Case Management Focus: The Case Manager’s Role in First Report of Injury

Sarasota, FL (WorkersCompensation.com) -- Most businesses have signs strategically placed to alert workers to report a workplace injury or illness as soon as possible. This is to ensure the injured worker receives the care they need to address their injury/illness as soon as possible. In addition, it is important to be able to document that the work injury or illness did happen in the workplace. Employees are covered for workers' compensation claims from the first day of hire.  

In addition, the employer, risk manager, and others assigned by the company to handle worker compensation claims, investigate the injury to gather facts as to the cause of injury/illness. There are time specific rules that need to be followed so adhering to these rules is important to the process. Documentation is important from a safety and legal standpoint to document the injury that occurred did in fact occur while working.  

Each State has its own rules regarding the First Report of injury, and these rules and regulations need to be followed as outlined in the law for each State. The First Report of Injury forms may need to be filled out by the employer, the employee, and the medical team. Some of these forms are time specific so it is vital for training to be done to ensure all involved know the rules so that penalties for non-compliance can be avoided.  

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In all States, a workers' compensation claim is considered 'no fault’. ' This means that injured employees are entitled to receive compensation without proving fault against the opposite party. Workers' compensation insurance is an essential investment for business owners to cover claims arising from an injury or illness in the workplace.  

What role does the nurse case manager play in the first report of injury when an injury or illness happens?  

The workers' comp nurse case manager is a liaison between the injured worker and their family, the healthcare providers, the insurance company claims adjustor, and the employer. In many companies, a nurse case manager will be called to meet the injured worker at the hospital emergency department or Urgent Care Center to learn what happened and to ensure that the injured worker is seen, evaluated, and treated promptly.  

The nurse case manager acts as a patient advocate. Duties include 

• Help the injured worker and their family understand what happened as far as the injury is concerned and how the injured worker is doing 
• Understand what diagnostics need to be done to determine the status of the injury 
• What treatment options are there to consider 
• Help the injured worker and the family understand these options and call in 2^nd opinions as needed 
• Ensure the injured worker receives the assistance necessary based on their personal treatment plan. 

Once the nurse case manager arrives and assesses the situation, they work with the treatment team to:  

1. Make sure the injured worker is in the most appropriate level of care. That could mean the patient who is sent initially to an urgent care center might need to be moved to a hospital emergency department or a trauma center 

2. Work with the treatment team to ensure tests are done and results are communicated with providers who can determine treatment.   

3. Coordinate care and transition the patient to the appropriate level of care to meet their needs.  

4. The nurse case manager assesses the patient and develops a customized plan of care to address the unique needs of patients. 

As the plan of care is implemented, the nurse case manager stays involved to ensure that providers are part of the managed care network. If they must go out of network, arrangements are made for payments to non-provider network professionals. Doing this sooner rather than later is important to control costs moving forward.  

The goal is to ensure proactive, cost-efficient medical case management for the injured worker at the first Report of injury to ensure prompt treatment and cost-effective care. As the liaison, the nurse case manager keeps everyone informed and keeps the case moving forward.  

The nurse case manager stays involved as the injured workers progress through the healthcare system. They address issues as they arise and ensure the injured worker gets the care they need to meet their needs in the least restrictive environment. Suppose the injured worker can go home, and home care is required to assist the injured worker with activities of daily living, wound care, or other needed services based on their injuries. The nurse case manager will gain approval and get things set up with vendors who are part of the network.  

The Nurse Case Manager attends staffing meetings with the team to be aware of needs early on and can gain approval to ensure arrangements are made. This can decrease the length of stay and move the injured worker to the appropriate level of care. The nurse case manager works with the claims adjustor and the employer so that all are aware of the injured worker's needs.  

The Nurse Case Manager will address the return-to-work status as the injured worker progresses and work with the medical team and employer to determine the type of work to which the injured worker can return.  

By being involved, the nurse case manager can make sure the case stays on track and address any issues the injured worker and family have. This is important as the patient and family are usually stressed, and having someone they can go to who can help address issues and set realistic expectations is important.  

As a nurse case manager, I have found that being involved as soon as an injury occurs helps to avoid challenges that can grow into lawsuits as everyone is on edge. Developing a trusting relationship from the start can avoid legal involvement, which increases the cost of the case.  

Documenting what you did to assist the injured worker, the family, and the treatment team is important to show the value the nurse case manager brings to a workers' compensation claim.  

I look forward to learning about your experiences as a nurse case manager who was called in or the first Report of injury and how your presence helped the injured worker, the family, the treatment team, the employer, and the claims adjustor work together to ensure care was coordinated and there was a smooth transition of care.  

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