Tag Archives: psychocosial

The Buzz Is Getting Louder

 

“We know the single greatest roadblock to timely work injury recovery and controlling claim costs. And it’s not overpriced care, or doubtful medical provider quality, or even litigation. It is the negative impact of personal expectations, behaviors, and predicaments that can come with the injured worker or can grow out of work injury.

This suite of roadblocks is classified as “psychosocial” issues – issues which claims leaders now rank as the number one barrier to successful claim outcomes according to the Workers’ Compensation Benchmarking Study’s 2016 survey – and they drive up claim costs far more than catastrophic injuries, mostly due to delayed recovery.”

That’s the beginning of a new White Paper authored by friend and colleague Peter Rousmaniere and Rising Medical Solution’s Rachel Fikes. The Paper, How to Overcome Psychosocial Roadblocks: Claims Advocacy’s Biggest Opportunity, reports on Rising’s 2016 Benchmarking Survey and describes how the workers’ compensation claims management community is ever so slowly coming to realize the leading cause of delayed recovery for America’s injured workers is psychosocial in nature and that efforts to deal with this have, up to now, been woefully inadequate.

Rousmaniere and Fikes point to enlightened employers and insurers who are leading their companies to a greater acceptance of the need for competent, professional intervention to help injured workers overcome mental and emotional barriers delaying their return to employment.

They cite the work of Denise Algire, Director of Risk Initiatives and National Medical Director for Albertson Companies, a grocery chain with more than 250,000 employees. They also report on efforts by The Hartford, Nationwide Insurance and CNA.

All of the progressive actions undertaken by these organizations have one thing in common: the development of an empathic interview methodology devoted to understanding the “whole person” to discover which claims will need more intensive and specialized intervention.

At The Hartford, Medical Director Marco Iglesias reports 10% of claims fall into this bucket, but they consume 60% of total incurred costs. He says adjusters now ask each injured worker an important question: “When do you expect to return to work?” The Hartford’s analytics indicate any answer longer than ten days is a red flag for the future.

Nationwide Insurance, under the direction of Trecia Sigle, VP of Workers’ Compensation Claims, is building a specialized team to address psychosocial roadblocks. Nationwide’s intake process will consist of a combination of manual scoring and predictive modeling, and then adjusters will refer red-flagged workers to specialists with the “right skill set.”

Pamela Highsmith-Johnson, national director of case management at CNA, says the insurer introduced a “Trusted Advisor” training program for all employees who come into contact with injured workers. CNA’s Knowledge and Learning Group helped develop the training with internal claims and nurse staff.

This White Paper adds to the now undeniable research indicating the psychosocial problem is the biggest one facing the workers’ compensation claims community. The leading experts agree that empathy, soft talk and the advocacy-based claims model is the method of choice for helping injured workers whose claims carry a psychosocial dimension. The experts cited in the White Paper all agree that adjusters will require extensive and repetitive training to learn the new techniques.

However, all of this is a heavy lift for an adjuster community overburdened and overwhelmed with work, a group for which the average lost time claim load is often north of 150. Even with better training, they can’t do it alone. To really turn the psychosocial tide will require a well-rounded team of claims adjusters, nurses, case managers and external, well-trained clinicians working together with transparent, technologically advanced communication.

The missing links thus far are those well-trained clinicians and the advanced communication. And that is why Work Comp Psych Net exists.

We have to say, boast really, that it’s nice to get the solid validation found in this compelling White Paper. Writing today from Berlin, where he’s vacationing, Peter Rousmaniere said, “The article was timely and definitively supports your program.”

So, yes, the buzz is getting louder.

 

Reader Reactions To Last Week’s Psychosocial Issues Series

We received a number of reader comments to our psychosocial claim issues series of last week. Our series highlighted the difficulty in dealing with these sometimes intractable claims where recovery is delayed and costs exacerbated.  In Part One, we listed the litany of challenges facing claim managers; in Part Two we described how we had built Work Comp Psych Net  in New Jersey to overcome those challenges.

A few readers pointed out that we paid scant attention to the “social” in psychosocial. These adjusters and nurses wrote that too often they’d seen and handled claims where life and “societal issues,” the social, seemed to get in the way of recovery.

Sue Separa, who has overseen workers’ compensation claims for more than 30 years in 40 states and jurisdictions, put it this way:

Employee loses car, loses license, loses driving privileges and can’t get to work, but still needs a source of income;

Employee is having daycare issues and needs to be home, but also needs a source of income;

Employee has a sick relative or child they need to stay with/watch, but still needs a source of income;

Employee is attending school to better themselves, has a heavy school schedule, but still needs a source of income;

Employee has a comorbid or health situation that requires medical care and possibly surgery or absence from work, and has not secured short term disability, or it is not available with the employer; 

Employee has asked for vacation time and it is denied due to no time left, or not eligible, or because someone else is off work at the same time.

And she’s right. Of course these real life situations occur. However, they’re present and happen all the time without injuries, too. They are non-physical, “social” comorbidities; things that can easily impede and delay return to work. Unless, that is, claim adjusters are trained and experienced enough, as Ms. Separa is, to dig a little deeper, find them and address them appropriately.

We also heard from our friend Robert Aurbach who wrote from Down Under to say, while he “applauds” our efforts and thinks “they are valuable,” he suggests “perhaps they don’t go far enough.” Rob believes the “problem is partly the system itself;” we create the harm our series cited. As that great American philosopher, Pogo, opined on Earth Day, 1971, “We have met the enemy and he is us.” The system is iatrogenic (system caused).

Rob Aurbach also sent a paper he authored in late 2015 for the Injury Schemes Seminar, put on bi-annually by the Australian Actuaries Institute. In the Paper (opens in pdf), titled “Better Recovery Through Neuroscience: Addressing Legislative and Regulatory Design, Injury Management and Resilience,” (bit of a mouthful that, but it won the Taylor Fry Award for the Seminar’s best paper) Rob explores Neuroplasticity, a theory dating from the 1800s and recently confirmed by functional Magnetic Resonance Imaging. Neuroplasticity is the process by which our brains continually rewire themselves throughout life due to environment, behavior, thinking and emotions. In short, it’s true; our brains are malleable. Rob writes that when work is disrupted through injury (or, through anything, really) for a long enough period, Neuroplasticity begins rewiring the brain to adapt to the new situation – being out of work. In other words, our brain creates a new “facilitated neural network.” This can happen in as little as 12 weeks, as Rob points out:

Timing is everything. There is a substantial research literature demonstrating that if a worker does not return to work within 12 -16 weeks, the probability of eventual return is reduced to 50% or less.

Rob Aurbach’s paper is a valuable contribution to understanding how easily a claim can deteriorate to the point where an injured person’s life is forever changed, and not for the better. We urge you to read it. It’s well-researched, well-written and profoundly thoughtful. It comes in at twenty-seven pages, the last seven of which are endnotes and references. We found the first half of the text compelling and enlightening. His common sense recommendations that follow are pretty simple, but wickedly difficult to implement: Claim managers and adjusters should intervene early, demonstrate respect for the injured worker, promote early return to work, align incentives that encourage recovery, restrain negativity, listen attentively to the worker’s story, etc. In short, all the things managers, nurses and adjusters like Sue Separa know they should be doing, anyway. Trouble is, for these often overworked professionals, each managing a steamer trunkful of claims, there isn’t a lot of time to devote to Rob’s prescription. The iatrogenic system isn’t built to allow it.

And that’s where behavioral health clinicians and therapists, for the most part underused and undertrained, ought to be helping far more than they are now. Part Two of last week’s series catalogued how, recognizing the difficulties, we built Work Comp Psych Net and trained our clinicians to help anyone confronted with these demanding and formidable claims get to the right outcome sooner, faster and smarter. Injured workers, as well as the professionals charged with helping them, deserve no less.

Workers’ Compensation’s Costly Psychosocial Issues (2)

Yesterday, we described the challenges confronting claims adjusters and injured workers when psychosocial issues are present in a workers’ compensation claim. These issues impede recovery and exacerbate costs. Whistling a happy tune, we  picked up our saw and confidently walked out on the proverbial limb to suggest this thesis:

Our nation’s current system for treating injured workers with mental health issues is uncoordinated, overly fragmented, highly wasteful and does not focus enough on speedy return to work. There is a critical need for a more systemic approach as well as an integrated coterie of clinicians and practitioners, trained in workers’ compensation, whose goals are to provide compassionate treatment with a steady return to work trajectory. 

Taking a large gulp after writing this, we listed the serious factors that make finding a solution to this looming crisis tremendously difficult.

But early in 2015 in New Jersey two Neuropsychologists, Mary Ann Kezmarsky and Richard Filippone, had an idea. Over a couple of decades, they’d treated a number of workers’ compensation claimants and had been appalled by what appeared to be the lack of a coherent system to deal with the issues they saw in their patients. They weren’t exactly sure what to do about it – they didn’t know much about workers’ compensation – but they saw it as a business opportunity. Well, they are “we,” and here’s what we did with that idea.

We contacted Tom Lynch, of Lynch Ryan, a nationally recognized consultancy in workers’ compensation, and over the next year and a half created a company, Work Comp Psych Net (WCPN), and built a systemically organized and integrated specialty network of workers’ compensation clinicians and therapists to treat injured workers in New Jersey who might have behavioral health issues delaying recovery. With Tom’s help, here’s how we did it:

  1. During the the last half of 2015, we recruited, credentialled and vetted 44 mental health professionals covering 55 offices throughout New Jersey’s 21 counties. Providers within WCPN’s network include psychologists and neuropsychologists, as well as cognitive rehabilitation and biofeedback specialists. All of the clinicians and therapists gave up a weekend to attend Lynch Ryan training in workers’ compensation. They learned about the New Jersey law, as well as the way workers’ compensation works – how a premium is constructed and  what indemnity and medical benefits are. They now understand experience modification, maximum medical improvement and the law regarding injuries “arising out of and in the course of employment.” Further, they have been educated regarding early return to work and have agreed to work with employers, adjusters and nurses to effectuate modified duty wherever possible.
  2. We built (with difficulty, because it wasn’t easy) the nation’s first electronic Claimant Intake & Referral Portal that allows claims adjusters, nurse case managers and attorneys to refer a claimant instantly. The paperless portal’s referral system is geographically and specialty based, meaning that referrers are assured that claimants will not have to travel far to reach their assigned clinician. In the past, referrals and appointments took weeks, even months, to arrange, but now they can be finalized within minutes. In Beta Testing from May through October, 2016, the longest time from referral to Provider scheduled appointment was 27 minutes.
  3. We built (with even more difficulty) the nation’s first mental health Electronic Health Record system for workers’ compensation. The EHR is set up as a roadmap for all WCPN clinicians to follow, meaning reports have a consistently structured form. The EHR is paperless, HIPPA-compliant and cloud-based. Initial Psychological Evaluations and subsequent treatment reports reach claims adjusters in pdf form within five business days.
  4. Our clinicians are all highly qualified and experienced; they know how to treat workers with mental health issues delaying recovery. But to make the system work we needed to understand the needs of adjusters and defense attorneys who would be referring the injured workers the clinicians would treat. Consequently, we conferred with experienced adjusters and defense attorneys. After doing so we decided that every referral would begin with a thorough Initial Psychological Evaluation (IPE), which, although not technically an IME, would be done at the IME level (we priced the IPE at $450, and, since nobody’s complained, we now think that’s too low, but we’re sticking with it). If the Initial Psychological Evaluation determines the presence of one or more mental health issues which are deemed to be work-related and requiring treatment, the treatment prescribed is initially authorized for up to 12 sessions unless medically justified, extraordinary circumstances are present. Additional treatment requires the approval of the referring party.

We officially launched in November, 2016. Over the intervening three months  we’ve learned two things (among a lot of others): First, our solution works extremely well; referrers have been highly receptive and pleased. They appreciate the ease of referral, the EHR reports and the fact that claimants do not have to travel far to see a qualified clinician. Even more, they appreciate that our clinicians and therapists have been trained in workers’ compensation.  Second, this could be a national solution.

So, our solution is working in New Jersey, but every state workers’ compensation system is grappling with how to deal with psychosocial issues that frequently hobble recovery. This may be work comp’s final frontier. Time will tell whether our template and software could help others. Regardless, we will continue to improve our solution at Work Comp Psych Net, as well as report on our outcomes.

It’s taken us nearly two years to get to this point, but, for the sake of the many injured workers suffering psychosocial comorbidities, as well as the claims adjusters who work tirelessly to help them, we think it’s been worth it.

Psychosocial Issues And How To Deal With Them

Workers’ compensation claims adjusters are busier than the Ed Sullivan Plate Spinner. Running around with one or two hundred lost time claims would make anyone dizzy, but at the recent National Workers’ Compensation & Disability Conference (NWCDC) in New Orleans, presenters tossed the frazzled spinners a few more plates to shoot up on the sticks.

The issue? Psychosocial factors delaying claim resolution.

At one well-attended session, Marco Iglesias, Medical Director for The Hartford, and Robert Hall, Corporate Medical Director for Optum went into great detail about how psychosocial factors rear their heads in the claim process and how they impede recovery.

For example, consider these research statistics based on a study of 75,000 claims:

Time out of work increases 30% for a musculoskeletal claim with one co-morbid complication;

Duration increases 57% if the claim co-morbidity is depression;

According to The Hartford’s Dr. Iglesias, 10% of claims, the ones with all those psychosocial issues, cause 60% of claim costs;

At another presentation, attendees learned that Mental Health, Addiction and Obesity are the three comorbidities causing the greatest cost and time away from work.

Also, according to an AETNA presentation, 97% of depressed patients have a second co-morbid condition.

Research aplenty; solutions, not so many.

The pitch at the conference seemed to be two-phased. First, here are a number of factors, which, if present, can significantly delay recovery (see our Predictive Triggers post for more on this). Second, if you’re an adjuster or nurse case manager and you recognize any of these factors in one of your claims, put on your sensitive side psychology hat and provide gentle guidance and counsel to help the injured worker overcome the problems delaying recovery.

At the breaks after the sessions adjusters were talking in small groups about how this was all well and good, but it required increased time on claim, time they didn’t have. Also, many of them admitted that their claim resolution approach, honed over many years, veered more to the cut and dried than the touchy feely.

So, what should overworked adjusters and nurse case managers do with this  fast-approaching, ever-enlarging, dead-ahead iceberg?

Well, there are three critical things to know when one suspects the presence of psychosocial triggers:

First, are they real?

Second, are they work-related?

Third, are they truly impeding recovery?

The only way to know with credibility the answers to those three questions is to have a qualified clinician conduct a thorough Initial Psychological Evaluation.

So, with all due respect to the excellent doctors who presented at the NWCDC, we suggest logging in to our claimant Intake & Referral Portal and referring these difficult claims with their thorny issues for a highly-reliable, speedy and comprehensive Initial Psychological Evaluation. The cost is only $450, and you’ll be glad you did it.

That’s all part of our pledge to you: Recovery – Sooner, Faster, Smarter!

 

Psychosocial Barriers in Returning to Work Following an Injury

If you want to know whether your employees expect to return to work following an injury, try asking them! In a recent study, 530 injured employees rated their outlook in terms of anticipated recovery and ability to return to work. Of the 162 respondents who predicted that their injury would prevent them from returning to work, 96% never went back to the workplace. Their negative expectations became reality!

Because expectations and beliefs greatly affect an injured employee’s motivation to return to work, even the best return-to-work program can’t guarantee that injured employees will return to the workplace. Some of the factors that may negatively influence an employee’s outlook include inadequate understanding of the medical condition, unrealistic expectations about recovery, and fear that returning to work may create further injury.

There are also various psychological and social factors that can affect how an injured employee feels about returning to work, including:

  • Level of overall job satisfaction
  • Support at home and/or at work
  • Relationships with supervisor and colleagues
  • Beliefs about the cause of injury or pain

How can employers proactively tackle these concerns before an injury occurs?

  1. Build and maintain positive relationships with employees.  Open communication fosters positive relationships and leads to higher levels of workplace satisfaction. Encourage your employees to share their ideas and concerns with you to demonstrate that you are interested in their well-being and value their contributions.
  2. Flexibility can help motivate employees. Understand what motivates your employees and be prepared to create new options. Some employees seek new challenges while others may want more flexibility in terms of work hours or job tasks. In general, employee motivation may be greatly influenced by your willingness to share planning decisions and adjust work environments or job tasks. Employees who enjoy their jobs are typically loyal to their employers and more eager to return to their workplace after an injury. These principles also apply when establishing a transitional work assignment for an injured employee.
  3. Explain your company’s return-to-work policy. Make sure that all employees understand your company’s motivation and commitment to helping injured employees return to work safely after an injury. You will boost company morale by actively engaging your employees to assist and encourage their recovering co-workers.

Although severe injuries can prevent an employee from ever returning to work, the good news is that an employer can directly and positively impact an injured worker’s recovery outlook and outcomes.

Although the path back to work can sometimes seem like a minefield for both employers and injured workers, the highly trained clinicians and therapists at Work Comp Psych Net are here to assist claims adjusters, employers and injured workers every step of the way.

Recovery: Sooner, Faster, Smarter