Case Study: Early Intervention Program to Identify At-Risk Employees for Delayed Recovery. Arizona Self Insurers Association 2015 Annual Seminar

Transcription

1 Case Study: Early Intervention Program to Identify At-Risk Employees for Delayed Recovery Arizona Self Insurers Association 2015 Annual Seminar

2 Objectives Understand the dynamics of Delayed Recovery Early intervention program overview Key implementation components What we ve learned from mistakes Keys to success

3 Why Are We Here? Small number of claims drive 90% of costs.why? Clinically simple or routine, noncatastrophic medical and indemnity costs have been escalating Opportunity curve identify employees at risk for delayed recovery

4 What is Delayed Recovery? You ve seen these claims. Some people develop persistent pain and delayed recovery due to non-medical psychosocial risk factors Delayed recovery and overutilization is driven by inadequate injured workers coping skills and physician lack of knowledge of real pain generator Chronic Pain (and poly-pharmacy) is the final common pathway of delayed recovery

5 The Dynamics of Delayed Recovery Medical diagnoses legitimize injured worker s distress The diagnostic/treatment process permits transferal of psychosocial issues MD advocate accepts locus of control Injury is medicalized OVERUTILIZATION of medical services occurs without constraint or explanation

6 What Does Delayed Recovery Look Like? Protracted recovery ACE (Adverse Childhood Experience) burden Catastrophic thinking, excuses Fear avoidance and embellishment Anger (perceived injustice) toward Employer and others Anxiety/depression by history External locus of control Minimal resilience

7 Consequences of Delayed Recovery An estimated 10% of claims consume 80% or more of medical and indemnity resources Needless disability Needless morbidity and mortality

8 The Paradox of Delayed Recovery Not inevitable Predictors have long been identified Effective treatment (CBT) is known, and is increasingly available Making delayed recovery a largely preventable or manageable phenomenon

9 Early Intervention is OUR Opportunity To prevent delayed recovery and promote function To improve employee s personal coping skills now, and for the future To resolve potentially disastrous claims timely (often without litigation) To conserve significant resources

10 Approach to Delayed Recovery Management A Functional Restoration approach Consistent with national treatment guidelines Focus on skill acquisition, improved function, and RTW Independent self-management is goal, but those at risk require more attention/care

11 Cognitive Behavioral Therapy The technique long used to establish behavioral change in Functional Restoration The most powerful tool in health education and psychology for effectuating behavioral change for independent self-management ( Resilience ) Neuroplasticity is basis for change

12 Brief and time-limited Principles of CBT The therapeutic relationship is not the focus A collaborative effort Structured and directive Based on an educational/self-management model, focused on skills acquisition/resilience Homework is a central feature of CBT

13 View from the payers desk

14 The Conundrum Psychosocial factors: Strongest predictive factors for recovery BUT Psych treatment may lead to psych claim Treatment never ends and PD is higher SOLUTION CPT codes without a Psych diagnosis Specialty panel using limited treatment Cognitive Behavioral Therapy

15 Early Intervention Program Implementation

16 Proof of Concept Pilot Early intervention pilot low back pain claims Clinical risk management screening questionnaire administered by initial PTP / Triage tool Risk for delayed recovery identified within the first 2-3 visits Intensive care at the outset of the claim -- Sports Medicine Approach Additional disciplines (psych and/or PT) provided immediately Results: no delayed recovery cases, no litigation, all RTW full duty

17 Implementation & Execution Issues with Pilot Provider Clinic only completed the screening tool in select cases Delay in patient identification, due to lack of clarity regarding payer Underestimated large organizational execution issues Payer/Employer Ineffective initial and ongoing training Lack of clear end-to-end workflow map Fragmented communication Lack of owner/key contact

18 Early Intervention Program Albertsons Safeway Approach 1. Screen at 2 weeks post injury ID high risk 2. Case management priority 3. Referral from PTP to panel for CBT 4. Team conferences to support CBT plan 5. Modified duty RTW programs 6. Communication, communication and more 7. If agenda is not recovery change strategy

19 Team Approach Team discussion regarding participation, problems and progress Medical Director involved to, educate and support physicians to integrate CBT into treatment plan Minimize and discontinue overutilization of medications A focus on timely, coordinated RTW Avoid psych diagnoses Reduce perceived need for legal representation where possible

20 Program Trends 12% score high for delayed recovery risk PTPs beginning to refer earlier Employees showing positive results with RTW Average sessions of CBT = 6 About half of at-risk IWs understand new skill acquisition for resilience is in their best interest About half of at-risk IWs have other agenda(s) and will not engage

21 Implementation Considerations Early intervention must be started early post injury Integrated into the Treatment plan by the PTP Effective interdisciplinary communication, full participation of carrier, and dedicated medical supervision are all required Coordination of care ( hand-to-hand combat ) is laborintensive and time consuming, not a plug-and-play solution

22 Keys To Successful Implementation Screen all claims universal precautions approach Identify point of contact to serve as the implementation liaison Schedule formal claims and medical staff training Map the workflow Use Consistent personnel to administer the screening tool Select the best program partners Ensure clinical resources, TCM/OHN is assigned Identify how you will measure success/performance measures

23 Conclusion Encouraging and exciting results to date Resources are conserved, and claims are settled reasonably in about half of cases (projected reduction in total medical/indemnity spending of more than 30%) Physicians want CBT as a clinical resource Newly acquired skills have utility in workplace post RTW In the process of completing a study with a research partner

24 Questions Contact Denise Zoe Algire, MBA, RN, COHN-S/CM, FAAOHN Director, Managed Care & Disability Corporate Risk Management Anita Weir, RN MS Director, Medical & Disability Management Corporate Risk Management