WorkCompWire
Full article on: workcompwire.com
Kathy Galia, RN, BSN
Chief Clinical Solutions Officer, Paradigm
When they occur, catastrophic workplace injuries instantly upend the lives of injured patients, families, organizations, and communities—bringing tremendous uncertainty to every person they touch. In response, employers and plan administrators must rapidly create a comprehensive recovery plan, engage specialized providers, and set medical reserves for what are typically extremely volatile and unpredictable diagnoses.
To achieve the best chance of a successful outcome, serious workplace injuries—including traumatic brain injuries (TBIs), spinal cord injuries, and limb loss—require the expertise and experience of a catastrophically trained care manager to reduce the risks of runaway costs, suboptimal outcomes, and diminished patient (and family) experiences.
The results clients and injured workers need for these high-stakes cases rely on several key fundamentals, including dedicated clinical expertise, a record of provable outcomes, a commitment to communication, and financial certainty while being flexible to the needs of each individual case and client. But above all, care management should start with a focus on the outcome, align the interests of key partners in the process, and place people squarely at the center of the care experience. The following explains why each of these elements is so critical to successful catastrophic workplace injury recovery.
Catastrophic injuries require a dedicated team of clinical specialists
Catastrophic and severe workplace injuries come with substantial clinical needs, with dozens of providers, multiple appointments, and specialized home health being the norm. Successfully coordinating care for these cases requires a partner dedicated to clinical excellence and a commitment to working with providers who share the same focus on value-based care and accountability. For example, matching a TBI patient to a Physical Medicine and Rehabilitation (PM&R) specialist with brain injury medicine certification/expertise will ensure the best possible care.
Another key is cross-functional collaboration. Catastrophically injured workers need the support of care coordinators, nurses, behavioral health specialists, and other medical professionals—with the experience and knowledge of cutting-edge clinical research, treatments, and medical innovation—to act as a resource and guide toward a return to maximum function.
Specialized clinical expertise in the context of a team-driven multidisciplinary approach enables catastrophic injury managers to develop evidence-based treatment projections to help ensure optimal outcomes and efficient resource utilization.
Accountability for provable and mutually agreed-upon outcomes
A proficient partner should work to understand their clients’ needs and goals before providing an agreement that is transparent and includes a flexible financial model best suited for their individual needs. For catastrophic injuries, this means clear contractual language that guarantees the outcome. The ability to consistently guarantee outcomes for these exceptionally challenging cases requires an unwavering commitment to client service, clinical excellence, data curation, results measurement, and versatility to address the specific requirements of payers.
A trusted catastrophic injury partner should also back up their promises by objectively demonstrating a long-standing history of excellence through verifiable results and superior outcomes—and clearly articulate the risks so the client can make informed decisions.
Open and detailed information yields strong recoveries
Navigating the workers’ compensation system after a serious workplace injury can be an isolating and fragmented experience, causing dissatisfaction, disengagement, and prolonged recovery. Open and seamless interdisciplinary communication with established protocols between stakeholders is essential for effective patient engagement and a smoother overall experience.
A valuable partner serves as an advocate for the injured worker and collaborates closely with the recovery team, while delivering detailed information to the payer. This includes the client’s ability to speak with any member of the care team directly.
Risk transfer ensures financial certainty
Life-altering injuries bring endless questions—and risks—around estimating costs, setting medical reserves, directing care, and developing recovery goals. These injuries often have a long tail, and stakeholders benefit from an approach that allays financial, administrative, and outcome uncertainties head-on. Transferring risk to a partner with dedicated, established resources increases certainty.
Partnerships that are structured to fully assume medical risk and volatility provide financial certainty and stability to help client teams manage these complex claims. And when transferring risk, a contract should only conclude when there is mutual agreement between the treating provider and payer that the planned outcome has been achieved. This is critical to ensuring interests are aligned among all key partners in the recovery journey.
By starting with a focus on the outcome—and bringing together a team of clinical specialists, open and clear communication, a transparent agreement with a flexible financial model, and a dedication to whole-person care—the results can be life-changing for everyone.
About Kathy Galia, RN, BSN
Kathy Galia is Chief Clinical Solutions Officer for Paradigm. She is responsible for Paradigm’s outcomes-focused clinical solutions, including catastrophic, risk-based products and case management services.
Prior to joining Paradigm, Kathy’s experience included 10 years in strategic leadership and medical case management at The Hartford; serving as a Senior Medical Case Manager at Procura Management, Inc.; and practicing as a registered nurse in various clinical settings.
Kathy received a Bachelor of Science in Nursing from Villanova University. She holds a registered nurse license and a property & casualty underwriter license.
About Paradigm
Paradigm is an accountable specialty care management organization focused on improving the lives of people with complex injuries and diagnoses. The company has been a pioneer in value-based care since 1991 and has an exceptional track record of generating the very best outcomes for patients, payers, and providers. Deep clinical expertise is the foundation for every part of Paradigm’s business: risk-based clinical solutions, case management, specialty networks, home health, shared decision support, and payment integrity programs.
Paradigm is headquartered in Walnut Creek, California, with offices across the U.S. For more information, please visit www.paradigmcorp.com.
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