized case management. There is simply no way to replace a nurse interacting with an injured patient at the time of the injury. A computerized data analysis alone can never achieve:

  • Medical knowledge to address health and wellness issues

  • Encouragement and guidance to injured employees

  • Assistance in facilitating timely recovery and locating quality care

  • Guidance in navigating a complex medical environment

When you choose PDI, you are choosing a true partner, and we will utilize insights gleaned from discussions and interactions with all parties involved as well as data, and translate that into action; namely, appropriate, evidence based high-quality services - delivered quickly and efficiently at a reasonable cost.

When you work with PDI, you are working with a team that will cultivate a tailored methodology to your specific case management intervention needs, and that leads to claims that achieve better and more cost-effective outcomes than a commoditized low-cost bidder.

Let’s talk,

PDI’s team of Workers’ compensation case managers are dedicated to improving the lives of injured workers. The data is clear, when case managers are called on early in the claim, they can significantly advance return to work, reduce claim costs and litigation rates.

Let us show you how your organizations workers comp program could benefit from 24/7 Nurse Injury Reporting and Nurse Case Management Intervention. If you are serious about reducing your claims costs, click here to schedule a free expert consultation or to schedule a chat directly with PDI’s CEO. We look forward to hearing from you.

Telephone: 800-591-5501

Fax: 800-591-5502

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