New WC CM Nurse

nurseprnRN, BSN, RN · Jun 27, 2014

This is absolutely a nursing job, even though, like many nursing and other professional jobs, the documentation and notification doesn't feel like it. You will start having a greater appreciation of this as you do it for awhile.

The definition of case management includes influencing the course of medical care. You are NOT a passive observer/recorder. Even though you work for the carrier and are charged with watching for unnecessary costs, you are a nurse and patient advocate first. That's why they hired you. For an example:

You get a referral for an IW with a knee injury. He has been seen by the occ med clinic and referred to an orthosurg for possible repair. To do your initial assessment, you go to his house. You take a full history, including a vocational history. Why? Because your first phone call back at the office will be to the employer, asking about modified duty later when he gets clearance for it. If they don't have an established modified duty program, you're going to help them see the wisdom of it and explain what he will probably be able and not able to do over the course of his recovery.

Meanwhile, back at the house doing your initial eval, you go into patient teaching mode, explaining the entire process and saying that you will meet him at the MD office appt and what will probably happen there. You obtain a signed release for medical records from him. If you are smart, you say that some people might tell him that you work for the insurance company, you don't care about him, you just want to save money. However, you are a nurse first and your duty is to see he gets good care.

Besides, you say, there is nothing inherently wrong about saving money; if we were all independently wealthy neither of us would be here right now, right? Comp is an insurance plan his employer pays for, just the way he pays for car insurance. If you get him better faster, he gets back to work sooner rather than later the employer saves money on premium, AND saves money on training a replacement who doesn't know the job as well as he does. And of course, if he gets better faster, the carrier saves money. And if he gets better faster, he earns more money too, because comp indemnity isn't as much as he was earning, is it? So voila, everybody does better when he gets better and goes back to work except you, because you are on salary. He laughs, and you take your leave.

At the appt, you give the office mgr a copy of the release and attend the exam with the patient's permission to observe. This is critical, so you are glad you put the time into developing rapport and trust with him at your initial eval. You listen to what the physician has to say, take good notes (also noting if the physician does a good exam, asks about what the job entails physically, and takes a good history) and tactfully insert missing data the MD forgets to ask. Or say, "Mr. IW had some concerns about ..." when the doc looks about to leave without asking. Or, perhaps, making a mental note that perhaps a second opinion might be a good idea.

Surgery is recommended and scheduled. You will make the first postop appt AND the first postop PT eval appointment according to the physician's routine before you leave the MD office. This is because you will know that the doc will say that PT can proceed right after the first postop check, because you will ask. You will attend that postop check, but if you wait to call to make the PT appt til then, you won't get your guy seen until a week or two later, and this is an unnecessary delay. If for any reason the postop check indicates a need to postpone, you can always do that. You will also arrange to get the office notes faxed to you stat. Finally, when you and the IW leave the office, you say, "Did you understand what Dr Smith plans about your surgery and postop care?" Dollars to doughnuts the answer will be something like, "Ummm, sorta..." and you will explain the treatment plan all over until you are satisfied that he understands it. If he isn't happy with it, or you aren't, you explain that he can have a second opinion, and you know the best knee guy in town who will get him in within a week or two. And remember, since this is comp, the "in network" thing from his regular health insurance DOES NOT APPLY, so you ca do that.

So the surgery goes down and he goes to a good PT place you recommended, because you know who's good at that. Like surgeons and hospitals, all PT facilities are not created equal. You get a copy of his initial eval and call to see that he's doing OK c it. You see him at the MD office in follow up in a month, and because you have already been working with the employer, you have a job description for a desk job while he recovers. The physician ticks off the boxes for physical aspects, hours, and days on the form you have for him (and you may have created yourself), so the employer knows what's OK.

There's more, but you can see that all along you are using your nursing expertise in assessment, patient teaching, teamwork, planning, and documentation to move this IW along the continuum of care in more ways than just being a passive observer. You are also educating the adjuster, who may know less about knees than you think, especially if you know Dr Smith has lousy outcomes and you'd like to have the IW seen by Dr Excellentkneeguy, who you know is very functionally-oriented and gets people back to full function faster. YOU are the most important variable in thus guy's recovery.

Hope that gives you a teeny taste of field case mgmt in work comp. As you get more expertise, as in any other nursing specialty, you get better at it, with different injuries, diagnostics, specialties, and acuities. And personalities. As in any nursing specialty, there are some nonadherent patients, liars, and scumbags, and you will learn how to work with (or around) them. The vast majority of IWs really did get hurt, really do want to get better, and really do want to RTW, and you will make all the difference to them.

WC Case manager · Jun 29, 2014

Go GrnTea! You are exactly on!

cleom925 · Jul 25, 2014

This is absolutely a nursing job, even though, like many nursing and other professional jobs, the documentation and notification doesn't feel like it. You will start having a greater appreciation of this as you do it for awhile.

The definition of case management includes influencing the course of medical care. You are NOT a passive observer/recorder. Even though you work for the carrier and are charged with watching for unnecessary costs, you are a nurse and patient advocate first. That's why they hired you. For an example:

You get a referral for an IW with a knee injury. He has been seen by the occ med clinic and referred to an orthosurg for possible repair. To do your initial assessment, you go to his house. You take a full history, including a vocational history. Why? Because your first phone call back at the office will be to the employer, asking about modified duty later when he gets clearance for it. If they don't have an established modified duty program, you're going to help them see the wisdom of it and explain what he will probably be able and not able to do over the course of his recovery.

Meanwhile, back at the house doing your initial eval, you go into patient teaching mode, explaining the entire process and saying that you will meet him at the MD office appt and what will probably happen there. You obtain a signed release for medical records from him. If you are smart, you say that some people might tell him that you work for the insurance company, you don't care about him, you just want to save money. However, you are a nurse first and your duty is to see he gets good care.

Besides, you say, there is nothing inherently wrong about saving money; if we were all independently wealthy neither of us would be here right now, right? Comp is an insurance plan his employer pays for, just the way he pays for car insurance. If you get him better faster, he gets back to work sooner rather than later the employer saves money on premium, AND saves money on training a replacement who doesn't know the job as well as he does. And of course, if he gets better faster, the carrier saves money. And if he gets better faster, he earns more money too, because comp indemnity isn't as much as he was earning, is it? So voila, everybody does better when he gets better and goes back to work except you, because you are on salary. He laughs, and you take your leave.

At the appt, you give the office mgr a copy of the release and attend the exam with the patient's permission to observe. This is critical, so you are glad you put the time into developing rapport and trust with him at your initial eval. You listen to what the physician has to say, take good notes (also noting if the physician does a good exam, asks about what the job entails physically, and takes a good history) and tactfully insert missing data the MD forgets to ask. Or say, "Mr. IW had some concerns about ..." when the doc looks about to leave without asking. Or, perhaps, making a mental note that perhaps a second opinion might be a good idea.

Surgery is recommended and scheduled. You will make the first postop appt AND the first postop PT eval appointment according to the physician's routine before you leave the MD office. This is because you will know that the doc will say that PT can proceed right after the first postop check, because you will ask. You will attend that postop check, but if you wait to call to make the PT appt til then, you won't get your guy seen until a week or two later, and this is an unnecessary delay. If for any reason the postop check indicates a need to postpone, you can always do that. You will also arrange to get the office notes faxed to you stat. Finally, when you and the IW leave the office, you say, "Did you understand what Dr Smith plans about your surgery and postop care?" Dollars to doughnuts the answer will be something like, "Ummm, sorta..." and you will explain the treatment plan all over until you are satisfied that he understands it. If he isn't happy with it, or you aren't, you explain that he can have a second opinion, and you know the best knee guy in town who will get him in within a week or two. And remember, since this is comp, the "in network" thing from his regular health insurance DOES NOT APPLY, so you ca do that.

So the surgery goes down and he goes to a good PT place you recommended, because you know who's good at that. Like surgeons and hospitals, all PT facilities are not created equal. You get a copy of his initial eval and call to see that he's doing OK c it. You see him at the MD office in follow up in a month, and because you have already been working with the employer, you have a job description for a desk job while he recovers. The physician ticks off the boxes for physical aspects, hours, and days on the form you have for him (and you may have created yourself), so the employer knows what's OK.

There's more, but you can see that all along you are using your nursing expertise in assessment, patient teaching, teamwork, planning, and documentation to move this IW along the continuum of care in more ways than just being a passive observer. You are also educating the adjuster, who may know less about knees than you think, especially if you know Dr Smith has lousy outcomes and you'd like to have the IW seen by Dr Excellentkneeguy, who you know is very functionally-oriented and gets people back to full function faster. YOU are the most important variable in thus guy's recovery.

Hope that gives you a teeny taste of field case mgmt in work comp. As you get more expertise, as in any other nursing specialty, you get better at it, with different injuries, diagnostics, specialties, and acuities. And personalities. As in any nursing specialty, there are some nonadherent patients, liars, and scumbags, and you will learn how to work with (or around) them. The vast majority of IWs really did get hurt, really do want to get better, and really do want to RTW, and you will make all the difference to them.

Is going to the IW's home safe? Has there been any harassments experienced? I just need to know before I jump in to this kind of work.

nurseprnRN, BSN, RN · Jul 25, 2014

Is going to the IW's home safe? Has there been any harassments experienced? I just need to know before I jump in to this kind of work.

You know, I never once got any grief going to someone's house. If you are enough of a grownup to feel comfortable on a public bus, you can do fine with meeting new people in their homes.

Once I had to go see a guy in an inner-city housing development, big anthill of a place, some broken glass in the lobby, trash in the parking lot. I got onto the graffiti-encrusted elevator and a coupla big scary looking dudes looked at me, and one of 'em rumbled, "You da nurse?" Now, I was wearing a businesslike pant suit and black Danskos and carrying my leather bag that held files and stuff, didn't look like a VNA bag at all, so it's not like I was in scrubs or anything. But he knew. I said with a confident smile, "Yup!" and he said something like, "Nurses he'ped my mama once," and the other guy nodded. I said that was good, I was glad to hear it, thanks, and got off at my floor.

cleom925 · Jul 25, 2014

Oh woow!!!! That would have frightened me. I guess I will just have to bring a Tazer just in case and for my sense of safety. Thank you GrnTea for your help!

nurseprnRN, BSN, RN · Jul 28, 2014

Don't get the Tazer, for god's sake, no! If you think I was telling you that story to make you feel more scared, you got it exactly backwards. Nurses have power intrinsically, people recognize it. You don''t want to frighten or antagonize people by fidgeting with a Tazer in your hand, good grief. You need to seriously reconsider your participation in public places if you think that story was scary at all. If you don't mind my asking, how old are you?

Nobody has ever invented a weapon that hasn't been used inappropriately. Carrying just makes you more apt to shoot. Don't do it, as a matter of planetary hygiene.

SummerGarden, BSN, MSN, RN · Jul 28, 2014

Oh woow!!!! That would have frightened me. I guess I will just have to bring a Tazer just in case and for my sense of safety. Thank you GrnTea for your help!

OP: You’re NOT a good fit for the patients that need your help in this position. You are better off working away from poor people and people that have caregivers that live in poverty… In fact, you should not have patients that scare you!

Maybe a telephonic CM position or a nurse that works in a posh well-to-do area is a better fit??? Definitely don't become a CM that makes home visits and goes to doctor appointments with poor people. I was going to write all this, but I do not work in the field anymore and I did not want to come off as judgmental. Now I do not care if I do come off as judgmental! I am advocating for the poor patients who will unfortunately have you as a nurse in the future. Honestly, I am not trying to shame you... Your personality belongs with a different population. Good luck!

Don't get the Tazer, for god's sake, no! If you think I was telling you that story to make you feel more scared, you got it exactly backwards. Nurses have power intrinsically, people recognize it.

Thank you, GrnTea. I was appalled by the OP writing she was going to get a Tazer. In fact, I also got the gist of your story and was horrified that she is so afraid (a scary person) that she took it the wrong way. You are a powerful person and carried yourself well. Your demeanor and your status as a Nurse showed! On the other hand, the people you came in contact with were not bad people even if they are poor, but the OP is not someone who understands that concept and needs to work somewhere else.

-A former Field Case Manager of impoverished people and a current Acute Care Case Manager of impoverished people.

cleom925 · Jul 28, 2014

Grn Tea and MBARNBSN thank you for all your inputs. I was not scared about the patient, I was more concerned of the environment. But both your inputs have opened my eyes and gave me more confidence. I don't want to be defensive but I really do care for people from all walks of life, from old to poor, name it. This will just be my first time trying the field nursing and as such I am really doing my best to know more about it before I get my feet wet and get discouraged. I am really looking for more encouragement and at the same time a real picture of field case management.

I had an interview today for case management for workers comp and was told that I will be on the field most of the time meeting clients for their doctors appointments and not so much of home visits.

nurseprnRN, BSN, RN · Jul 29, 2014

Sure, you make one home visit for most folks, and then it's lots of MD office visits after that. So yes, most of your field visits WILL be MD office visits or the like. But you will have to assess your patients personally too, and the very best way to do that, to do a full nursing assessment, is seeing them in their own environment.

How else are you gonna see that the reason that guy's hands are all greasy is because of the car he's taking apart in the driveway (when his back hurts him waaaaaay too much to go to work)?

Or that she's hefting that toddler even though it hurts and she isn't supposed to lift anything more than 5 lbs, because she has no daycare now that her paycheck is cut in half? Or that he has two flights of rickety stairs to climb after he goes home from his total knee replacement?

SummerGarden, BSN, MSN, RN · Jul 30, 2014

I had an interview today for case management for workers comp and was told that I will be on the field most of the time meeting clients for their doctors appointments and not so much of home visits.

Yes, OP, you will be doing home visits. Do not be fooled by your potential employers. Once you get to know your clients well, the home visits may drop significantly, but they do not necessarily go away all together. In fact, the reason you are will be called a field case manager is because you are in the field more often than not, which is good.

For example, as GrnTea mentioned, there is no other way to get a true idea of how a patient is living if you do not assess their home environment or that of a caretaker if he/she stays with someone else during the day or night. I am not trying to discourage you but you really need to ask yourself if you wish to work in a job that has you going into people's home often. Field case management is not for everybody. It does not mesh with everybody's personality.

Once upon a time, I did not like working in offices. I hated it so much that I only looked at jobs and accepted positions that had me in the field more often than not. My personality was a great fit for field case management and so I was a good one.

Maybe try the job out and if it does not work for you, try something else? Good luck to you....

cleom925 · Jul 30, 2014

Totally make sense! Now, I really have a better understanding of Case Management for IW.:)