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OhioBWC - Basics: (Policy library) - File

On-site Case Management Policy and Procedure

Policy/Procedure Name:

On-site Case Management

Policy #:

MP-15-01

Code/Rule Reference:

N/A

Effective Date:

03/07/16

Approved:

Freddie L. Johnson, Chief of Medical Services (Signature on file)

Origin:

Medical Policy

Supersedes:

All medical policies, procedures, directives and memos regarding on-site case management claims that predate the effective date of this policy/procedure.

History:

New

Review date:

03/07/21

 

 

I.      POLICY PURPOSE

 

The purpose of this policy is to ensure that the Bureau of Workers’ Compensation (BWC) provides direction to the managed care organizations (MCO) for completing an on-site case management visit(s) and for developing and/or managing an individualized care plan for the injured worker (IW).

II.    APPLICABILITY

 

This policy applies to BWC catastrophic nurse advocates (CNAs) and MCO staff.

III.   DEFINITIONS

 

Case Management Plan: Compilation of all information that the medical case manager has gathered from the IW, the physician and the employer as well as any other pertinent sources that impact the progress and successful outcome of the claim resolution; action- oriented, time-bound and specific to the intervention(s) and resources to be used to assist the injured worker in achieving the specified goals specified within each phase of the plan; ensures that accountabilities are established so that all participants are aware of respective responsibilities in meeting the goals.

 

Catastrophic Claim: A claim in which there is a serious injury or occupational disease resulting in limited mobility and/or cognition related to the allowed conditions in the claim that severely limits the ability of the IW to perform activities of daily living and has a high probability of resulting in permanent disability.

 

Medical Case Management: Collaboration to assess, plan, implement, coordinate, monitor and evaluate options and services to meet an IW’s health needs using communication and available resources to promote quality cost-effective outcomes; within the Ohio workers’ compensation program, includes identifying and minimizing potential barriers to recovery, identifying and assessing future treatment needs, evaluating appropriateness and necessity of medical services, authorizing reimbursement for medical services, resolving medical disputes and facilitating successful return to work or claim resolution for injured workers; can be telephonic and/or on-site depending on the need of the IW.

Non-catastrophic Claim: A claim that does not involve a catastrophic injury or occupational disease, but requires an on-site visit to remove barriers that undermine a case manager’s effective management of the claim.

 

On-site Case Management: Oversight of a claim that requires a case manager to travel to various settings (e.g., hospital, home, rehabilitation center) when assessing, planning, implementing, coordinating, monitoring and evaluating the options and services required to meet the IW’s health and human service needs; characterized by face-to-face advocacy, communication and resource management that promotes quality and cost-effective interventions and outcomes.

 

Task-based Visit: A one-time case management activity with a specific purpose or objective.

IV.  POLICY

A.    It is the policy of BWC that on-site case management visit(s) may be conducted for catastrophic and non-catastrophic injuries for injured workers who reside in Ohio. Examples of claim issues or conditions that may require an on-site case management visit(s) include, but are not limited to, the following:

1.    For catastrophic injuries or occupational diseases:

a.    Brain injuries, moderate to severe;

b.    All major extremity amputations, multiple complex fractures, crush injuries, loss of use of one or more limbs;

c.    Spinal cord injuries such as paraplegia, quadriplegia, hemiplegia or diplegia;

d.    Total occupational blindness (blindness that occurs as a result of work or occupational activity);

e.    Severe burns, such as second or third degree burns on more than 25 percent of the body;

f.     Anticipated hospitalization in excess of four weeks, i.e., ventilators, ICU, psychiatric hospitalization;

g.    Severe occupational diseases (not end stage); bloodborne pathogens; and toxic exposure with long term complications; and

h.    Any other medical diagnosis identified by the MCO and CNA.

2.    For non-catastrophic injuries or occupational diseases where the case manager has clearly documented the barriers in the claim:

a.    Inability to obtain medical records precipitating the need for on-site record review and/or retrieval;

b.    Documented unsuccessful telephonic case management;

c.    The transfer of an injured worker from the hospital to another facility for rehabilitation or other care;

d.    An extended hospital stay, recurrent admissions and failed or repeated surgeries;

e.    Non-compliance with physician and/or rehabilitation appointments;

f.     Delayed healing process;

g.    Lack of an acceptable support system for the IW;

h.    Delayed return to work;

i.      Request by an employer, physician, injured worker, and/or the injured worker’s family and/or representative request on-site case management;

j.      BWC recommendation for an on-site case management visit; and/or

k.    BWC and /or the MCO’s medical director determine that on-site case management would remove barriers that may impede the injured worker’s return to work.

B.    It is the policy of BWC that on-site case management visit(s) shall be executed as follows:

1.    For catastrophic claims:

a.    A minimum of one, unless waived by BWC’s CNA; and

b.    More than one visit at the discretion of the MCO.

2.    For non-catastrophic claims:

a.    No minimum number of visit(s) required; and

b.    One or more visit(s) as determined by the MCO.

C.   It is the policy of BWC that on-site visit(s) shall be integrated into an individualized case management plan for cases that are in active case management in accordance with chapter three of the MPRG. The case management plan shall clearly outline how such visit(s) can support or address care of the IW.

D.   It is the policy of BWC that cases not in active case management but requiring the case manager to execute a task-based visit shall be documented in the claims management notes or integrated into a case management plan.

E.    It is the policy of BWC that only one task-based on-site visit shall be permitted on claims that are not in active case management and it shall be documented in claims management notes. If more than one on-site visit is necessary to address the IW’s care or to remove barriers, a case management plan shall be developed or reactivated to reflect the current condition of the IW.

F.    MCO responsibilities:

1.    The MCO shall ensure that on-site case management visit(s) are executed for catastrophic and non-catastrophic claims, as appropriate.

2.    The case manager develops an individualized case management plan for catastrophic claims that:

a.    Incorporates any planned on-site case management visit(s), clearly outlining how such visit(s) will support or address care of the IW; and

b.    Identifies and evaluates options and services needed to meet the IW’s needs.

3.    The case manager shall develop the case management plan and share it with appropriate individuals, as needed, when on-site case management is deemed appropriate.

4.    The MCO shall ensure that a summary of the on-site case management visit(s) is documented in the claims management system using a standard note title “MCO On-site Case Management Visit.”

5.    The on-site case management  note shall include, but is not limited to, the following components:

a.    The date of visit;

b.    The care setting/location;

c.    The name of participants and their roles;

d.    The clinical justification or purpose for visit;

e.    The summary of the visit including accomplishments and objectives met during visit; and

f.     The follow-up steps from visit.

6.    The MCO shall send a request for waiver of an on-site case management visit to the BWC CNA mailbox at bwc.catnurse@bwc.state.oh.us with the subject line “Request for a Waiver.”  The email shall include the  following information:

a.    Claim number;

b.    Name of the injured worker;

c.    Date of injury; and

d.    Explanation for waiver.

7.    The BWC CNA shall ensure that any case management visit(s) that he or she waives is documented in notes.

8.    The CNA may waive on-site case management visit(s) for catastrophic claims when:

a.    The CNA makes a clinical determination that an on-site case management visit is not indicated; or

b.    The claim is managed by Paradigm.

9.    When waiving an on-site case management visit, the CNA shall:

a.    Conduct a careful assessment of the catastrophic claim to determine if it is appropriate to waive the on-site case management visit; and

b.    Document the rationale in notes.


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