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Implementing a case management program: a case study

At a glance:
In workplace case management programs, occupational health nurses can manage the needs of injured employees, speeding up their recovery and return to work. One study has shown that employers with case management programs have an average absence rate of 1.4%, as compared with 5.3% for those without case management programs. Return to work programs reduce health care costs and sickness absence, help employees to recover, and give them a sense that they are cared for. Key components of a successful program include:

Communication with employees
Early incident reporting and medical referral
Regular follow up
Strong working knowledge of employer health and safety regulations
Case management programs have many benefits to employees.
Workplace programs that manage the care of sick and injured workers can reduce sickness absence and costs. These programs can also improve employee morale. Implement a program based on:

Immediate medical management of the injury of illness
Immediate incident reporting
Ongoing communication between all team members
Follow up of all employees on sick leave
Periodic review of injury cases
Timely referral to specialists
Health and safety regulations and legislation
The case study presented in this paper shows that managing workplace injuries in this way can successfully reduce work days lost to sick leave. This program was operated by occupational health nurses, who have traditionally worked in this field. Similar workplace interventions have employed nurses or non-medical staff as case managers.
This article shows that integrated treatment of workplace injuries can hasten a patient's recovery. Contact your patient's workplace early, and encourage their employer or supervisor to be involved in the return to work process. Encourage communication between your patient and their workplace – this can facilitate co-operation. If possible, visit the worksite to suggest appropriate modified duties or ergonomic
Designing activities and the workplace in a way to minimize discomfort. i.e. Adapting work tasks, hours, or workstation to accommodate people. An ergonomic computer workstation allows the person to work in the best position to relieve load on the muscles of the neck and arms.

In this study, occupational health nurses were employed as case managers. Other staff, also without medical training, often fill this role. Adequately trained and experienced case managers can make a difference to difficult return to work cases. Encourage case managers to see the broad issues involved in return to work. You might encourage them to read the employer section of this website, which provides information on a broad range of workplace approaches that improve return to work processes and outcomes.
Workplace case management programs can reduce health care costs and sickness absence, as well as hastening the employee's rehabilitation. Key components of a successful program include:

Communication with employees
Early incident reporting and medical referral
Regular follow up
A strong working knowledge of employer health and safety regulations
Encourage client companies to implement case management programs: these can reduce workers compensation costs.
Original Article, Authors & Publication Details:
I. R. Elba (2006).

Occupational health nurses and case management. Nursing Economics; 24(1):30.
Background, Study Objectives, How It Was Done:
“Case management' is the system where each case is managed individually, with one person usually coordinating patient care. Goals of case management are to provide quality health care in a continuous process, prevent fragmented care and delays with recovery.

This study reviews the case management approach, and then gives a case study of one company's implementation of a return to work management system. This is not a scientifically designed study as it does not have a control group.

Case management background

In the United States, occupational health nurses typically coordinate and manage health care for sick or injured workers until they return to full or modified work duties. Case management approaches have evolved over time, with a focus on work adjustment in the 70s, modified work in the 80s and work rehabilitation
The process of helping a person back to their former abilities and quality of life (or as close as possible) after injury or a medical condition.
 in the 90s.

Several studies show that quality care can be cost effective. One study surveyed 106 organisations from different sized workplaces in different industries. Each employed more than 1000 workers.  This study found that organizations that implemented disability
A condition or function that leaves a person unable to do tasks that most other people can do.
 case management and absence management programs had an average sick leave rate of 1.4% (percent of working hours taken as sick leave) compared to 5.3% for those who didn't have a case management program. 

Key benefits:

Case management benefits both the employer and the employee.

Benefits for injured employees include:

Financial security

Reinforced positive self image

Positive reinforcement of efforts toward recovery

Promotion of daily contact with co-workers

Reinforcement of the “going to work' habit

Promotion of a sense of wellness, instead of illness

Benefits to the employer include:

Establishment and communication of good will

Active participation in the employees recovery

Enhanced company image

Reduction or elimination of cost associated with temporary and replacement workers

Maintenance of productivity

Reduced claim costs

Reduced workers compensation and health care benefits claims
Key components:

Key components of case management include:
Immediate medical management of injury and illness

Immediate incident reporting

Ongoing communication between all team members

Follow up of all employees on sick leave

Periodic review of injury cases

Timely referral to specialists

Knowledge of health and safety regulations and legislation
Implementation of the program:

Support from management is critical to the implementation of an effective case management program, especially when it comes to identifying possible alternative duties for recovering workers. It is important to have a corporate return to work policy which defines roles, responsibilities and accountabilities in the case management program. The implementation process can be described as follows:

1. Assessment

Find out how widespread disability is within the workplace, and the types of disability that are present. This is the programs target population. Current rates of sickness absence and health care costs also need to be identified before the program is implemented: this information will provide a reference point against which to evaluate the programs success. Make the potential positive impact of the program clear to management.

2. Development

Program planning requires education of the target population, emphasizing the benefits to employer and employees and demonstrating a positive outcome within a definite period of time. Develop a policy statement with program goals and objectives, and a timetable. Identify the resources required and establish a network with other health professionals in the community.

3. Implementation

Implement a trigger system to notify the case manager of injured workers to be included in the program. Link the injured or ill employee to appropriate services as soon as possible. Document the expected outcome, savings and return to work date. Establish a case management committee to assist with return to work.

4. Evaluation

Develop a method for evaluating the success of the program. Do this in the planning stage. When conducting evaluations, collect data on days of sick leave taken, costs associated with absence and worker effectiveness before and after implementation of the program. Assess which outcomes are changed by the implementation of the program.
Study Findings:
Case study:

Program assessment:

A company decided to implement a case management program in order to reduce the incidence of health problems in the workplace. They wanted to improve their management of all aspects of the disability process by coordinating health care services to meet each employees needs in a cost-effective way.

Program development:

The company arranged meetings between occupational nurses at its four worksites to develop a comprehensive case management program. Once the program had been developed, each nurse was to implement it at their site. Before the program was implemented, return to work data from 1997 was reviewed. Data from the year following implementation (1998) was also reviewed. A total of 115 reported disability cases were identified from the 1997 data (50% of workers), with a total of 758 lost days. These results were reported to management, emphasizing the extent of absence and the related costs, and the potential benefits of a case management program. Senior management was informed that their commitment to the program was crucial to its success.

Utilizing multiple treatment approaches at the same time. e.g. combined treatement with psychology, physiotherapy and hydrotherapy
 case management committee was appointed, including an occupational physician, case manager, supervisor or manager, human resources manager, safety coordinator, the employee and his/her family.

Supervisory and management support was important for identifying suitable modified duties to accommodate injured workers on their return to work. When the employee's physician deemed them fit to return to work, they were examined by the company's occupational physician. If the occupational physician agreed that the worker was fit to return to modified work, the case management committee met to discuss appropriate work modifications. Modified duties were given for a maximum of six weeks, with weekly meetings to discuss progression.

At one of the sites, a nurse case manager also developed and implemented a training program for employees, stressing the purpose of the program, and the responsibilities of everyone involved.

Program implementation:

When the program was implemented, all employees were given education and training that focused on the Family Medical Leave Act policy. Each step in the case management process was discussed, and everyone's role in the program identified. Company policy dictated that employees absent from work for more than 3 days entered the case management program automatically. At this point employees were mailed an information pack that told them about the program.

To measure the success of the program objectively, the number of days of absence was recorded and the total associated cost was calculated. Both were expressed as “per employee' values to simplify comparison and evaluation. Scheduled hours were assumed to be constant (2,080 per year).

Program evaluation:

Elements of the program found to be important to its success were:

Early intervention
A treatment or management program. Interventions often combine several approaches. In this field approaches include training in problem solving, adaptation of work duties, graded activity, an exercise and stretching program and pain relief.
 by the nurse case manager at the time of injury or onset of illness

A multidisciplinary approach, with various health professionals and services available to attend to the needs of the injured or ill employee
Before the program began, the amount of time lost from work for each case of illness or injury was 5 – 7 days. The program reduced this figure to 3 – 5 days. This reflects a cost saving of $360 per case, including the cost of paying the injured worker and a replacement worker.
Case management involves early intervention by the case manager at the time of injury and does not end until the employee returns to work successfully. Implementation of a case management program requires the commitment of the institution, and everyone must take responsibility for their own role in the program.

Some injuries prevent employees from returning (initially) to full productivity. In these cases, partial capacity might be sufficient for the person to return to work on modified duties. A well-established case management program can reduce workers compensation costs, avoid the cost of hiring and training replacement workers and increase employee morale. The case study presented in this article describes a case management program that reduced absence by 0.05%, saving the company $108 000 in one year. The company continued using the case management program, evaluating and improving the process annually.
PubMed Abstract

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