case management principles 2787

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CASE MANAGEMENT

PRINCIPLES

WorkCover.Watching out for you.

NOVEMBER 2005


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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This publication may refer to WorkCover NSW administered legislation that has been amended or repealed.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).


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CONTENTS PAGE

INTRODUCTION 2

PRINCIPLE 1 CASE MANAGEMENT PHILOSOPHY AND CASE MANAGERS ROLE 4

PRINCIPLE 2 TRIAGE AND SCREENING 6

PRINCIPLE 3 CLEARLY-DEFINED PRACTICES 7

PRINCIPLE 4 PEOPLE MANAGEMENT AND LEARNING AND DEVELOPMENT SYSTEMS 10

PRINCIPLE 5 RECORDS MANAGEMENT 12

PRINCIPLE 6 SOUND DECISION-MAKING 13

PRINCIPLE 7 COST-EFFECTIVE SERVICE 15

PRINCIPLE 8 QUALITY ASSURANCE AND CONTINUOUS IMPROVEMENT 17

GLOSSARY 18

ATTACHMENT 1 THE OPTIMISING MODEL OF DECISION-MAKING 19

BIBLIOGRAPHY 20

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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 approachthat 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, safeand 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.

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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.

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screening

practices

people

records

decisions

cost-effectiveness

quality assurance and continuous improvement

case management philosophy

and case managers role


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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.

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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.

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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.

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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.

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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.

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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 managementincludes 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.

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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 service provider management

o medical treatment, injury and disability management

o 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.

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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.

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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.

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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-basedand 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.

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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.

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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 theworkers 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.

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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.

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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 ensuresopportunities are thoroughly analysed and strategies planned, piloted, refined and implemented to ensure

improved performance and outcomes.

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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 elements of a principle.

injury management plan 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.

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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-basedand 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 thecriteria. 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

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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.

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