When We Work Together: The System Works!

Nurse Advocate 

As workers comp case managers, we all have that one case that allows us to believe in what we do. I had such a case a few years ago. I was assigned a case of a man working up in Jacksonville as a pipefitter. I will call him Jake. My service request said that Jake had severe back pain due to a work injury. He worked in Jacksonville, FL, but his home was in Miami, and he wanted to come back for treatment. Once he was cleared from the emergency department, his company arranged for him to be brought to Miami. I was to work with the case manager at the hospital in Jacksonville and get things set up in Miami for Jake when he returned on Monday. My assignment was to arrange for an appointment with an orthopedic surgeon and accompany the patient to assist with care coordination.

Our First Meeting

I met Jake at the appointed time. He was a man of about 35 years old in obvious pain. He was in a wheelchair and could not walk or stand for long periods. He was uncomfortable sitting and wanted to lie down. I asked the office staff if they had a place for him to lie down until the Doctor could see him. They brought us into the back, and we got him on a stretcher. I asked if he had any pain medication, and he said he had taken something before he left home, but it was not helping.

Thankfully, the Doctor came in a few minutes later. He introduced himself to the patient, the wife, and me. He asked the patient what was going on, and the patient explained that he was putting a pipe into the ground and felt something pop in his back. He had immediate pain. He said he was given a script for pain medication, but it was not helping. His company arranged for transportation back to Miami, and here he was. He had been seen in the ER in Jacksonville and had an MRI. He gave the Doctor the disc of the MRI.

The Doctor examined Jake and looked at the MRI. He returned and said that Jake would need to be admitted to the hospital and have emergency surgery for a herniated disc. When Jake heard this, he said he did not want surgery. He said he had heard from too many people who had had back surgery, which made things worse. He begged the Doctor to try conservative treatment first.

The Doctor said he did not advise this route but would give the patient a trial of steroids, muscle relaxants, pain medication, and physical therapy. He would see him in a week to re-evaluate him. He wrote the scripts for muscle relaxants, steroids, and stronger pain medication.

The surgeon said he hoped the plan would decrease the swelling and give him some relief. I called the adjuster to get a referral for physical therapy. The wife said she would fill the scrips so he could start the medications immediately. The Doctor told the patient to go to the ED directly if he had any trouble, such as urinary or bowel incontinence.

The adjuster called me back with authorization for physical therapy. I knew of a facility in his area that also had water therapy that might be helpful. I called the Director of Case Management and got an appointment that day, so we left the surgeon's office and went to the therapy center. 

The wife met us at the rehab center and gave the patient one of his new medications. We saw the psychiatrist who evaluated the patient. He looked at the MRI report and spoke to the patient candidly, saying he agreed that surgery would be his recommendation also. The patient said he wanted to try something else first. He did not want to jump to surgery. The therapist said he recommended starting water therapy to allow the medications to work. The patient agreed and made an appointment to start treatment the next day.

I traveled to the appointment where the patient met the water therapy therapist. She did her evaluation and got him in the pool to do some gentle exercises. The therapist recommended daily therapy for two weeks. After this, she will re-evaluate him.

I updated the adjuster and explained the plan of care. The adjustor provided authorization for the therapy. I also arranged transportation to get the patient into treatment as it was hard for him to get into the car.

Water Therapy was the trick!

The patient started water therapy the next day. When I talked to him later that day, he said the water allowed him to walk around the pool and do some mild exercises. The plan was for him to continue daily for two weeks. The patient was agreeable to this and thanked me for my help.

I called the patient a few times during the week. He said he was still in pain but was feeling a little better. He was going to water therapy daily and was tolerating the program. I told him I would meet him at the orthopedic surgeon's office on Monday.

The 2nd MD Visit

I arrived at the Doctor's office and found the patient standing with a walker. He said he felt a lot better and could walk small distances. The water therapy and the meds were helping. When the orthopedic surgeon walked in, he was surprised to see the patient standing and in better spirits. The Doctor examined the patient and said to continue the medications and water therapy. He said he would allow the therapist to decide when to add land exercise. He was to remain off duty at this time, but he was making progress. An appointment was made for two weeks.

Therapy continued for the next few weeks. The physical therapist started to add a few land exercises and the patient tolerated them well. He continued daily water therapy and every other day did gentle land exercises.

Week Four was a turning point.

By week four, the patient was doing much better but was getting bored being home. I told him I would call his employer to see if he had any light-duty work for the patient. I called the employer to give him an update and asked if he had any light-duty work. He said he did not, but he had a desk full of business cards that he had been thinking of organizing into potential leads for his business. I told the employer I would ask the Doctor what his restrictions were at the next appointment.

Week 5

I met Jake at the Orthopedic Surgeon's office. The Doctor examined the patient. He was impressed he was doing so well. The patient could sit and stand; he still had some pain but was much improved. I shared that I had talked to the employer last week, and he had some light-duty work for the patient if the Doctor would consider returning to work. The Doctor asked the patient how he felt. The patient said he thinks he can do light-duty work. The Doctor said Jake could go back to work if he would be allowed to sit and stand and take breaks and have a place in case Jake could lie down. He was to lift at most 3 pounds. The Doctor agreed and wrote the restrictions for the employer. I discussed the visit with the adjustor and then the employer. The employer agreed to allow Jake to return to work and said he would allow the patient to set his schedule and do what he needed to do to protect himself.

The physical therapist worked with the patient to create a schedule to continue therapy and return to work. They agreed on the best week times, and the patient talked to the employer. All agreed and the Jake started working on Week 6.

Having the Injured Worker’s By-In was Key

Jake adjusted well to this routine and found organizing contacts to be interesting. He knew which business could use their services as he had a good handle on the company's work. Once the business cards were organized, Jake called people to see if they needed the company's services. He got a few leads that he shared with his boss. The boss agreed to let Jake follow up with these clients. Many of the follow-ups turned into new work for the company.

Jake liked the work he was doing and asked for more hours. He continued his therapy daily and worked five days a week for about 5 hours.

Week Seven

I met with Jake and the Orthopedic Surgeon's office for his checkup. The Doctor was pleased to hear about the progress and felt that Jake had reached MMI. The surgeon said that he should continue the exercises and could increase his work time as he felt comfortable. The patient agreed. I talked to the therapist, and she agreed with the plan and was glad he was doing well. She said he worked hard, and it was good to see it pay off.

She relayed that Jake was independent in all activities, so she thought the patient could do well with an exercise plan on his own. The therapist said she opened her office to the public and he could use the gym. She shared the membership cost. She reiterated that Jake had to keep up with the exercise so he would not have a relapse. The gym was opened at 6 am. If he came early, he could do his exercise and get to work on time. Jake agreed to the plan.

I shared the plan with the adjustor, and she agreed and authorized a six-month gym membership. I also talked to the employer. The employer was happy to have Jake return to his administrative job. He was good at it, and it has gotten the company a few new contacts. He said he would give Jake a raise and allow him to set up his hours. If he felt up to it, he could go on some sales calls to make sure his past customers were satisfied and check to see if they needed additional work. Jake was pleased with this and anxious to move forward. The plan was laid out in a follow-up email to the orthopedic surgeon, who approved it. 

Case Closed!

I closed the file after one month as the IW was doing well. He was compliant with his exercise program and was working full time in a new job, as he could never return to pipe fitting. I accompanied the patient to his orthopedic surgeon’s last appointment. The Doctor was pleased with the progress and put him at MMI. The patient said he was glad he did have surgery and was grateful to the Doctor for giving him the time to heal naturally. He still had pain at times, but the pain was controlled with Tylenol.

As a Worker's Compensation Nurse Case Manager, this was a rewarding case. Everything worked, and we had a good outcome. The entire team worked together to meet the goals of the patient. The orthopedic surgeon gave Jake time to heal. The physical therapist had the tools to allow Jake to exercise to build up his muscles. At first, he did water therapy and progressed to land exercises. He was not rushed and was able to heal at his own pace. The employer was open and tried an innovative approach to finding a light-duty position for Jake. Jake fully participated in his care. He expressed his goals and was willing to do the work it took for him to heal. The adjustor worked with the team and authorized the care and resources needed. As the case manager, I advocated for the patient and put together a team that worked together and achieved a good outcome. It reinforced to me – when the system works, it works well!

What was your most successful case as a Worker's Compensation CM? Let me know, and I will share it in a future column!

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