The Role of Nurses as Case Managers in Workers' Compensation Cases

1. The Role of Nurses as Case Managers in Workers’ Compensation Cases Laura Reis, ReisLaw LLC, Atlanta, GA https://reislaw.com/ (404) 876-4200 AAJ Annual Convention 2015 Montreal X

2. Their Job • Case Nurse Managers can create or put out fires in your cases. • In most states, catastrophic claims require a CAT designated manager, and depending on the case they can help you run the case or be a fatal disaster and a bird in the ear of big insurance.

3. The Fire • In non-CAT designated claims, case nurses are generally allowed to be removed and therefore the direct line between your client and the carrier is removed. • This also de-facilitates direct communication between the adjuster into the treating physician’s ear. It is our job to help our client get the best care possible, at any cost. The adjuster’s job is to ultimately limit the carrier’s expenditure.

4. Fighting the Blaze • It is OUR job to facilitate OUR client and that’s why OUR clients hire the premiere workers’ compensation specialists. • Under-represented Claimants rely on the case nurse managers to facilitate the treatment, schedule appointments, communicate with the doctor, and update both the Claimant’s attorney and the carrier by generating a report.

5. First Response • Involved and informed counsel can remove the Case Managers in non-CAT cases and should manage the treatment themselves unless the injury or circumstance is unusual or overly complex. In CAT cases where they are required to have case nurse management, smart attorneys have a repertoire of trusted Rehab Suppliers that can be designated to the claim. Generally, carriers are flexible and agreeable to have a CAT supplier everyone likes as smart adjusters know that this will save them litigation expenses.

6. First Responders • Trusted Case Nurse Managers can help manage the client and their expectations. • They can also help a Claimant communicate their needs to the ATP. • Further, the nurses have medical and outside resource training and can even help a Claimant manage non-WC related medical issues like diabetes.

7. The Warning It is imperative to remember who ultimately pays the bill. The Nurse has the adjuster’s phone number and generally likes their job. If the Claimant presents extreme signs of recovery, it makes sense that their payor would receive first wind.

8. Logistics • On CAT cases most states have a list of designated Rehab providers. Know who is on the list and have friends on the list. • When choosing – for whatever reason – to leave a Case Nurse Manager on a non-CAT case, it is generally preferable to pick a rehab provider with a CAT-certification so they can remain on the case should you ultimately pursue a CAT-designation. They can help you pursue the designation and keep their job. • Remember that Rehab providers have resources outside of the Comp System and can link families in need with special volunteer services. CAT providers work with the WHOLE PERSON

9. Case Analysis- The Imperial Sugar Explosion Close to Savannah, Georgia in 2008 a massive explosion occurred at the Imperial Sugar Plant in Port Wentworth. 110 workers, including the CEO, were inside the plant. The fire temperature exceeded 4000 degrees and 45 workers were critically injured. The sugar dust ignited and thermoplastically stuck to everything it touched, including the workers, and burned into their flesh removing everything it touched.

10. Laying the Groundwork • There was not enough water at the plant to douse the flames so water was pumped out of the Savannah River to fight the blaze. • This compounded the problem as chemicals, petroleum, and toxins were in the water, which eventually created complex infections in the burn victims’ bodies. • Immediately after the explosion, fortunately, the carrier was notified and the carrier’s case nurse management team was put ‘on deck’. Had this not happened, the disaster would have had more complications.

11. Patient Assessment • The explosion caused thermal burn injuries ranging from 5% Total Body Surface Area (TBSA) damage treated onsite or in local emergency departments, to 95% TBSA critical burn damage that in most cases is notsurvivable. • Twenty patients were transported to Augusta with injuries ranging between 60% and 95% TBSA; 18 directly to the Burn Center and two to MCG with major trauma injuries as well as serious burns.

12. Patient Assessment • Most of the burns were to the face and upper body. However, because the heat was so intense, burns suffered on the face were generally third-degree not second-degree as is usually sustained, because the face is highly vascular and can normally dissipate the heat more quickly. • Seventeen workers were considered critical. Eight people were killed in the explosion itself. Five died later of their injuries.

13. Tips on Managing Burn Disasters • Case Nurse Managers Know Transport Protocols • Stop the burning process. Use Airway and C-Spine precautions. Follow CPR protocols. • Administer high flow 100% oxygen per mask or intubate, if inhalation injury presents or is suspected. Be prepared to suction and support ventilation. • Case nurse managers can get on the ground quickly to educate non-certified or rural first responders as to properly manage a complex injury.

14. Protocols Continued • Savannah and other nearby hospitals were notified by the case nurse managers to be ready. This was not enough. • Fortunately, Georgia has one of the top burn centers in the world, the Joseph M. Still Burn Center in Augusta. • Unfortunately, this is several hours from Savannah (Georgia is the largest U.S. state east of the Mississippi River- really ) • The burn center and their team flew to Savannah and initially treated the injured workers there. Patients were prioritized and flown to Augusta if needed. The case managers coordinated this effort and notified the families as to the location of the victim.

15. Protocols Continued • Patients were then flown by helicopter to the burn center in Augusta or treated by burn specialists from the Augusta burn center who arrived immediately due to the nurse case manager contacts. • 18 patients arrived to Augusta by helicopter. Many lives were saved and families were notified due to Nurse Management.

16. Who’s on First? In a situation like this there is a critical need for someone to be “In Charge”. This is an extreme case but an example that at times case nurse managers are crucial in emergency situations. They CAN be helpful in non-emergency situations, but you need to be careful with friendly vs. non-friendly relationships

17. What’s on Second? • The Case Nurse Response Team set up a dedicated toll free line for information on the injured, and to coordinate services. Since they already had a toll free line in place, that was a very simple, but extraordinarily helpful step. They set up a command center with an incident manager, and started calling in their resources. They gave their call center workers a special script so they could respond to inquires. They developed a team with their Crisis Management Team and the Safety Manager and CEO at Imperial Sugar.

18. I Don’t Know Is On Third • OK – YOU MY FRIEND IS ON THIRD. • IT IS THE ATTORNEY’S JOB TO FIGURE OUT THE NEXT STEP • Prosthetics • Pain management • Additional surgery You limit your client by not taking control now

19. Communication Is The Key • Starting Friday morning the team began a routine of telephone calls every two hours to communicate with the other teams on the ground in Savannah and Augusta. After the initial phase calls were coordinated daily. They had someone on the ground in Savannah and Augusta Friday morning gathering information on what the needs were. Nurse Case Managers were assigned to each of the hospitals in Savannah and Augusta. They were a part of communicating to the team what was happening with the cases in each hospital there.

20. The Case Management Response Because there was no clear picture of where all the injured were or were going at that point, and the adjuster did not even have a list of the injured, they reassured the adjuster that since the patients were all still in the process of being evaluated and treated emergently that there was time for the rehabilitation team to get to the scene. Major Case Nurse Management companies have a Crisis Response Team in place already. At 9:30 PM – immediately after the explosion- the Case Nurse Manager got a call from the lead adjuster with the carrier. There had been a catastrophe and they needed case management services NOW! They began assembling a team to be on the ground the next morning.

21. Resources • They had identified resources already in place. Their ability to draw resources from South Carolina and Florida as well as Georgia made it possible for them to have people available the next morning. Since they also had a specialist in burns on their team, that specialist was able to consult with the burn specialists at The Burn Center for support and problem-solving.

22. Unforeseen Issues • As you can imagine. There were many issues, such as managing the media and hospital security to maintain not just confidentiality but also the crowd of people. They had to get staff members coming to work and volunteers into the hospital and where they needed to be. The system for doing that was already in place, but it must have been daunting to have a crowd like that converge on the Center. This provided a valuable learning experience in how to expand that system. Case nurse management helped manage this as well.

23. Insult To Injury • Soon the Safety Manager at Imperial Sugar notified the Coventry team that he was going to have to quarantine the site of the explosion in order to put out the remainder of the fire. There were still bodies which had not been recovered. The team instantly understood how the families would feel, if they were not even able to recover their family member’s body for burial. At that point the director again called in the case nurse team and began calling in all the crisis counselors they had in the area.

24. Tips on Managing Disasters • Develop Volunteer Alliances • Designate a Volunteer Coordinator to oversee and manage non-clinical needs and make the response effort more efficient and effective. Be sure you have emergency contacts available 24/7. Remember, the first patient arrived at the Burn Center at midnight and they kept coming every thirty minutes throughout the night. If you can control this, leg-up immediately. • Designate On-Call “Incident Teams”. • All disasters are unique, so having a leadership team to customize your existing emergency response plan will maximize your response. • Re-evaluate and Refine

25. Complexity of Needs • The Burn Center has always provided support for patient families, but as you can imagine the Burn Center quickly filled up with patient families arriving in the middle of the night.

26. Community Support • The entire Augusta community rallied to the call for everything from covered dishes to prayer warriors. And, they were there long after the initial disaster. They provided gas, gift cards, and many other things to help families pay their essential expenses week after week and month after month.