Although catastrophic injuries represent a small percentage of all workers’ compensation claims, for these injured workers, recovery requires collaborative care.
A catastrophic injury can happen in any workplace. Just imagine an employee slipping on a wet floor or tripping over a rope and hitting their head or breaking their hip, and it’s easy to see why all businesses need to be prepared for worst-case injury scenarios.
Although catastrophic injuries represent only a small percentage of overall claims, they require the attention of employers, medical professionals, insurers, case managers, workers’ compensation representatives and others to ensure that the case of an injured employee is handled with care and compassion.
These cases must also be handled properly on behalf of employers who could suffer financially if they are not.
So what are the best practices for doing good by both employee and employer?
First, experts say it’s important to understand what a catastrophic injury is: “Catastrophic injuries are most commonly defined as those that are life altering, often affecting a person’s ability, or in the long term, to carry out the activities of daily living. like in the past,” said Ray DiCello, senior vice president and chief claims officer for PMA Companies.
“These injuries can be purely physical injuries or cognitive injuries often resulting from head trauma. They can not only impact the injured worker, but often their immediate family members as well, as the family struggles to find a new normal.
Robert Biltz, vice president of claims at AmTrust Financial, added that catastrophic injuries also carry the risk of hospitalization, rehabilitation and/or complicated and extensive recovery. Typical catastrophic injuries include severe brain damage, spinal cord injury, injuries resulting from violent crimes, crush injuries, amputations, internal injuries, and serious eye injuries.
Get the best results for catastrophic claims
Although a catastrophic injury can be devastating on many levels, it does not necessarily prevent a worker from eventually returning to work.
“A lot of injured workers who experience a catastrophic injury end up having some ability to return to work,” Biltz said. “They may not be able to return to the same type of job or the same employer, but we are working with them to get them back into the workforce whenever possible. We also see injured workers who have recovered fantastically and are able to return to full duty or pursue any job of their choosing.
Robert Hall, corporate medical director of the diversified health services company, Optum Workers’ Comp and Auto No-fault, said there are a few steps to take to provide top-quality patient care and minimize costs for the employer.
The first, similar to the oath doctors take to do no harm, is to focus on preventing a patient’s health from deteriorating, which will certainly increase costs.
“When we’re taking care of anything, from a sprained ankle to a spinal cord injury, the first thing we do is prevent complications and hospital readmissions and all those things,” Hall said. “And after that, we work to improve a person’s function which will help them regain their quality of life. This will help reduce their dependence on home health and help reduce the cost of home health care.
Of course, the scene of an accident or traumatic injury can be chaotic. It is crucial to get a person the emergency care they need as quickly as possible.
“Medically, it is necessary to get the patient to safety and to a place where their condition can be treated immediately and save their life, if their life is in danger,” Hall said.
Communication is key
Once this happens, communication between all parties involved in providing care or monitoring the patient’s progress, especially as they transition through levels of care, is paramount.
“It’s always about communication, from the very first day through recovery,” Hall said. “That means communication between any stakeholder involved in the case, whether that be their medical team, their nurse case manager, their payer’s claims professionals, their benefits managers such as their pharmacy or their attendant service providers, and members of their family or caregivers. ”
A patient starting in the ER may then be moved to a medical floor, and the ER physician and attending physician must communicate about the patient’s injuries, medications needed, and other special circumstances.
The same high level of coordination and communication is needed when a patient goes to rehab or home.
“For example, if they were to transfer this patient with an inaccurate list of medications and the doses of medications he needs, it could put that patient at risk of receiving a medication that he is allergic to or receiving a higher dose than the one he needs,” Hall said.
Whether called roundtables, conferences or team meetings, Hall said the best way to communicate is to bring everyone involved in a patient’s care together.
“Everyone is talking about the same patient,” he said. “That way, if there’s a question, misunderstanding, or lack of knowledge about the patient’s treatment plan, the issue is resolved there.”
DiCello agreed that a multidisciplinary approach is needed: “Having an integrated process across all disciplines means we’re teaming up to get the best results,” DiCello said. “We focus on what is medically the best option for the injured employee and what will produce the best overall results. To help drive positive results, we have a shared responsibility with all partners and our colleagues in care and claims management work together to deliver the highest level of service and results.
Biltz said his company moved quickly to meet a patient’s needs.
“We have escalation criteria that notify our team of major casualties from a new injury as soon as it is reported,” he said. “The team then immediately arranges a roundtable with anyone we deem necessary.”
This team may include AmTrust’s Managed Care Team, Claims Team, Subrogation Team, Legal Team, Special Investigations Unit, and Loss Control Team.
The roundtable discusses:
- What happened?
- What is our strategy?
- Who should be there?
- How do we get in touch with who we need?
- How can the injured employee’s needs be best met?
- What investigation is needed?
- Where do they get medical attention and is it the right place for the type of injury?
Biltz said they are also trying to get to the scene to meet with the insured, family and injured worker.
“It gives them the opportunity to educate them on how the system works, explain its benefits and answer any questions,” he said. “We want to build a relationship of trust and assure them that we want to do everything we can to help the injured worker recover.”
A multidisciplinary approach
Continuous monitoring of a patient’s progress can provide an alert when care is being overdone.
“There are certain usage patterns that you see that are outside the norm and those are a trigger to take a closer look at what an individual’s needs are,” Hall said. “If someone is getting 24-hour home health care, we’ll take a closer look at what this injury is and ask ‘What is the medical basis for this?’ ”
Hall said his company will review the claim, the injured person’s diagnosis, the care provider’s notes and whether the level of care matches the type of injury and the patient’s current level of functioning.
“Usually it’s very clear if the level of care they’re getting is excessive,” Hall said. “If so, we work with the [team] to better understand why they think the level is appropriate – just to make sure we haven’t misunderstood or overlooked anything.
It is also important not to neglect a patient’s mental health.
“Often, when there are so many [different] levels of complexity and different types of injuries, it’s almost as if there could be an excessive focus on their specificity [physical] injuries, because they’re there, they’re documented,” Hall said. “Mental health can be overlooked.”
“It may not just be the injured worker who needs care following a catastrophic accident,” Biltz added. “A catastrophic injury has a ripple effect on the injured worker’s family, co-workers and other loved ones. &