Getting Delayed Recovery Claims Back on Track

WorkCompWire
Full article on: workcompwire.com

Deborah M. Benson, Ph.D., ABPP
Vice President, Clinical Solutions, Paradigm

Delayed recovery for both catastrophic and minor workplace injury cases has become an increasingly serious challenge for the workers’ compensation system. Complications and volatility, including mobility limitations, recurrent infections, and chronic pain, can hinder outcomes and increase lifetime medical costs for nearly any work-related injury or diagnosis. Although they only represent a small portion of claims, these cases have an exponential impact on medical and indemnity costs.

For employers, third party administrators, and insurance carriers, longer-term recoveries go hand in hand with higher resource utilization related to multiple treatments, surgeries, and medications. Claims become even more unpredictable in the face of psychosocial challenges, inaccessible or suboptimal care, and patient noncompliance—which creates additional barriers to successful and timely recovery.

Despite the significant resources and lifetime cost exposure associated with delayed recovery, practical solutions do exist. Stakeholders can successfully manage these challenging claims and achieve positive outcomes by identifying risk factors early and taking a proactive, team-driven approach.

For at-risk cases, early identification is key
Because these cases often go unnoticed until they are out of control, catching them early is critical. The medical field recognizes a wide range of comorbidities strongly correlated with the development of complications that interfere with healing and rehabilitation. The sooner in the care process that higher-risk patients receive attention and support, the better the chances for a timely return to healthy, productive activity.

For example, factors such as substance misuse, smoking, excessive drinking, obesity, poorly controlled medical conditions (e.g., pain, diabetes), and a sedentary lifestyle can all negatively impact the healing process for workplace injuries. Social determinants of health—such as education, social support, feelings of perceived injustice, transportation availability, economic status, and geographic location—can also impact access to or compliance with care and recovery timelines.

No two cases are the same, but the presence of medical and psychosocial comorbidities are common indicators of complications and the accompanying increase in treatment needs and costs. Unaddressed psychosocial and mental health challenges in particular frequently intensify or prolong treatment and interfere with participation in care management. According to one recent study, hospitalization costs are 34% higher for patients who are admitted for a physical condition if they also have a mental health diagnosis.¹

Along with spotting risk factors and comorbidities, care managers need to be able to see the early warning signs and triggers for delayed recovery. These can include suboptimal compliance, pain preoccupation, recurrent infections and wounds, delayed functional improvement, seeking multiple providers or emergency room visits, and deteriorating psychological health or family support. No matter where the injured worker is in the recovery timeline once identified, these cases require proactive, team-driven support.

Practical solutions for volatile claims
While delayed recovery cases can become volatile and lead to unpredictable outcomes and excessive costs, timely and appropriate action can get recovery back on track. Keys to recovery include:

• A specialized, team-driven approach: Dedicated care coordination backed by experienced clinicians with injury-specific complex recovery expertise helps injured workers navigate an often-fragmented system, while detailed communication and regular status reports keep employers and plan administrators informed.
• Fully integrated psychosocial support: Unaddressed behavioral challenges extend recovery and costs as much as 75% higher,² so at-risk cases need robust support, including a care plan promoting positive psychosocial adjustment.
• Flexibility to meet unique and shifting needs: These cases benefit from personalized, expert-guided management plans that establish immediate needs and longer-term goals, backed by evidence-based functional and behavioral health metrics.
• Proven recovery models: Too many injured workers are bounced from provider to provider without outcome-driven, data-backed guidance. The more volatile and unpredictable the case, the more often a proven, structured model results in a successful outcome.

Complex recovery in action
In a powerful example of the effectiveness of dedicated care management for delayed recovery, one injured worker with multiple complications experienced a dramatic turnaround through personalized support. Initially diagnosed with a minor knee injury, the injured patient developed subsequent complications, including severe back pain, recurrent fevers, hypertension, and infections resulting in multiple emergency room visits, hospitalizations, and spine surgeries. At this point, the claims professional sought an expert-guided management plan to stabilize the medical and behavioral health care configuration and get recovery back on track.

On the recommendation of a comprehensive clinical assessment and team-driven care plan, the injured worker was admitted to an acute rehabilitation facility for medical stabilization and training—to promote independence—followed by a course of home-based support to ensure adherence to the newly established treatment protocols. Following these critical interventions, there were no reported ER visits, hospital readmissions, or any significant recovery complications. With treatment back on track, the injured worker has begun re-engaging in community activities and exploring vocational options, and is anticipated to be released to return to work by the treating physician within the next several months.

For complex claims with delayed recovery, utilizing a personalized, expert-guided management plan—that adjusts for the specific medical and psychosocial needs of the injured worker—can mitigate risk and help to reduce long-term medical costs.

About Deborah M. Benson, PhD, ABPP
As Vice President of Clinical Solutions at Paradigm, Dr. Deborah Benson leads the Directors of Clinical Services team to develop and oversee clinical management plans that ensure positive outcomes for patients with complex/catastrophic brain, spinal cord, burn, and multiple trauma injuries.

Before joining Paradigm in 2008, Deborah served as Director of post-acute neuro-rehabilitation services within the Northwell Health System for 15 years. Over the course of her rehabilitation career, she has evaluated and treated neurologically impaired patients and families, conducted basic and clinical research in neuroscience, taught undergraduate and graduate psychology courses, and served as Clinical Supervisor for graduate neuropsychology students.

A New York and Florida state-licensed psychologist with a PhD in clinical neuropsychology from the City University of New York and board certification in rehabilitation psychology from the American Board of Professional Psychology, Deborah has served on the board of the Brain Injury Association of New York State (BIANYS), the New York State TBI Coordinating Council, and the advisory board of the Coma Recovery Association. She has been awarded the Ted Weiss Consumer Advocacy, Champion of Hope and Founders Awards from BIANYS and was inducted into the Long Island Volunteer Center Hall of Fame for founding Common Ground Alliance, an organization promoting long-term support and wellness for brain injury survivors and families. She has co-authored multiple scholarly articles and books and has presented at numerous brain injury conferences.

Sources:
¹ European Journal of Public Health, Volume 29, Issue Supplement_4, November 2019
² American Hospital Association (AHA) Market Insights Behavioral Health Integration, 2019