Nurse Case Management

Targeted Nurse Assignment Boosts Outcomes

Nurses with the right skills and experience have been shown to have significant impact on red-flag claims.
By: | July 9, 2015

Data analytics is not new to workers’ comp, but applying it more specifically to the decision to include nurses on a claim is a new and effective way to improve outcomes and lower costs. A new report from Helmsman Management Services, a third party administrator for Liberty Mutual that provides claims management and risk control services, describes a “decision-support model” that helps clients determine which cases can benefit from adding a nurse, and when.

To prove the advantages of including a nurse, Helmsman compiled 4,000 claims with similar profiles – except that half had a nurse and the other half did not. Their side-by-side comparison showed that claims that had a nurse involved were resolved about 15 percent faster, reduced overall costs by 26 percent and lowered future medical costs by 18 percent. The report dubbed this impact the “N-Factor.”

But this doesn’t mean every claim should automatically be assigned a nurse.

“Take the example of an injured employee who had no comorbid conditions and a positive relationship with the employer, was receiving appropriate medical care and was working in transitional duty,” said Mary O’Donoghue, vice president and manager, medical services, commercial Insurance, at Liberty Mutual. “Adding a nurse to this claim would not significantly impact its outcome but would increase its cost.”

Helmsman’s analytics program collects data on 25-30 variables, which include body part injured, the claimant’s motivation to return to work, bill payments for comorbid conditions, and above-average use of narcotics. It then alerts claims managers when a case is high-risk, and recommends assigning a nurse

Nurses can be instrumental when claims get more complicated, both by helping the worker stick to his treatment plan, and by keeping lines of communication between worker, employer and claims managers open.

“In talking with a claimant, a nurse might identify a comorbid condition, and get that injured employee into a management program to better control the condition so that the workplace injury can be more effectively treated,” O’Donoghue said.

“Or a nurse might question a proposed treatment plan — including the timing or quantity of powerful prescriptions — review his or her concerns with one of Liberty Mutual’s medical directors, and arrange for the medical director to speak with the treating physician about those concerns and the latest evidence based treatment options.”

Nurses can be instrumental when claims get more complicated, both by helping the worker stick to his treatment plan, and by keeping lines of communication between worker, employer and claims managers open.

Finding the right nurses to navigate a claim can be a challenge. The best candidates possess the “soft skills” of effective communication and attentive listening, as well as understanding of the workers’comp process and the goals and expectations of every party involved.

“The most effective nurses also have advanced case management/rehab certifications, as well as experience and education in mental health,” O’Donoghue said.

Finding and training the right nurses certainly requires an investment of time and resources, and applying data analytics to key decision-making is a trial-and-error endeavor, but the “N-Factor” is worth pursuing.

According to the report, “The N Factor: How Nurses Add Value to Workers Compensation Claims,” by 2019, “some insurance experts predict that medical care will make up two-thirds of workers’ compensation claim costs.”

Katie Dwyer is a freelance editor and writer based out of Philadelphia. She can be reached at [email protected].

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