Targeting Clinical Support to Improve Outcomes

By Jamie LaPaglia, RN, CCM

Implementation Manager & Clinical Educator
ODG an MCG Health Company

At the beginning of a claim, it can be difficult to know if or when referring to a case manager would be helpful. Having a case manager at the beginning of every claim would seem valuable, but it would dramatically increase overall costs, stretch limited resources too thin, and might fail to focus on critical claims.

Historically, knowing if and when to use these limited resources has been elusive. However, several tools are now available to help identify which claims would benefit from referral: various risk assessment and long-term disability predictor scores, soon to be amplified and automated by artificial intelligence.

Several models support the benefits of case management, with studies going back decades; a 1987 Intracorp study reviewed 300,000 disability claims and identified timely referral to a case manager as the best predictor of a good outcome.¹ More recently, a 2015 report from Safety National compared shoulder surgery claims with a nurse case manager at one employer to claims without a case manager at 31 other companies. The study found 57% shorter disability durations for the managed cases, 18% reduction in projected medical costs, 26% reduction in total loss dollars, and 15% reduction in additional lost time from work.²

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