Center of Occupational Health & Education (COHE)

transcript

Renton COHE APP2013-2014 Annual Training

Each Center of Occupational Health & Education (COHE) is a contractual partnership between the Department of Labor & Industries (L&I) and healthcare organizations. ◦ Facilitate the implementation of

occupational health best practices during the early phase of a claim.

◦ Promote collaboration between stakeholders (Labor, Business, Unions, Providers, Insurers) involved in a worker’s injury or illness.

COHE Claim◦ WA State Workers’ Compensation State Fund

claims ◦ NOT: Federal, Self-Insured, Tribal or Out of State

Workers’ Compensation claims. Claim filed with a COHE provider and/or

COHE provider is the attending provider on the claim.

Resources focused on claims within the first 90 days of claim being filed.

Reduce Worker Disability Improve Employment Outcomes

Promote Patient SatisfactionEnhance Clinical Efficiency

Community◦ Renton COHE – Valley Medical Center◦ Western WA COHE – Franciscan Medical Center◦ Eastern WA COHE – St. Luke’s Medical Center

Institutional◦ The Everett Clinic◦ Group Health Cooperative◦ Harborview

Establish Mechanism to Identify High Risk Cases for Long Term Disability

Develop Procedures for Coordinating Care Implement Quality Procedures & Best

Practices Foster Communication between Providers,

Workers & Employers Offer Training & Mentoring in Occupational

Health Best Practices to Participating Providers

Provide Feedback to Providers on their Performance

12111098765432100

% IW Receiving Disability Payments

Time-Loss Duration (months)

Early Intervention PeriodFocus of COHE Activities

Substantially prevented long-term disability, reducing costs by an average of $480 per claim & lost work time by an average of four days.

Savings continue to accrue three to four years after the claim is filed, even though the current COHE intervention occurs during the first 90 days of the claim.

In the first year alone, the COHEs (Renton & Eastern Washington) saved approximately $8 million compared to control groups.

Claims treated by COHE providers resolve faster◦ Faster resolution may be due to COHE Best

Practices preventing some medical-only claims from becoming time-loss. (Wickizer, et al, 2007)

Majority of COHE providers are medium or high adopters of COHE Best Practices◦ Currently 62% of COHE providers are high &

medium adopters. COHE’s are striving to improve the adoption rate to 80%.

50% of inured workers have access to a COHE provider

Community based Reduced disability Encourage clinical best practices Provider must be in catchment area Deliverables

◦ Physician Recruitment, Enrollment & Training◦ Clinical & Occupational Health Advisors◦ Health Services Coordinators◦ Best Practices & Quality Improvement

Methods◦ Communication & Community Outreach◦ Performance Monitoring & Annual Review

Over 200 Providers◦Chiropractors◦Emergency Physicians◦Family Physicians◦Nurse Practitioners◦Physician Assistants◦Specialty Providers Neurology, Occupational, Orthopedics,

Podiatry, Physical Medicine & RehabilitationAround 5,500 Claims Annually

Report of Accident (ROA)◦Timeliness To L&I within 2 business days of initial

office visit Speeds up processing & adjudication of claim Strong association between time from injury

to receipt of claim at L&I and substantially longer duration of time loss

80% benchmark

Must complete each box to avoid delay in claim adjudication

Claim is initiated at L&I by the completion of the ROA.

Missing information may unnecessarily delay the adjudication of the claim, delaying treatment and payment for services.

When the ROA is received at L&I within 2 business days of the initial office visit, you receive higher payment for completing this form.

L&I processes COHE claims twice as fast as non-COHE claims.

When determining whether to file a claim for a patient:◦ If patient asks you to file a claim, you must

regardless of your opinion as to it’s work-relatedness. Indicate on the ROA that the claim is work-related or

not. Inform the patient that inappropriate filing of a claim

can cause delays in payment by other insurers.◦ Claims should be filed even for minor injuries.◦ Fear of retaliation by employer.

Inform patient that the law protects them from discrimination for filing a claim.

If patient refuses to file and you feel condition is work-related:◦ Tell patient of his/her rights under the law (Title

51) and provide assistance with filing claim. If patient still refuses, should not file claim.

◦ L&I will not pay for visit if ROA is not completed and filed.

◦ Patient cannot seek payment from other insurers by withholding that condition is work-related.

Title 51 prevents an employer from paying directly for an injured worker’s care to avoid filing a claim.

Determining Work-Relatedness◦ Depends on a variety of factors (medical, legal

and administrative) ◦ May be difficult to determine◦ In box 7 on the ROA, you are required to answer

yes/probably or no/possibly By law, a claim can be accepted only if the provider

states the condition is work-related “on a more probable than not basis” or greater than 50% certainty, e.g., yes/probably.

◦ For condition to be work-related, the industrial injury or exposure must be a “proximate cause” of the diagnosed condition.

Activity Prescription Form (APF)◦Complete at first office visit ◦Complete with any work status change

Gives claims manager & employer information on the tasks worker can do.

Better chance of worker returning to work in a timely manner.

Claims manager uses form for time loss certification & treatment authorizations.

HSC uses the APF to facilitate return to work efforts with employer.

◦80% benchmark

General Section

◦ Patient stickers may be used, as long as all the requested information is provided.

◦ Either ICD-9 codes or written diagnoses may be listed in the diagnosis box.

◦ Providing this information will ensure the form gets into the correct claim file.

◦ Including the provider’s name and the visit date is important for billing purposes.

Released for Work Section

◦ If released to job of injury without restrictions, skip to “Plans” section.

◦ Objective medical findings are needed to certify time loss or loss of earning power benefits.

◦ Be realistic on “to” dates. May not necessarily be the next office visit, but the point at which patient’s status is expected to change.

Released for Work Section Cont’d◦Must include at least one “key objective

finding”.◦Examples of objective findings are:

Limited ROM Decreased strength Swelling Muscle atrophy Do not include subjective complaints such as pain,

tenderness or fatigue.◦Be specific with date ranges.

Estimate What Worker Can Do Section

Estimate What Worker Can Do Section◦Enables employers to identify potential

light/modified duty positions.◦Complete with assumption that light/modified

duty is available.◦Check as to how long the current capacity will

last or if are permanent.◦Estimate based on provider’s clinical opinion.

Conservative estimates are acceptable.◦ MUST be completed even when worker is not

released to work. For worker to understand what should physically do and

not do to enhance recovery.

Estimate What Worker Can Do Section◦ Only address restrictions applicable to claim

covered condition. Boxes left blank will be considered as not

restricted.◦ “Other instructions” could include need to

elevate limb periodically, no use of left arm, etc. Be specific.

◦ Note to claims manager is intended to help you draw the their attention to an issue, i.e. “need authorization for…” Also has space for new diagnosis and opioid prescriptions.

Plan/Sign Section

◦ Quickly/briefly establishes plan for rehabilitation.◦ Succinctly indicates whether patient is progressing.◦ Comments are strongly encouraged.◦ Identifies what should happen next.

Alerts claims manager to actions needed, e.g., impairment rating exam schedule, Independent Medical Exam needed, claim closure.

Provider-Employer Contact◦ Provides timely communication between

provider and employer regarding return to work

◦ Call employer at or after the initial office visit. Ascertain if light/modified duty available. Provide information on worker’s restrictions,

treatment planned, etc.◦ Note outcome of contact with employer on

section in APF.◦ Contact employer at or after subsequent

office visits as needed.◦ Be sure to bill for phone call and use

appropriate modifier.◦ 25% benchmark

Barriers to Return To Work Addressed◦Worker has been off work 4 weeks or

greater Receiving time loss

◦Ascertain reasons worker is off work◦Develop action plan◦Identify clinical evaluation/rehab

services needed◦80% benchmark

Barriers to Return To Work Addressed◦Barriers Exam Can be completed by the APP or a COHE

Advisor. In addition to the regular exam. Must include an extensive SOAPER note

addressing barriers.◦Medical Case Conference◦HSC Services Billed

S: The worker’s subjective complaints

O: The provider’s objective findings A: The provider’s assessment P: The provider’s treatment plan E: Employment issues R: Restrictions to work

Set expectations for injured workers regarding return to work.

Help avoid administrative claim delays. Eliminate barriers to care. Facilitate communication with all parties. Establish & maintain communication with

employer. Enhanced payment for services if provider

meets the Occupational Health Best Practices benchmarks.◦ Scorecards are published by L&I on a quarterly basis.

Care of the injured worker.◦ Make the diagnosis.◦ Comment on work-relatedness.◦ Complete ROA.◦ Always consider work abilities.◦ Complete APF.◦ Include claim number, date of injury and

employer on each patient encounter. If help is needed with the patient’s return to

work process, please contact an HSC.

COHE Project Directors◦ Jaime Nephew, PT, DPT, MBA, FACHE◦ Grace Casey

COHE Medical Directors◦ Karen Nilson, MD◦ Scott Morris, MD

COHE Advisors◦ Wide variety of disciplines represented

COHE Health Services Coordinators (HSC)◦ Diena Wasson, RN-BC, CCM, BSN◦ Ellen Hull, M.Ed., CRC◦ Heather Latvala, M.Ed., CDMS◦ Kathryn M. Visser, M.Ed., CDMS

One-on-one training◦Promote occupational health best practices◦Provide training for nurses and other office

staff Assist with return to work coordination

◦Even missing 3 to 7 days of work can increase disability and a long-term earning capacity.

◦Research has shown that a worker remaining on payroll during recovery has a greater chance of full recovery and a higher family income while recuperating.

Evaluate potential barriers to return to work early to prevent ongoing disability

Identify claims that are at risk for long-term disability.

Intervene on claims that need HSC assistance.

Track claims to ensure early return to work services, care coordination and improved clinical outcomes of injured workers.

Act as a liaison, on behalf of the provider, between injured worker, employer and L&I.

Help employers, providers and injured workers navigate the Workers’ Compensation system.

Renton Worker Survey◦As satisfied as on key satisfaction

measures of: Quality of Care Coordination of Care Overall Treatment Experience

◦Better employment outcomes 55% more likely to return to same

employer 65% more likely to be working at time of

survey

Renton Provider Survey◦75% indicated they have improved

ability to treat Injured Workers◦74% are satisfied with their

experience◦70% reported improved ability to

communicate with employers◦50% stated they are more willing to

treat Injured Workers

Please see attached COHE APP Quiz 2013 Microsoft Word document for instructions and to complete the quiz.

Center of Occupational Health & Education (COHE)

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