Nurse Case Manager - A Workers' Comp Perspective

What exactly is the role of the nurse case manager in Workers' Compensation (WC) cases?  What criteria defines a nurse to function and practice as a nurse case manager?

Many nurses are employed by insurance carriers, employers and TPA's to "manage" the medical aspects of a WC claim in addition to using outside nurse consultants.

In this arena, the role of the nurse case manager is dependent on who you ask and you will get a myriad of answers ranging from utilization review,  to actual "case management" of an injured/ill party.

Let's review what the concept of 'case management' means.  The definition of case management was promulgated by the professional association of case management - CMSA (Case Management Society of America - cmsa.org).  That definition is as follows:

"Case Management is a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes."

CMSA introduced the first "Standards of Practice for Case Management" in 1995, there have been two additional revisions, 2002 and 2010.  The most recent revision addressed fragmentation in the health care system, using evidenced-based guidelines, transitions of care, expansion of the interdisciplinary team in planning care for individuals, incorporating adherence guidelines and other standardized practice tools and improving patient safety [www.cmsa.org - Standards of Practice for Case Management].

The practice of 'case management' requires a multitude of skills and specific knowledge base to effectively manage a persons' health care needs in and out of the context of Workers' Compensation.  It is an advanced practice.

The Commission for Case Management Certification (CCMC - ccmcertification.org) is the certifying body for case managers. Not all case managers who are practicing case managers are "certified."   What does that mean, well, between CMSA and CCMC these organizations have provided a framework for ethical sound and safe practice.  CCMC issued the "Code of Professional Conduct for Case Managers" which delineates the Ethical conduct in which a case manager must practice.

These organizations were initially established from a grassroots process. Concerned, season Registered Nurses across the country came together; they recognized the importance of setting standards and criteria for practice to insure ethics and standards of practice be observed.  The role of case management was a relatively new role that would, as it has, evolve and spill over to group health, medicare, medicaid, private pay individuals, hospitals and primary care settings.

I encourage the reader to visit these websites to better understand what the role of nurse case managers include and the standards of excellence and ethics that ought to be in alignment with the value system of the purchaser of such services.

Workers Compensation is unique because of the medical-legal aspects of a claim.  The role of the nurse case manager is to take an aerial view of the case, identify the care needs and how those can be met qualitatively, efficaciously and timely.  Establish a relationship with the injured/ill person and educate and empower them to make sound decisions.  Quality medical care is not only cost effective in the long term, but a win-win for both the employee and the employer.

A healthy workforce is a happy and productive workforce.  Remember we will all have similar needs for quality medical care at some point in our lives.  Create a program that you yourself would submit to, that is the litmus test.

Maria Perez, RN, BSN, MPH, CCM