Telephonic case managers coordinate with the injured worker andtreating providers without face-to-face interaction. Although sometelephonic case managers are RNs and handle complex cases, oftenthese case managers have less extensive clinical backgrounds andare limited to scheduling appointments and facilitatingcommunication between the patient, the employer/carrier and thehealth-care providers.

The typical field case manager is a seasoned rehabilitationspecialist (typically an RN) who lives in the local area and bringsvalue to both the injured worker and the insurance adjuster byknowing the local medical community and understanding the medicalissues resulting from the work injury. The field case manager helpsthe worker understand his injury and helps the adjuster (who oftenlives in a different city or state) find the most appropriatehealth-care providers. The more serious the injury, the more valuea case manager can bring to the claim.

Catastrophic case managers provide case management for themedically complex cases, such as spinal cord injuries, headinjuries, amputation, or multiple trauma. The catastrophic casemanager often is brought into the case immediately after injury,and may counsel the family at the hospital.

Going Global

But what happens when the injury is catastrophic, the injuredworker has been stabilized and wants to go home? If the injuredworker is from the local community, the case manager assists withhome modifications, transportation, and coordinating on-goingmedical care. If the injured worker will be living with family inanother state, the adjuster transfers the case to a new casemanager. This is a little more complicated, but with today'sselection of national case management companies, the adjuster canfind a good case manager who can set the injured worker up with newphysicians in the new location.

In our global economy, just as goods and services cross borders,so do workers. In cases of a catastrophic injury to a foreignworker in the U.S., the employer/carrier remains responsible foron-going care. It is not unusual for the injured worker's family towant him to return to home, and for the injured worker to want tobe with family. With complications such as language barriers andhealth-care providers unfamiliar with the U.S. workers'compensation system, the need for case management increases.

A good international case manager brings value to the case byassisting the carrier identify local (i.e., injured workers' homecountry) medical providers and facilities that not only provide theappropriate level of medical care, but also represent a significantcost savings for the care (when compared to the cost of that carein the U.S.). The following examples of recent cases are typical ofthe cost of medical care in another country:

Example 1. Pneumonia, traumatic brain injury. Total Cost:$27,000

• $25,000: 10-day in-patient hospitalization, Mexico City PrivateHospital
• $12,000: Second 10-day in-patient hospitalization, Mexico City,National Institute for Respiratory Diseases

Example 2. Paraplegic/spinal cord Injury. Patient lives in ruralarea in Mexico. Total costs per year: $1,200 - $1,800

• Spinal cord injury evaluation every two years, two-dayin-patient stay, renal sonogram, renal ultrasound, X-rays, EKG,laboratory studies, family physician, internal medicine,urology
• Additional annual costs: $1,700

International Team

These examples illustrate the cost containment advantages thatmay result from using local health-care providers. However,integral to the success of the process is an experiencedinternational rehabilitation team. The team typically includes aseasoned U.S.-based case manager, a U.S.-based rehabilitationphysician with a background in carrying for injured workers, and anon-U.S.-based physician who serves as the local medicaldirector.

The case manager performs the usual case management roles, withthe added responsibility of identifying the other members of theinternational rehabilitation team and coordinating theiractivities. The U.S.-based physician is a board certified physicalmedicine and rehabilitation (PM&R) physician with experiencetreating spinal cord and other traumatic injuries. In addition, theU.S. physician must be knowledgeable on disability guidelines andcompensability issues. The third member of the team, the localphysician (licensed as a treating physician in the country of theinjured worker) is an extremely important member. This doctoradvises on, and helps evaluate, the local health-care resources. Aspart of that countries' local medical community, he establishes thecredibility of the other team members. The international physicianis similar licensed in PM&R and is familiar with the variousmedical and disability management of spinal cord injuries, headinjuries, and poly-trauma cases in his country. The internationalphysician also works closely with the international case managerfor coordination of medical services and payment of medicalproviders, in accordance with required medical documentationprocesses.

A successful international program:

• Evaluates local health-care providers to make sure theirservices are equal to the care standards the injured worker wouldreceive in the U.S.
• Assures that only medically necessary treatment related to thework injury is paid for by the insurance carrier. As adjustersknow, it is often difficult to educate U.S. providers on thisissue. Educating health-care providers in another country is evenmore challenging.
• Provides communication during the year, as needed, with localproviders
• Facilitates a smooth transfer of care from the U.S. to the homecountry

As dramatic as the cost savings can be, equally important arethe socio-psychological benefits for the injured worker. A languagebarrier often exists when an injured worker whose native languageis not English receives care in the U.S. This hinders not only thepatient's full under understanding of his medical condition, butalso the development of a good physician/patient relationship.Cultural differences and expectations may be subtler, but just asmuch of a barrier to the patient's wellbeing. Returning the patientto his home country reunites him with his family and to a medicalsystem that is complementary to his beliefs and culture.Additionally, the indemnity benefits the injured worker continuesto receive most likely will provide a higher level of living in thelocal economy.

For settled cases, the trust administrator retains a higherlevel of control and oversight by the on-going involvement of aninternational case manager.

Naomi G. Anderson, RN, CDMS, CCM, CLCP, is president ofAries Management Services, a case management and life care plancompany. She may be reached at 432-426-3080 [email protected]; www.ariesmanagementservices.net.