OhioBWC - Basics: (Policy library) - File

Policy and Procedure Name:

Initial Assessment and Assessment Plan

Policy #:

VR-09-01

Code/Rule Reference:

O.A.C. 4123-18-02; O.A.C. 4123-18-04; O.A.C. 4123-18-05

Effective Date:

07/01/21

Approved:

Deborah Kroninger, Chief of Medical Operations

Origin:

Vocational Rehabilitation Policy

Supersedes:

Policy # VR-09-01, effective 08/20/18

History:

Previous versions of this policy are available upon request

 

 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure that a thorough initial assessment is completed, including an initial assessment report and an assessment plan, when needed.

 

II. APPLICABILITY

 

This policy applies to the:

  • BWC disability management coordinators (DMCs);
  • Managed care organization (MCO) staff involved in the coordination and management of the vocational rehabilitation program; and
  • Vocational rehabilitation case managers (VRCMs) assigned by the MCO.

 

III. DEFINITIONS

 

See Vocational Rehabilitation Definitions.

 

IV. POLICY

 

It is the policy of BWC that a thorough initial assessment will be conducted to develop information and make recommendations to best serve the vocational needs of the injured worker (IW).

 

V. PROCEDURE

 

A.    Initial Assessment Contacts

1.    The VRCM shall contact the IW, the employer of record (EOR), the physician of record (POR), and the MCO. The VRCM may contact other people, as needed, who may provide information related to the IW’s vocational needs.

a.    The VRCM shall use all contacts as a means of establishing a good working relationship that will aid in the sharing of information and generally contribute to the IW’s successful vocational outcome.

b.    Before contacting the POR or any other provider, the VRCM shall ensure that the IW has signed a proper authorization to release information to the VRCM.

c.     The VRCM shall document each initial contact on the Vocational Rehabilitation Initial Assessment Report (RH-42). Documentation must include:

i.      The time and date of each initial contact;

ii.      The name of the person contacted; and

iii.    A summary of the information received.

d.    If, for any reason, a required initial contact cannot be made, the VRCM shall clearly document on the RH-42:

i.      All attempts at establishing initial contact (i.e., the VRCM made several initial contact attempts); or

ii.     The reason contact is not possible (e.g., the EOR is out of business).

2.    IW Contact

a.    The VRCM shall contact the IW within five calendar days of case assignment to schedule a face-to-face initial interview.

b.    During this interview, the VRCM is responsible for gathering any information relevant to the initial assessment not already in the referral documents, including but not limited to:

i.      The IW’s hard copy signature on the Rehabilitation Agreement (RH-1) acknowledging the IW’s interest in vocational rehabilitation services;

ii.     Any medication usage, prescribed or over-the-counter, frequency, dose and prescribing source;

iii.    Demographics (e.g., age, marital status, number of dependents, transportation issues);

iv.   Education;

v.     Employment history (e.g., previous employment, job descriptions, reasons for leaving any prior employment, union affiliations, military service);

vi.   Legal considerations (e.g., arrests, convictions, pending legal matters, non-citizen work status);

vii.  Medical concerns (e.g., abilities and limitations, unrelated medical or mental conditions, medical insurance);

viii. Financial disincentives (e.g., other financial benefits, other household income);

ix.   BWC Information (e.g., any previous claims, pending hearings); and

x.     Vocational rehabilitation participation information (e.g., any previous vocational rehabilitation including participation through other agencies).

3.    EOR Contact

a.    The VRCM shall, whenever reasonably possible, visit the EOR or current employer’s worksite and meet with the employer representative responsible for decisions regarding the IW’s work status.

b.    If a visit to the employer is not reasonably possible, the VRCM shall make telephone contact.

c.     The VRCM shall:

i.      View and/or obtain a detailed description of the work environment and job tasks performed by the IW in order to determine if job modifications or alternative jobs may be available to the IW;

ii.     Discuss opportunities for transitional work, return to work (RTW), and/or other services with the employer representative; and

iii.    Obtain information about the IW’s work strengths.

4.    POR Contact

a.    The VRCM shall make contact with the POR, preferably in person.

b.    The VRCM shall obtain from the POR any documentation of:

i.      The IW’s current physical restrictions related to the allowed conditions;

ii.     Current medications; and

iii.    Any needed prescription for plan services.

c.     The VRCM shall discuss with the POR:

i.      The IW’s medication usage and specifically how this may impact the IW’s ability to perform specific work tasks (e.g., operate machinery, drive);

ii.     The IW’s restrictions as they relate to the IW’s targeted job goal, using the job description or job analysis;

iii.    The RTW options available through the employer, including transitional work or other early RTW services; and

iv.   The IW’s ability to participate in vocational rehabilitation services.

5.    MCO Contact: The VRCM shall contact the MCO to:

a.    Obtain any recent information received in the claim, especially any recent treatment requests and their status;

b.    Obtain feedback regarding vocational rehabilitation services for the IW;

c.     Obtain assistance with gathering information from medical providers or the EOR, if needed; and

d.    Staff current strategy and recommendations.

6.    Attorney of Record (AOR) Contact: The VRCM shall contact the AOR, if applicable, to:

a.    Update the AOR on the status of the initial assessment and recommendations;

b.    Provide contact information;

c.     Obtain AOR input; and

d.    Enlist AOR assistance with the IW, if necessary.

 

B.    Complexity Factors: Throughout the initial assessment phase, the VRCM shall use the Complexity Factors Reporting Form to record any barriers or issues that impact the IW’s RTW.

 

C.   The Initial Assessment Report (RH-42)

1.    Job Retention Services

a.    The VRCM is not required to complete an RH-42 for job retention services.

b.    After completing all initial contacts, the VRCM shall proceed directly to completing a job retention plan (see the Job Retention Plan Development and Implementation policy and procedure for further information).

2.    In all other cases, the VRCM shall complete an RH-42. When completing the RH-42, the VRCM shall:

a.    Ensure all information is reasonably based and that any subjective inferences are substantiated with an objective behavioral description;

b.    Summarize and document the current vocational factors identified by the VRCM;

c.     Identify current vocational barriers and strengths;

d.    Identify additional vocational questions, if any; and

e.    Include a recommendation for:

i.      Case closure; or

ii.     Development of an assessment plan to answer any identified questions and/or obtain additional information; or

iii.    Development of a comprehensive vocational plan.

f.      Hard copy sign the RH-42.

3.    Within 21 calendar days of assignment, the VRCM shall submit to the MCO:

a.    Any releases hard copy signed by the IW;

b.    The RH-1; and

c.     The completed RH-42.

4.    If the RH-42 cannot be completed within the 21-day timeframe, the VRCM shall submit to the MCO:

a.    A written justification for the delay;

b.    The current status; and

c.     The projected submission date.

5.    Upon receipt of the RH-42, the MCO shall confirm the VRCM has included all of the required information.

6.    Requesting a Corrected RH-42

a.    The MCO may request a corrected RH-42 from the VRCM when:

i.      There is information missing from the RH-42 that was available to the VRCM at the time the RH-42 was completed; or

ii.     The RH-42 contains an error (e.g., incorrect claim number, misspelled name, incorrect diagnosis).

b.    A corrected RH-42 is not needed when:

i.      The MCO requires additional clarifying information; or

ii.     The VRCM obtains additional relevant information following the submission of the RH-42.

c.     In cases where the VRCM is not required to submit additional information on a corrected RH-42, the VRCM shall utilize other appropriate means to communicate this information to the MCO (e.g., progress report, e-mail).

 

D.   Assessment Plan

1.    The VRCM and MCO shall staff assessment plan recommendations required by the Vocational Rehabilitation Plan Review and Decision policy and procedure.

2.    When the VRCM identifies the need for an assessment plan, they shall develop and submit the plan using the Vocational Rehabilitation Assessment Plan form (RH-43) within seven calendar days of submission of the RH-42.

3.    When preparing the RH-43, the VRCM shall:

a.    Ensure all sections of the RH-43 are complete;

b.    Describe the specific questions to be answered by the services;

c.     Identify and justify the services needed;

d.    Complete the service grid; and

e.    Complete plan of service approvals, which includes:

i.      The hard copy signature of the VRCM that prepared the RH-43 and the date; and

ii.     Verification of verbal approval by the IW.

a)    The VRCM shall obtain an updated verbal approval from the IW anytime there is a substantive change to the RH-43 (e.g., job goal changes, adding or removing a service).

b)    The VRCM is not required to receive an updated verbal approval from the IW if the RH-43 is being corrected for clerical errors (e.g., date corrections).

4.    Assessment services may include the following services and activities:

a.    Vocational evaluation;

b.    Evaluation of functional and physical capacity;

c.     Multi-disciplinary evaluation;

d.    Evaluation by a physical medicine and rehabilitation physician;

e.    Psychological evaluation;

f.      Work conditioning evaluation;

g.    Vocational screening;

h.    Situational assessment;

i.      Career counseling;

j.      Informational interviews;

k.     Pre-test for GED;

l.      Job analysis;

m.   Ergonomic study;

n.    Transferable skills analysis (this may be conducted by the VRCM during the initial assessment);

o.    Labor market survey;

p.    Vocational rehabilitation case management for assessment and plan development (W3000-W3040);

q.    Travel; and

r.     Other services as authorized by the MCO.

5.    The following are not appropriate services for an assessment plan:

a.    Employment services;

b.    Work adjustment;

c.     Actual training;

d.    Therapy;

e.    Conditioning;

f.      Job modifications; and

g.    The provision of tools and equipment.

6.    Refer to the Special Vocational Rehabilitation Plan Types policy and procedure for information on plans:

a.    That require an extension of reimbursable service guidelines;

b.    That include payment of services above fee schedule;

c.     That include service codes that have no established fees for the identified service (i.e., services paid “by report”);

d.    Involving rehabilitation injury claims;

e.    Requiring interpreter services; and

f.      Developed in collaboration with the Opportunities for Ohioans with Disabilities (OOD) agency.

7.    If the VRCM cannot submit the RH-43 to the MCO within seven calendar days of RH-42 submission, the VRCM shall provide to the MCO:

a.    A written justification for the delay;

b.    The current status; and

c.     The projected submission date.

8.    The MCO shall review the RH-43 in accordance with the Vocational Rehabilitation Plan Review and Decision policy and procedure.

9.    The VRCM shall obtain and submit to the MCO a hard copy signature on the RH-43 from the IW within 30 days of the start of plan services.

 

E.    Assessment Plan Amendments

1.    If unusual circumstances exist and the VRCM determines that additional assessments are needed, the VRCM shall submit an amended assessment plan with justification for the additional services to the MCO so that it is received by the DMC no later than three business days prior to the end of the previous assessment plan. This will ensure there is no interruption in the IW’s LM payment.

2.    The MCO shall review the amended RH-43 in accordance with the Vocational Rehabilitation Plan Review and Decision policy and procedure.

 

F.    Living Maintenance (LM)

1.    The DMC shall evaluate and facilitate, when appropriate, payment of LM to the IW during the IW’s participation in an assessment plan.

2.    LM shall start on the first day of the IW’s participation in the assessment plan and continue throughout the period the IW is participating in the assessment plan.

3.    The IW may continue to receive LM for up to 14 days following completion of the assessment plan if a comprehensive vocational rehabilitation plan is being developed.

4.    If further information is required, refer to the Living Maintenance Compensation policy and procedure.

 

G.   Outcome of Assessment Plan

1.    Within seven days of the IW’s completion of active services in an assessment plan, the VRCM shall make a recommendation to the MCO as to whether the IW is a viable candidate for participation in a comprehensive vocational rehabilitation plan for purposes of RTW.

2.    If the VRCM determines the IW is a viable candidate, the VRCM shall:

a.    Staff with the MCO their employability recommendations, if required by the Vocational Rehabilitation Plan Review and Decision policy and procedure;

b.    Detail the recommendations on the comprehensive plan; and

c.     Follow the Comprehensive Vocational Rehabilitation Plan and Progress Reports policy and procedure.

3.    If the VRCM determines that the IW is not a viable candidate and therefore not feasible for vocational rehabilitation services,the VRCM shall present their recommendation to the MCO.

a.    If the MCO agrees with the VRCM’s recommendation, the MCO and VRCM shall follow the Vocational Rehabilitation Case Closure policy and procedure.

b.    If the MCO disagrees with the VRCM’s recommendation, the MCO and VRCM shall discuss alternatives to case closure, including but not limited to:

i.      Additional assessments;

ii.     Additional documentation; or

iii.    With the IW’s agreement, VRCM reassignment, following the Assignment and Reassignment of the Vocational Rehabilitation Case Manager policy and procedure.

 

H.   Reopened Cases

1.    Cases closed during or after the assessment plan may only be reopened with justification of significant changes in the IW’s circumstances.

2.    If a comprehensive vocational rehabilitation plan is reopened within two months of closure due to a rescinded closure or claim transfer, another initial assessment is not necessary.