ALERT-Aggressive Case Management

ALERT is an acronym which describes the process of aggressive case management.  It is not additional information that is required to be documented in the case.  This process should be completed on every verbal encounter to ensure consistent, high quality customer service. 

ALERT ensures aggressive return to work and promotion of an active treatment plan.  The nurse’s recommendations establish an appropriate plan of action and proactive recommendations.  The file is managed by utilizing established criteria, goal setting and timely communication.

First the nurse assesses the return to work plan and treatment plan by asking the following questions:

•   Did I compare the treatment plan with criteria?
•   Do subjective and objective findings match the diagnosis given?
•   Do subjective and objective findings gel with the treatment plan proposed?
•   Did I question, probe, and challenge the treatment plan?
•   Did I compare the work status with criteria?
•   Do the subject and objective findings match the return to work status/recommendations?
•   If totally disabled, why?  Is it appropriate?
•   If partially disabled, why?  Is it appropriate?
•  What are the injured worker’s capabilities?
•  What can she/he do?
•  Have I discussed light, modified duty?

The case manager then formulates a clear direction.   She maintains control of the case while giving the account assistance in making his/her claim decision.  The emphasis is the “big picture” and not just one episode of care.

The case manager formulates her plan of action by asking herself the following questions:

•   Was I aggressive in obtaining information so that I can move forward?
•   What steps do I plan to take to stay in control?
•   How do I keep my recommendations alive and achieve my case goals?

The case manager then turns her attention to comparing the treatment plan against the criteria for the injured worker’s diagnosis.  She addresses the following:

•   Have I determined within optimal criteria when this injured worker should be expected to return to work?
• Have I determined within optimal criteria when this injured worker should be expected to reach maximum medial improvement?
•  Did I update the return to work and maximum medical improvement estimates when the time frames were exceeded?
• Did I establish my own goals for return to work and maximum medical improvement when no criteria information is available?
•  Did I consult a resource to establish a goal if there was no criteria available and I was unable to establish a goal?

The next step is to review the expectations and service request from the account. 

• Does my referral source have an agenda that is somehow different from my own?
• Have I communicated any red flags that I might have encountered?
• Have I communicated in a way that is beneficial to my referral source?

The last step in the process is communication to provide all parties with the rationale for the medical information supplied so that they have a clear understanding from a medical standpoint.  All parties will understand why the recommendations are what they are and why the treatment plan is appropriate.  The case manager gives the account the rationale for the disability status.  Stating that “the injured worker is disabled and I will follow-up “, is not sufficient.  

In summary, case management is not a passive information collecting process.  The nurse case manager is an active participant utilizing the nursing process of assessment, diagnosis, outcome planning, implementation and evaluation.

Medical Coding-why hire a nurse?

Many times we are asked if a nurse with a coding certification is really necessary. NurseValue believes the answer is a definitive yes as medical coding is a complicated, multifaceted process. A nurse is familiar with the medical procedures and services, but is not always aware of the financial piece of the process (coding). We are not the only ones that feel this way! The Department of Labor’s occupational handbook (www.stats.bls.gov/oco/ocos103.htm) recognizes only AHIMA and AAPC certifications. The Office of Inspector General (OIG) requires independent review organizations to have AHIMA or AAPX certified coder for claims review. The state of Hawaii requires certified coding for medical claims review, again recognizing only the CCS and CPC credentials.

Bilingual Nurse Advantage

Many times patients gravitate to a healthcare provider that speaks their language.  This makes a lot of sense as it makes it less difficult  to describe symptoms and feelings to someone that understands. 

The bilingual nurse does not replace the provider’s interpreting staff.  They are invaluable in their own right. 

There is a huge advantage for the patient with the opportunity to interact with a bilingual nurse, specially when they are involved in a complicated medical condition or a workers compensation case that has rules and regulations they must abide by over and beyond the medical treatment plan.  When trying to communicate with a patient via a translator there is the tendency to forget to ask certain questions or you can miss the minute clues that may lead to a clearer understanding of the patient’s needs and concerns thus facilitating a good medical outcome.  Often patients will express their concerns to a bilingual nurse that they would not feel comfortable asking through a translator.  The relationship is built on mutual understanding of both the language and the culture. 

Herlinda Rodriguez joined NurseValue in 2011 with background in orthopedics  and  workers' compensation nurse case management.  She was an integral participant in Liberty Mutual's telephonic  case management program; 2004-2005,was a translator for Princeville Medical center, and was a community outreach worker for a year with the Hispanic Outreach Partnership.  We knew she was a team player with a penchant to pay it forward.  Today, we find that our injured workers depend upon her for calm understanding, careful direction and comforting demeanor to move their recovery forward.  NurseValue depends upon Herlinda's never ending optimism!