Delayed recovery for workplace injuries is a growing problem that is costing the workers’ compensation system millions of dollars each year—and seriously disrupting the lives of injured workers and their families. Even in situations where an injured worker has met a majority of restorative outcomes, ongoing complications, comorbidities, and psychosocial barriers can derail recovery and destabilize the claim.

Although these longer-term recoveries are often associated with catastrophic diagnoses, seemingly minor injury claims can also become volatile, resulting in multiple treatments, surgeries, and medications. Across the injury severity spectrum, a relatively small number of cases have become responsible for a substantial escalation of medical resource utilization and lifetime cost exposure. In fact, according to a report released Dec. 5, 2024, by the National Council on Compensation Insurance, expenses associated with catastrophic workplace injuries that cost more than $2 million represent less than 0.1% of workers’ compensation claims, but account for up to 2% of all costs to insurers.¹

While the causes and challenges are significant, it is possible to take control of these cases and ultimately reach successful outcomes. Effective management requires identifying risk factors on a case-by-case basis and engaging with a proactive, team-driven approach. For years, Paradigm Restorative Recovery Plans have delivered clinical management expertise—based on our proven care management model—to get claims on track.

Recognizing the delayed recovery warning signs
Due to the nebulous and cumulative nature of causes, delayed recoveries too often go unnoticed until the claim is out of control. Cases can become unpredictable due to a range of issues stemming from the initial injury, including chronic or recurring wounds, recurrent infections, and chronic pain. Additionally, comorbidities that have become increasingly common in the workforce, including substance abuse, smoking, excessive drinking, opioid use, obesity, and lack of exercise can have compounding negative effects on recovery.

Psychosocial challenges, social determinants of health, and unstable or inadequate care constitute yet another category of recovery barriers associated with highly volatile claims. This can include instability at home, perceived injustice at work, and even geographical location impacting access to quality care.

Effective recovery plans must be able to identify these concerns on a holistic basis and account for disparate factors ranging from home life to work environment. For example, an injured worker with a seemingly routine musculoskeletal injury who is also dealing with economic instability and a mental health diagnosis will be at an elevated risk of delayed recovery and increased costs. According to research, hospitalization costs can be up to 34% higher² for patients admitted for a physical condition if they also have a mental illness diagnosis. When care managers are able to successfully address the broader care picture on an individualized basis, they can better stabilize both the medical and psychosocial care configuration to optimize outcomes.

Expert care management makes the difference
For volatile, unpredictable cases and their underlying contributors, Paradigm Restorative Recovery Plans put recovery on track with expert medical guidance and cost savings. This time-based, risk-bearing solution has been carefully structured to manage existing and emerging medical and behavioral health concerns for complex or chronic claims with delayed recovery.

Restorative Recovery Plans are primarily designed for injured workers who have achieved a majority of the fundamental restorative outcomes, but are still managing complications such as complex daily care needs, behavioral dysfunction, or psychosocial challenges. Case types can include, but are not limited to, complex or catastrophic acquired brain injury, spinal cord injury, multiple trauma, amputation, and burns that are at least six months post-injury. In specific cases with uncertainty around the initial diagnosis, a Restorative Recovery Plan can also help achieve the stability necessary to predict outcomes better and make better informed long-term care decisions.

To stabilize these volatile claims and get recovery back on track, Restorative Recovery Plans follow a proven care management model based on:

• A collaborative, team-driven model: Injury-specific recovery expertise from industry leading clinicians ensures cohesive care coordination. That’s why each case is assigned to a hand-selected Paradigm Management Team that includes an experienced and catastrophically trained nurse case manager, specialized medical and clinical directors, and behavioral health experts to thoroughly assess care needs. The team will work to rapidly create a detailed picture of the current problems, future risks, and overall stability of the case to ensure appropriate and adequate care decisions.
• Comprehensive psychosocial support: Because unchecked behavioral challenges can increase recovery time and costs significantly—as much as 75%, according to research³—at-risk cases require thorough support. Paradigm’s behavioral health experts develop comprehensive integrated plans that support healthy psychosocial adjustment and positive outcomes for any identified risk factors.
• Adaptability to changing needs: Each case benefits from tailored management strategies guided by expert insights, addressing both immediate requirements and long-term objectives using evidence-based functional and behavioral health measures. Upon completion of the initial assessment, the Paradigm Management Team will convene to review and determine the injured worker’s current medical status, as well as any requirements for skilled care, additional medical evaluations, or diagnostic procedures.
• Validated recovery frameworks: For complex and unpredictable cases, structured, outcome-focused recovery models supported by data lead to more successful results. Our proven approach enables the Paradigm Management Team to identify opportunities to optimize the current medical or rehabilitation care plan, while improving functional and psychosocial recovery. Additionally, Restorative Recovery Plans focus on changing medical utilization, reducing medical costs, negotiating rates, and identifying cost savings opportunities through network utilization. Clients can also explore the potential to access services through Paradigm’s curated, value-driven, highly specialized provider network.

As the case progresses, stakeholders will be able to see results and improvement through a monthly report summarizing the injured worker’s status, key management interventions, and action items planned for the next reporting period.

Taking control for successful outcomes
For unpredictable, volatile injuries facing significant recovery barriers, an individualized, expert-guided management plan is critical to significantly reducing risk and long-term medical cost exposure. Paradigm’s Restorative Recovery Plans have a dedicated focus on achieving key management objectives, while providing risk protection, cost stabilization, reduced medical resource utilization, and decreased lifetime cost exposure. Whether for complex, catastrophic, or even routine injuries with delayed recovery, predictability is the key to getting recovery back on track.

Paradigm has the expertise and experience to manage uncertainty for the widest range of injuries. Refer a case today and we will work with you to identify the best solutions for your needs.

Sources:

1. Countrywide Mega Claims Accident Years 2001-2021
2. European Journal of Public Health, Volume 29, Issue Supplement_4, November 2019
3. American Hospital Association (AHA) Market Insights Behavioral Health Integration, 2019