A Case Managers Role in Managing Shoulder Injuries

1
A Case Managers Role in Managing Shoulder
Injuries

• Joanne L. Sargent RN, CCM, CPUR
• April 24th 2007

2
Objectives

• Establish a team approach in managing shoulder,
  arm and neck injuries
• Understand the MA UR guidelines in relation to
  shoulder injuries
• How to facilitate the case to the specialist
• Address RTW strategies and rehabilitation
  following surgery

3
Definitions of Case Management

• Services which will assist an injured worker in
  gaining access to needed medical, and other
  ancillary services.
• coordinating services for injured workers.
• A formal strategy which coordinates and
  facilitates access to a variety of services in a
  timely manner for people who need assistance in
  organizing and managing their care.

4
Team Approach and Communication is

• The
• Key
• To
• Successful CM

5
Responsibilities

• Ideally case management for the injured worker
  begins at the time of the injury!!!!! And
  continues until the employee has returned to work
  and sometimes beyond

6
(No Transcript)
7
The first step is knowing when its appropriate
to refer your injured worker, then..

• Educating the injured worker and our clients when
  referral to a specialist is appropriate

8
Case Review

• 77 year old female
• Date of injury 3-31-2005
• Right shoulder fracture when she fell extending
  her right arm to brace her fall.
• Discussed with family referral into Boston

9
Radiology Report

• Significantly displaced fracture involving the
  neck of the humerus
• The humeral shaft is displaced inferior to the
  glenoid fossa
• A large bony piece is seen just below the humeral
  head
• Joint space is significantly widened consistent
  with a large hemarthrosis

10
(No Transcript)
11
Case review continued

• On 4-4-2005 she underwent a Right Shoulder
  Cemented Hemiarthroplasty
• 1gram of Ancef given pre-operatively
• Pre-op labs results
• WBC 10.1
• Sedrate 29 ( 0-30)

12
(No Transcript)
13
Complication Concerns ??
14
Post Op course

• Within 2 weeks wound began to drain
• WBC was 15,000
• Sed rate was 119
• On 4-25-2005 had an operative ID with hemovac
  placement
• IV antibiotics
• Post Op diagnosis was Wound infection as a
  consequence of significant traumatic hematoma
  suffered at admission

15
Postoperative course cont

• In June of 2005 orthopedist concerned about joint
  infection recommends removal of the arthroplasty
• Sling swathe for 6 months
• 6 months of antibiotics
• Referral to Boston for a Reverse Shoulder
  Prosthesis
• this was based on his opinion of her
• x-rays

16
(No Transcript)
17
(No Transcript)
18
Dr. Curtis
19
(No Transcript)
20
Dr. Curtis Evaluation

• Evaluated x-rays
• Not convinced there is an infection
• Evaluated hospital course and primary orthopedist
  recommendations
• Suggests a referral to Dr. Mason

21
Case Conclusion

• Sees Dr. Mason - follow up lab studies remain all
  normal
• Reviewed treatment options, surgery versus no
  surgery and discusses with her quality of life
• Patient had accommodations made for her ADLs
  except the ability to drive, so she had not
  achieved her full independence

22
Decides not to have the surgery
23
So when dealing with our practitioners keep the
following in mind
24
Written Communications To Practitioners

• Use short, concise letters
• Have information organized
• Free of typos/errors
• Clear identification of who they should contact
  if they need further information
• Follow-up with them to see if they have received
  information sent to them

25
Written CommunicationsContinued

• Send appropriate forms
• Condense the amount of paperwork you send to the
  specialist
• Complete as best as you can any forms PRIOR to
  appointment
• Include simple easy instructions

26
Job Capabilities Form
27
RETURN TO WORK RECOMMENDATIONS FOLLOWING
INJURY/SURGERY
Patients Name (First)
(Middle Initial) Last
Date of Injury/Illness
__________________________________________________
__________________________________________________
____________ Employer Name and Address  
__________________________________________________
__________________________________________________
__________ Diagnosis   _______________________
__________________________________________________
_______________   ______________________________
__________________________________________________
________
TO BE COMPLETED BY ATTENDING PHYSICIAN
(Please Check)
  I saw and treated this patient on
__________________________________ and
Date q       Patient is fully recovered
with no residual disability.   q      
Recommended he/she return to work regular duty on
_______________________.
Date q       He/She may return to work with the
following limitations on ____________________.
Date q       Patient is
unable to return to work at this time.  
  q       These restrictions are in effect until
reevaluated on _____________________________
Date q       Patient referred to Dr.
__________________________________ on
_______________________ Phone
__________________
Date q Referred to P.T.
__________________________ O.T.___________________
_____________
  Physicians Name_______________________________
Address__________________________ Telephone
No._____________________   Physicians
Signature Date   __________________________
__________________________________________________
_________________________
 
28
Release of Medical Documentation HIPPA
29
(No Transcript)
30
Some FYIs If using E-mail

• Keep messages to the point/brief
• NEVER use injured workers SS
• Use ONLY their case number with first last
  initials of their name
• Never use derogatory/inflammatory language

31
More Hints

• Suggest having MRI, x-rays, CT scan done before
  referral to help maximize the appointment and
  treatment options
• Know when to fold them!!!!!!!

32
RTW Strategies

• Provide Specialist with Work Capability Form
• Be familiar with Official Disability Guidelines
• If no release discuss options with client,
  adjuster..Medical Director IME
• Co attend important appointments to secure RTW

33
MA UR Guidelines

• Department of Industrial Accidents
• HEALTH CARE SERVICES BOARD
• Treatment Guidelines

34
Guidelines

• Guideline Number 3 Thoracic Outlet Syndrome -
  Vascular Origin-Venous
• Through
• Guideline Number 13 Shoulder Arthroscopy for
  Diagnostic Purposes Shoulder
• Deal with shoulders

35
Utilization Review Continued

• UR Agents also utilize secondary sources
• Internal Guidelines
• Medical Director input

36
Utilization Case Management

• A Case Manager cannot provide UR determinations
• CM notes and UR notes must remain separate
• UR and CM must maintain separate files
• CM cannot request a determination on a treatment
• CM cannot request medicals from UR without an
  authorization

37
Case Management, UR and Adjusters

• A CM can educate an adjuster as to when its
  appropriate to override a UR agents
  determination.
• Make sure the CM is familiar with the UR
  mandatory time frames to hold UR agents
  accountable and not delay treatment.
• You can report UR agents who do not comply.

38
Complaint Process
39
(No Transcript)
40
Complaint Process Cont

• The complaint and medical release must be signed,
  therefore the complaint should NOT be sent by
  E-mail
• http//www.mass.gov/dia/

41
Questions ??????