CASE MANAGEMENT

PRINCIPLES

NOVEMBER 2005

WorkCover. Watching out for you.

Disclaimer
This publication contains information regarding occupational health, safety, injury management or workers compensation. It includes some of your obligations under the various workers compensation and occupational health and safety legislation that WorkCover NSW administers. To ensure you comply with your legal obligations you must refer to the appropriate Acts. This publication may refer to WorkCover NSW administered legislation that has been amended or repealed. When reading this publication you should always refer to the latest laws. Information about the latest laws can be checked at www.legislation.nsw.gov.au or contacting (02) 9238 0950 or 1800 463 955 (NSW country only).

CONTENTS
INTRODUCTION PRINCIPLE 1 CASE MANAGEMENT PHILOSOPHY AND CASE MANAGERS ROLE PRINCIPLE 2 TRIAGE AND SCREENING PRINCIPLE 3 CLEARLY-DEFINED PRACTICES PRINCIPLE 4 PEOPLE MANAGEMENT AND LEARNING AND DEVELOPMENT SYSTEMS PRINCIPLE 5 RECORDS MANAGEMENT PRINCIPLE 6 SOUND DECISION-MAKING PRINCIPLE 7 COST-EFFECTIVE SERVICE PRINCIPLE 8 QUALITY ASSURANCE AND CONTINUOUS IMPROVEMENT GLOSSARY ATTACHMENT 1 THE OPTIMISING MODEL OF DECISION-MAKING BIBLIOGRAPHY

PAGE 2 4 6 7 10 12 13 15 17 18 19 20

INTRODUCTION
To assist organisations develop their case management approach, this publication outlines the case management principles WorkCover has developed following a thorough review of available literature, data analysis from WorkCover systems, and consultation with industry. When applied to workers compensation, case management means a coordinated and managed approach that integrates all aspects of injury and claims management, including: payment of benefits and entitlements liability determination treatment rehabilitation retraining factual investigation claims estimation investigation of recovery potential employment management practices eg risk management, return to work programs and occupational health and safety. WorkCovers case management framework is a set of clearly-defined practices, underpinned by quality assurance and continuous improvement. It ensures effective management of a claim from notification through to finalisation, supported by sound decision-making. It focuses on cost-effective service delivery and aims to ensure the achievement of timely and sustainable return to work outcomes and maximum functional capacity. The goal of case management is a timely, safe and durable return to work for injured workers. Fundamental to the framework is the appointment of a single appropriately qualified person who is responsible and accountable for actively managing an injured workers claim.

case management philosophy and case managers role

quality assurance and continuous improvement

The framework incorporates eight case management principles: 1. case management philosophy and case managers role 2. triage and screening 3. clearly-defined practices 4. people management and training systems 5. records management 6. sound decision-making 7. cost-effective service 8. quality assurance and continuous improvement. Through application and further development of the case management principles within their business models, WorkCover expects organisations to: approach managing injuries, claims and return to work in a holistic and systematic manner maximise return to work and health outcomes for injured workers, while minimising risk of re-injury establish an effective claims management infrastructure with open communication channels deliver cost-effective case management with a strong focus on outcomes.

cost-effectiveness

screening

decisions

practices

people

records

PRINCIPLE 1 CASE MANAGEMENT PHILOSOPHY AND CASE MANAGERS ROLE

Principle
The philosophy of case management integrates injury and claims management with a multi-disciplinary, holistic, individual and cost-effective approach, and operates within the legislation. A single, appropriately qualified person is responsible and accountable for active management of an injured workers claim. The case manager is the principal decision-maker who uses all relevant facts, options and information, and promotes a working partnership between the injured worker, employer and service providers. For each case, a management plan is developed in consultation with the injured worker, employer and other relevant parties. It identifies stakeholder responsibilities and outlines the agreed way forward, including the return to work goal.

Components
Case manager roles and responsibilities An appropriately qualified case manager: is accountable for the entire case and is the primary contact is accountable for influencing key parties including the injured worker, employer, nominated treating doctor and other service providers to achieve agreed goals maintains regular and appropriate contact with all parties to determine the injured workers progress and possible barriers to progress, or any risks of delayed return to work, recovery and finalisation accurately determines provisional and ongoing liability coordinates services and manages providers to achieve identified outcomes through a collaborative approach to medical treatment, return to work, dispute management, legal matters and other claims decisions has up-to-date knowledge of services that will meet the needs of the injured worker and achieve goals approves appropriate and effective services is active in the management of the claim and has the authority to direct service providers and key parties in ongoing achievement of goals and outcomes throughout the claim regularly reviews all aspects of the claim, including service provision, service levels and appropriateness of treatment, service providers adherence to protocols and guidelines, ongoing liability, claim estimations and recovery potential considers WorkCovers Claims Estimation Manual.

Roles, responsibilities, levels of authority and legal obligations of the organisation, injured worker, employer and service providers who influence case management outcomes must be identified and supported by management and training systems.

Information management and support systems Relevant, accurate and timely data ensures consistent and up-to-date management of claims, provided systems and practices are regularly reviewed. Management systems facilitate decision-making and assists the case manager to: identify factors as early as possible that place recovery or return to work at risk record case management activities and actions identify, diarise and monitor milestones, including capacity to prompt review dates review activities retrieve claim details identify exceptions.

Communication Clear and accurate communication forms a central feature of case management. The provision of effective internal and external communication systems support, encourage and direct communication between key parties. Key elements of effective communication includes: provision of information about roles, responsibilities and obligations of key parties to ensure realistic expectations confidentiality and informed consent . application of a customer-focused approach demonstration of assertive and empathic communication, interview, listening and reflecting skills consideration of stakeholders literacy levels.

Privacy Legislation requires that all privacy, confidentiality, consent and security issues relating to case management be adequately addressed.

Risk management A risk management approach to the provision of best-practice case management identifies the likelihood of strategic and operational risks that could adversely affect delivery of case management. It identifies where systems and practices fail, and allows rapid remedial action to be taken. Mechanisms to set and review case loads appropriate to the nature of the claim and the competency of the case manager are required.

PRINCIPLE 2 TRIAGE AND SCREENING

Principle
Early and accurate identification of the needs, risks and potential barriers to achieving health and return to work outcomes ensures the focus of management is upon risk factors indicative of poor outcomes. Categorising claims according to the risk of delayed return to work, long-term disability and delayed finalisation allows the organisation to quantify, track and prioritise claims activity, and assign claims to a case manager with relevant skills. Re-screening throughout the life of the claim facilitates periodic review of risk factors and barriers to ensure that intervention is effective in mitigating the risk and reducing the impact, and continues to be relevant to the worker and key parties. These reviews provide evidence to support or refine the screening system.

Components
Evidence-based systems and practices Triage is sorting claims into broad categories and making an early assessment about the extent to which an injured workers return to work and recovery are potentially at risk. Evidence-based systems and practices for gathering accurate and relevant information are essential to effective triage. Screening and re-screening is an assessment of risk factors, psychosocial indicators and return to work barriers. An effective screening tool must be consistent, replicable, research-based and capture data. Screening facilitates assignment of the case manager with appropriate competencies relevant to the claim, allocation of resources and prioritisation of activities.

Risk management Strategies are required to identify, manage and mitigate risk factors and return to work barriers. Inappropriate action to address these risks and barriers will jeopardise goals, compromise the effective use of resources, and increase claims costs. It is vital to establish risk management strategies and evaluate them over a period of time. Screening is only valuable when accompanied by an accurate response to the risk factors.

Timeframes Systems must be in place to ensure the case manager performs initial screening of all claims within the required timeframes, as outlined in section 43(4) of the Workplace Injury Management and Workers Compensation Act 1998. Risk factors and return to work barriers vary throughout the life of a claim. Screening occurs on an ongoing basis, and at pivotal points in the life of a claim, to improve effective management and identify milestones not achieved. Screening may also highlight a need for more intensive management, or alternative management. It identifies the impact of intervention on risk factors, changes in risk factors, and the development of new barriers and new risk factors.

PRINCIPLE 3 CLEARLY-DEFINED PRACTICES

Principle
Clearly-defined practices reflect case management that proactively moves the claim towards finalisation and manages the expectations of key parties. These practices support appropriate interaction with key parties that ensure injured workers and employers receive services in a supportive, efficient and cost-effective manner. They underpin the delivery of proactive case management that is aligned with the legislation. The identified outcome and service delivery of each practice should be attuned to the organisations case management philosophy. These practices may be performed concurrently, or in isolation, but no practice should compromise the objectives of the case management plan.

Components
Early contact and assessment Initial contact must occur within the legislative timeframe. It should involve a comprehensive assessment to: establish a positive relationship with each stakeholder and assess their needs establish facts and analyse information to facilitate sound decision-making engage the injured worker and identify potential risks or barriers to return to work identify realistic outcomes identify resources and interventions required to achieve outcomes.

The case managers contact in the early days of a claim is critical in setting direction and is the first opportunity to commence case management planning.

Claim finalisation Claim finalisation requires the case manager to set expectations and explain the benefits of early case closure to all key parties, based on expected recovery and return to work timeframes. Finalisation does not mean rushing to finalise a file. Problems may arise. Goals may need to be redefined. At all times, however, service providers need to be managed proactively and strategies need to be in place to mobilise the claim to finalisation.

Case management planning Case management planning is a consultative approach to align expectations with key parties about how the injured worker will achieve health and return to work outcomes. Development The case management plan is an agreement between the case manager, injured worker, employer and, where appropriate, the nominated treating doctor. The plan confirms expectations and defines the objectives and responsibilities of all parties. It outlines the actions required to mitigate risk factors and return to work barriers. The plan establishes measures, timeframes and review points for achieving each goal and activity.

The case management plan incorporates the injury management plan, which is defined in the Workplace Injury Management and Workers Compensation Act 1998. A copy of the injury management plan is provided to the injured worker, the nominated treating doctor, the employer and provider (if required) within four weeks of receiving the claim (if the claim is not finalised). Implementation Implementation of the case management plan involves the case manager identifying and implementing the plans actions, and establishing and coordinating services. It includes communication with all key parties and agreement on expectations. Implementation requires: timely and accurate information regarding the goals, outcomes and proposed actions information that is clear, concise and understood by the recipient instant response to problems and potential barriers to progress effective and efficient service delivery.

Review Active and regular review of the plan implementation ensures that all key parties achieve their goals and meet their responsibilities, as the injured worker moves toward the identified outcomes. When new information is received, or circumstances change, a review is essential. Review of the case management plan involves: contacting key parties to track progress against outcomes and if necessary realign expectations ensuring return to work goals remain appropriate identifying barriers to progress and case finalisation documenting actions updating the plan when necessary.

A review requires active, ongoing assessment of the claim, and the plan must always adhere to the Claims Estimation Manual.

File handover File handover requires the new case manager to: review the claim and case management plan establish relationships with key parties re-establish responsibilities and commitment of the key parties.

Payment of benefits and entitlements The case manager must ensure that workers receive their entitlements, employers are reimbursed for wages paid, and providers receive payments for their services in a timely, accurate manner. This avoids complaints and disputes and assists early return to work.

Complaints management Complaints management includes a customer service focus that ensures early resolution of complaints. Strategies to resolve complaints are reflected in the case management plan.

Dispute management Dispute management includes integration of the Workers Compensation Commissions timeframes and an internal review mechanism to monitor and prevent unnecessary disputes. Strategies to resolve disputes are reflected in the case management plan.

PRINCIPLE 4 PEOPLE MANAGEMENT AND LEARNING AND DEVELOPMENT SYSTEMS

Principle
Human resources systems must support recruitment, professional development, training and performance management to enable full and effective application of case management.

Components
Case manager skills and knowledge The skills and knowledge of an effective case manager include: knowledge of: o workers compensation legislation, including privacy and confidentiality and claims and injury management o o o service provider management medical treatment, injury and disability management organisational processes and procedures (including records management, health and safety practices, management of conflict of interest) leadership skills decision-making skills customer focused approach communication, negotiation and people management skills self-directed approach (takes initiative and prioritise activities) team member skills (demonstrates personal integrity and respects the values and experiences of others) analytical and problem solving skills information technology skills dispute and conflict resolution skills.

Recruit and retain case managers An organisation should develop an adequate skills base by: providing sufficient skilled resources to match work loads assessing the workforce and its competencies identifying recruitment strategies and employing staff with the appropriate skill set implementing initiatives to retain staff.

10

Case manager support A performance management system will support the development of case manager skills and identify practices that provide opportunities for new case managers. The system will include: objectives and key performance indicators review and evaluation of performance skills and competency analysis professional development plan training, mentoring and coaching.

Learning and development To ensure knowledge and skills are developed and maintained, continuing learning and development programs are essential. Conferences, seminars, internal training sessions and mentoring programs will enhance the competencies and skills of a case manager.

11

PRINCIPLE 5 RECORDS MANAGEMENT

Principle
The scope of records management includes all communication in relation to a claim. A system must be implemented that will deliver complete, accurate, timely, secure and accessible information that contributes to an injured workers claim.

Components
Records management systems A records management system must comply with legislative requirements for record-keeping. It includes: case record identification archive, storage and retrieval procedures a record of events, including communication with key parties workers rights to give the authority to release and obtain information, application of confidentiality and privacy principles to the collection, maintenance and storage of information.

Documentation
Documentation provides tangible evidence about the chronology of a claim. It includes: case management plans notes about conversations with key parties, correspondence about the claim notes about claims activities, decision-making, expected outcomes internal and external responsibilities reviews by senior staff.

12

PRINCIPLE 6 SOUND DECISION-MAKING

Principle
Sound decision-making is free of preference and prejudice. It considers outcomes for the injured worker, the employer, and the NSW workers compensation system. Sound decision-making means considering options, then acting.

Components
Decision-making model A decision-making model needs to be clearly understood and consistently adopted by the case managers. It must be informed, outcomes-focused, cost effective, evidence-based and meet records management principles. See attachment 1 for further information.

Sound decision-making Sound decision-making reflects consistent application of an effective decision-making model in all aspects of case management. The case manager makes decisions in relation to liability, purchase of services and resources, reasonably necessary treatment, and use of expert opinion and assessments. Accurate and prompt decisions about entitlements to benefits and ongoing treatment ensure that case management initiatives are not compromised. A knowledge of available services and access to approved service providers is essential. To progress a claim, the case manager relies on available resources, recommendations from experts and appropriate use of the legislation.

Documenting decisions The case manager must document decisions. Case notes should include: information for consideration information relied upon to make decisions reasons for decisions expected outcomes of the decision to whom this information is communicated the final decision.

Communication Communicating decisions to all key parties in a transparent and consistent manner will: facilitate cooperation avoid confusion contribute to fewer complaints and disputes enhance involvement.

13

Protocol To assist the case manager handle complex issues, such as what treatment is reasonably necessary, protocols need to be developed to avoid misunderstandings between key parties. Sound decision-making on complex issues will identify escalation points and the potential for mentoring.

Review mechanisms Mechanisms must be in place to review the appropriateness, or otherwise, of the case managers decision-making practices for each and every claim, and across all claims generally.

14

PRINCIPLE 7 COST-EFFECTIVE SERVICE

Principle
Outcome-focused management of the injured worker and their claim for compensation includes the need to effectively manage the overall costs associated with the workers recovery, and determination of the vocational and return to work goals. There must be effective systems for: evaluating costs managing expenditure assessing outcomes against costs.

To be cost-effective, the service/treatment is likely to make a significant contribution to the injured workers recovery and their ability to return to work. However, the most cost-effective service/treatment is not always the cheapest option, nor is the best service/treatment always the most expensive.

Components
Criteria for purchasing provider services The purchase of provider services is based on qualifications, availability, accountability and ongoing evaluation of performance. Service providers are evaluated, selected and re-evaluated to ensure the case manager has ready access to the most appropriate services.

Costs and outcomes The evaluation of costs against outcomes is fundamental to decision-making about cost-effectiveness across provider services. The case manager requires information about: the motivational drivers of key parties the service costs outcomes against service provided previous expenditure, trends efficacy of requested services.

Access to information It is important that the case manager has ready access to a variety of information as a minimum, the profile and contact details of preferred and WorkCover-approved providers.

15

Provider management To ensure cost-effective selection and provision of services, organisations will establish: regular cost-benefit assessments of provider performance measures to identify and prevent ineffective and unnecessary services practices to manage/correct poor service and over servicing performance and service standards.

16

PRINCIPLE 8 QUALITY ASSURANCE AND CONTINUOUS IMPROVEMENT

Principle
Ongoing review, analysis and evaluation of systems and work practices, tools and resources are essential for effective and efficient case management. Using the data allows the organisation to identify areas of strength and opportunities to implement improvement strategies to enhance performance and achievement of outcomes.

Components
Documented procedures To ensure consistent case management practice across the organisation, documentation of essential procedures is necessary.

Review practices, measure outcomes and analyse data An organisation should implement appropriate techniques to review, measure and analyse the delivery of objectives across all case management principles. Techniques would include outcome analysis, peer and self reviews, identification of exceptions and analysis of customer feedback. Information management systems create a basis upon which to collect timely and accurate data to undertake analysis of performance, evaluate decisions and assess strategies.

Customer feedback Quality frameworks incorporate comprehensive complaints management and customer satisfaction systems. The information is collected and reviewed regularly and used as a source of evidence to continually improve practices and systems.

Continuous improvement Continuous improvement involves gathering evidence, turning data and evidence into knowledge and refining practices and systems to mitigate gaps and implement improvement opportunities. At an operational level, organisations will adopt a continuous improvement model that ensures opportunities are thoroughly analysed and strategies planned, piloted, refined and implemented to ensure improved performance and outcomes.

17

GLOSSARY
case management a coordinated and managed approach that integrates all aspects of claims injury management, including treatment, rehabilitation, retraining, liability determination, factual investigation, estimation and employment management practices for the purpose of achieving optimum results regarding a timely, safe and durable return to work for injured workers. case management plan a plan for coordinating and managing all aspects of claims and injury management it may be an in-house plan. case record all components of a workers case file, including electronic and paper records. clearly-defined practices case management practices that proactively move the claim from notification towards finalisation and manage the expectations of key parties to ensure agreement in relation to the purpose, delivery timeframes and expected outcomes. claims and injury management activities and practices undertaken to achieve a timely, safe and durable return to work for an injured worker, within legislative parameters. components injury management plan elements of a principle. a plan for coordinating and managing the treatment, rehabilitation and retraining of an injured worker to achieve a timely, safe and durable return to work. key parties injured worker, employer, nominated treating doctor, lawyer, union representative, insurer/agent, and other service providers. risk management the likelihood and severity of potential risks eg. environmental, social, political, technical, legal, economic and competitive.

18

ATTACHMENT 1
This attachment is an example of a decision-making model. A decision-making model needs to be clearly understood and consistently adopted by the case managers. It must be informed, outcomes-focused, cost effective, evidence-based and meet records management principles. The optimum decision-making model describes how individuals should behave to maximise an outcome. The model involves: ascertaining the need for a decision identifying the decision criteria allocating weights (values) to each of the identified criteria developing alternatives evaluating alternatives selecting the best alternative. Ascertaining the need for a decision The existence of a problem or, at a point in the defined practice, a disparity between the desired state and the actual condition will result in recognition of the need to make a decision. Identifying the decision criteria The criteria needs to be identified and, for frequently-made decisions, defined. The criteria are those factors that need to be considered in reaching the decision and the desired outcome. These are ingredients, not options. Allocating weights to the criteria Allocating weights to prioritise the importance of the criteria. All criteria may be relevant, but some more relevant than others some criteria will have a greater effect upon the desired outcome, and must be given greater weight in the decision-making process. Developing alternatives Determining all the options that solve the problem does not require weighting of alternatives, just identification of options. Evaluating alternatives Once alternatives have been identified, the decision-maker must critically evaluate each one by appraising each alternative against the weighted criteria the strengths and weaknesses of each alternative will become clear. This is best done by listing the criteria, assigning a weight, and listing the alternatives in a table format. Selecting the best alternative The best alternative is the highest score and, if the weightings have been accurately applied, this selection should lead to the most effective outcome. Reference: Robbins, Steven P Organisational Behaviour Concepts, Controversies, and Applications 4th Edition , New Jersey, Prentice-Hall International Editions 1989

19

BIBLIOGRAPHY
Gursansky D, Harvey J, Kennedy R, Case Management: Policy, Practice and Professional Business Sydney, Allen & Unwin 2003 Case Management Society of Australia, Journal of Case Management 2003 The Australasian Faculty of Occupational Medicine, Compensible Injuries and Health Outcomes Sydney, The Royal College of Physicians Health Policy Unit McMillan J, Case Management Systems in the USA, National Centre for State Courts 1998 Roberts DY, Reconceptualising Case Management in Theory and Practice, Melbourne Health Services Management Research, Research Directions for Case Management 2002 Robbins, Steven P Organisational Behaviour Concepts, Controversies, and Applications 4th Edition New Jersey, Prentice-Hall International Editions 1989

Related documents
AS/NZS ISO 9001:2000 Quality Management Systems Requirements AS/NZS ISO 9004:2000 Quality Management Systems, Guidelines for Performance Improvements AS4269-1995 Complaints Management System Requirements Case Management Standards 2004 (replaced by Case Management Principles 2005) Case Management Assessment Guidelines 2004 Case Management Assessment Guidelines 2005 Workers Compensation Act 1987 Workplace Injury Management and Workers Compensation Act 1998.

20

WorkCover NSW 92-100 Donnison Street Gosford NSW 2250 Locked Bag 2906 Lisarow NSW 2252 WorkCover Assistance Service 13 10 50 Website www.workcover.nsw.gov.au
Copyright WorkCover NSW 1105. Production and printing by Salmat 02 9743 8777