Today’s challenges for the nurse consultant in case management

By Maureen J. Orr, RN, BS, LNCC, CCM, QRP
© The Medical-Legal News 2007

One of the most challenging fields for legal nurse consultants is the case management arena. In 1995, the Case Management Society of America (CMSA) defined case management as “a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates options and services to meet an individual’s healthcare needs through communication and available resources to promote quality cost-effective outcome.”

There are opportunities for the legal nurse consultant to work as a case manager in various fields, including workers’ compensation, elder care, accident and health, automobile injury cases, hospital discharge and private management.

The commonalities among case managers are that the nursing process include assessment, planning, implementation, coordination, monitoring and evaluation.

Adherence to the standards as delineated by the CSMA utilizes the nursing process with the emphasis on outcome development. An outcome-directed process assists the client in understanding his needs and develops a plan to help him to fulfill those needs despite increasing obstacles that might arise.

The case manager then assumes a role similar to that of a “juggler” in working to meet the needs of the client, (whether it is an injured worker, disabled individual or an elderly person) by interacting with the provider and payor to ensure coordination of services. In most instances, the LNC will need to familiarize himself with the state laws that might govern the regulations relating in particular to workers’ compensation and auto liability, or with federal laws applicable to eldercare.

This balancing of care, in which the LNC must complete the assignment given by the payor while adhering to the ethics of providing the maximum benefits to the client, often leads to conflicts.

This is why the Commission for Case Management Certification has developed a Code of Professional Conduct for case managers (not unlike the code for legal nurse consultants) to ensure that they must at all times respect the integrity and protect the welfare of those persons or groups with whom they are working. The case manager can rely on this code as a guide for professional conduct and utilize it as a sort of fallback when requested to perform actions that the case manager knows will not help the client.

For example, the following include some of the changes I have witnessed in my role as rehabilitation nurse/case manager for the state of Florida . I have been faced with assisting clients in the face of shrinking or often absent safety nets for those in need:

• In 2003 there was a dramatic change in Florida ’s workers’ compensation law that resulted in a reduction in insurance rates that assisted employers in providing coverage for employees.

• Accompanying this change was a reduction in benefits for injured workers. The length of time for covering benefits was limited to 104 weeks. While most injured employees can achieve recovery and return to the employer well within that period of time, there are many who cannot. For those workers who require more recovery time, (such as those in motor vehicle accidents with several fractures that require multiple surgeries) this 104-week period passes all too rapidly and leaves them with no income while still requiring significant medical treatment. All treatments require adjuster authorization, and waiting for authorizations for treatments can take many months and add to the anxiety of the clock counting down in those 104 weeks.

• Another decrease in benefits was the near elimination of authorization for psychiatric care for problems that might have arisen as a result of the work-related injury. Injured employees who do not have private health insurance coverage to treat these emotional conditions suffer tremendously.

• Once out of work, those employees fortunate enough to have health insurance quickly find that they cannot pay COBRA charges to continue these benefits. Loss of health insurance leads to neglect of the underlying health problems for the employee and his family, adding to stress. It becomes impossible to treat the patient as a whole, leading to frustrations not only for the injured employee but also for the treating workers’ compensation physician. Frustrated physicians often become angry and either discharge the injured employee since they cannot treat them within acceptable standards of care, or the physicians become very cavalier in their attitude toward the patient.

• In worst case scenarios, if injured workers lose all indemnity benefits and do not have family members who can support them, they can find themselves homeless in a short period of time.  Unemployment benefits do not apply because typically they have not been terminated from their work — they simply are not yet physically ready to return to work.

• In some communities, waiting lists for food stamps have waiting times of as long as three months. This leaves church organizations in the front lines of providing life-saving resources of food, shelter and clothing to those in need.

 It falls to the case manager to patch together these resources for the injured employee, while coordinating medical services to maintain consistent treatment geared toward recovery.

Of course the physical consequences pale in comparison to the emotional distress accompanying these losses. Families are often separated, marriages ended, children displaced and injured employees can develop depression related to the changes that are out of their control.

Meeting with community resources and advocating for clients thus becomes a large part of the role of the LNC/case manager. Development of referral source guidelines based on the community served can be a good tool to provide to those who require ongoing assistance. It is vital that these tools be constantly updated.

Concurrently, it is important that the LNC/case manager communicates the unmet needs of the client to the payor/provider and governmental sources so that consideration of changes can also be accomplished.

In summary, there are many problems facing the LNC/Case Manager working in the workers’ compensation system in Florida , and it will probably take significant legal challenges to change the focus of the care for the injured employee before any improvements will be seen. •

Maureen J. Orr is a legal nurse consultant based in Florida, mjorr44@aol.com.