Telehealth: Early Intervention and RTW Case Management

The employer featured in this case study is a publicly traded U.S. healthcare company employing more than 26,000 people during the longitudinal study period of 2012-2018. The workforce is comprised predominantly of clinicians and professional staff distributed across the country.

This case study describes an innovative early intervention model that was applied in a WC plan. It includes a preclaim 24/7 telehealth model that leverages immediate telephonic access to occupational health nurses and physicians. Employees who call have the option to receive guided first aid/self-care and stay at work, as clinically appropriate. They can also request referral to a clinic, where a treatment and return-to-work (RTW) plan is developed.

The model is designed for effective transfer from each level of care, beginning with pre-claim. It includes referrals to onsite ergonomic resources and a dedicated nurse case manager (NCM) who facilitates optimal stay-at-work and RTW outcomes after a WC claim is filed. claim and possible recordable case for the Occupational Safety and Health Administration. Treatment Delays: Lack of understanding of possible severity by nonmedical staff resulted in prolonged employee work absence and potential for disability.

The guided first aid/self-care option is particularly relevant to this population: In 2017, healthcare and social assistance employees in private industry had the highest number of injuries/illnesses, accounting for approximately one in five cases reported by all private employers that year. Employees who are trained healthcare professionals, or other staff who have the additional support of onsite caregivers, may be more comfortable using guided first aid/self-care, compared to the general population.

Overcoming Challenges

The model was designed to address several challenges identified by the company’s human resources (HR), risk management, and safety professionals:

• The process of reporting injuries was administratively cumbersome for employees and supervisors, causing significant delays in appropriate evaluation and care.
• Employees were required to navigate a complex healthcare system with frequent delays in care, resulting in a high percentage of litigated cases.
• Initial injury severity assessments were made by supervisors, safety, or HR staff, with detrimental effects (described below) at both ends of the spectrum.

Overmedicalization of minor injuries: Employees with first-aid-level complaints were obtaining medical treatment, in turn triggering a WC claim and possible recordable case for the Occupational Safety and Health Administration.

Treatment Delays: Lack of understanding of possible severity by nonmedical staff resulted in prolonged employee work absence and potential for disability.

How the Program Works

1. For work-related injuries, employees are directed to call a 24/7 occupational health contact center for immediate access to nurses and physicians.
2. A nurse evaluates the condition and provides care recommendations. If needed, an occupational physician joins the call to consult with the employee.
3. If the condition is relatively minor and the employee agrees to manage it with self-care, the telehealth clinician provides detailed self-care instructions, including a follow-up call the next day to ensure the condition has not unexpectedly worsened.
4. When a provider referral is clinically warranted and/or the employee requests it, the telehealth nurse arranges the clinic appointment, gets approvals, and sends paperwork to the clinic in advance of the visit to improve the employee’s experience.
5. When there is a clinic visit, the occupational physician assigned to the case calls the treating provider for a peer discussion on the employee’s status and recovery plan, including safe work-return options. (In 2018, the physicians in this study were able to complete a peer discussion 97% of the time, a remarkable success rate that illustrates how well providers appreciate the model.
6. The contact center team fulfills reporting requirements and triggers referrals to ergonomic resources and/or the NCM.
7. If continued treatment or work restrictions are required, the NCM monitors all aspects of the case through return to work and ensures timely coordination of medical treatment.

Success Factors

Program success depends on a number of factors. For example, the telehealth team is trained to respond in a compassionate, caring manner. Another key contributor is application of basic principles of the SPICE model by the telehealth provider.

The SPICE model traces its origins to military applications and the medical management of soldiers experiencing post-traumatic stress disorders after World War I. It emphasizes:

• Simplicity: Providing a medical explanation and care instructions that are easy to understand
• Proximity: Keeping employees engaged in the workplace
• Immediacy: Responding immediately to work-related medical concerns
• 24 hours a day and optimally within the “golden hour” following injury or illness onset for best results
• Centrality: Collaborating on terminology, processes, procedures, and goals to reach agreement among all stakeholders
• Expectancy: Reassuring and educating employees to help establish realistic expectations for recovery and an appreciation for the therapeutic value of working.

The SPICE model has repeatedly been shown to effectively address common confounders in the workers’ compensation system such as: • Injuries that should have quickly resolved instead drag on for months or even years.

• Long-term cases concluded with large settlements
• Two employees with the same injury and same biology with dramatically different cost outcomes depending on how they were initially treated
• Psychosocial factors significantly influencing claims costs because adjusters and employers who do not change or enhance their process to address them

The SPICE model emphasizes return to health and function. It is easily integrated into a total worker health management strategy that encourages employees to take control of their own health and well-being with support from their employer. Employees who are educated about their condition are able to make an informed decision about their own care.

In some cases, particularly those involving nonspecific pain complaints and musculoskeletal disorders, the report from intake goes to the safety program for timely ergonomic interventions to help alleviate symptoms. If the employee is referred to a clinic or has work restrictions, the NCM follows up to ensure a smooth transition back to work, including timely and appropriate care. The onsite NCM has established rapport with company supervisors involved in job placement and accommodation of work restrictions.

The company’s risk manager noted: “The onsite NCM catches things that used to sit out there, like a referral to physical therapy or diagnostic imaging. She gets treatment scheduled and approved much quicker than going through our adjustor, which employees really value.”

The risk manager also closely monitored late reporting of workplace injuries in response to frequent alerts, investigations, and follow-up, providing an internal champion for program success.

Better Outcomes

Company leadership reported a 30% reduction in litigation within two years of implementing the early intervention and NCM delivery model. Overall WC claim costs decreased approximately 20% to 30%; the “long tail” of WC claims makes it difficult to report precise savings figures.

Additional outcomes were validated by an independent actuarial analysis using data from 2012-2017. The analysis was performed in August 2018 using fully mature claims data ending in 2017.

The findings included:

• 24% increase in claims reported within four days
• 8% increase in percent of claims closed within six months
• 10% reduction in average severity for claims
• 4.1% reduction in lost-time claim frequency

The actuarial analysis also showed a positive correlation between reporting lag time and attorney involvement. Summary In addition to substantial cost savings and improved WC claim metrics, the company reports that the program has improved business results and enhanced employee satisfaction with the process. In sum, the company’s Senior Director of Risk stated, “We have done three things that are very important:

1. “Doing the right thing for our employees by providing immediate clinical access through the telehealth contact center.
2. “Providing administrative ease: Our onsite team simply picks up a phone, resulting in timely reports to our claims administrator.
3. “We save a lot of money.”

Related Findings

Research corroborates benefits reported by the company in this case study.

Here are three examples:

• Each additional day between date of injury and report resulted in a $50.47 increase for medical-only claims and a $98.25 increase in indemnity claims.1
• Lost-time claims reported after two weeks are more likely to involve claimant attorneys, include lump-sum amounts, and stay open after 18 months.2
• Physicians who use time-of-need conversations to share expert knowledge and refer to best medical evidence produce a joint product “guided by similar sets of assumptions about how medicine is done in a particular community.”3

References

1. Integrated Benefits Institute. IBI Benchmarking Analytics: Costs of Delays in Reporting Workplace Injuries and Processing Worker’s Compensation Claims. April 2019.

2. National Council on Compensation Insurance. The Relationship Between Accident Report Lag and Claim Cost in Workers’ Compensation Insurance. NCCI Research Brief. January 2015. Retrieved from https:// www.ncci.com/Articles/Documents/II_IR2015-SHEPPARD.pdf.

3. Perley C. Physician Use of the Curbside Consultation to Address Information Needs: Report on Collective Case Study. Journal of the Medical Library Association. 94(2): 137–144. 2006.

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