Employers and other workers' compensation/disability management payers tend to become complacent about long-term, complex claims. Many employees who suffer injuries or illnesses affecting more than one body system and requiring intense home health care stabilize and adjust to their "new normal." After reaching that stage, it is easy for the patient and the payer to lay low for a while. If the claimant is not complaining, and there are no big-ticket bills, then it is easy to let sleeping dogs lie.

This is a dangerous and expensive strategy. Dormant claims can be a ticking time bomb, blowing up suddenly and requiring hospitalization, 24-hour home health care or other costly interventions. One medical crisis can cost hundreds of thousands of dollars, and in many cases involve life-threatening conditions.

Numerous factors play into a medical incident, including the aging process, medications, weight gain, multiple physician involvement, change in residence, change in family/caregiver support system, and co-morbidities. As claimants age they become more susceptible to muscle weakness, torn or worn-out shoulders, polypharmacy issues, and co-morbidities such as diabetes.

Recovery from just about everything from wounds to respiratory infections takes longer as patients get older. As an example, a claimant under 40 will recover from a rotator cuff strain in 4 to 6 weeks, while it takes 12 to 36 weeks for someone over 40 to recover. Naturally, the longer the recovery, the higher the medical and indemnity expenses. Thoroughly examining long-term cases every year and changing therapy or equipment can prevent many medical blow-ups and their associated costs.

Changes Over Time
One example is a case involving a 23-year-old construction worker who fell from a roof and lost the use of his legs. Some injured employees stabilize and do well for years, and that was true for this man. In time, he learned how to use a wheelchair and was able to cook meals, bathe himself, and take care of his personal needs. He led an active life in his wheelchair throughout his 20s and 30s.

By stiffening his arms and putting his weight on his shoulders, he transferred himself in and out of the chair. The longer he was in the wheelchair, the greater the wear and tear on his shoulders. Eventually his shoulders gave out, and at age 45 he underwent bilateral shoulder surgery.

Unfortunately, the surgery left him a virtual quadriplegic, unable to cook, dress himself, handle bowel and bladder tasks, write a check, or even lift a fork. Instead of being a fairly independent paraplegic, the claimant now required 24-hour home health care.

This scenario is all too common and very preventable. At some point, most claimants need to be upgraded to a power chair that assists in transfers. If this claimant had been monitored and assessed at home at least once every year, an experienced assistive technology specialist would have noted the deterioration in his shoulder muscle and recommended a power lift chair to assist with transfers. Compare the $1,500 to $3,000 cost of the lift chair to the multi-thousand dollar price tag for surgery and 24/7 care—not to mention the emotional cost of the claimant's complete loss of independence—to decide if paying for an annual in-home assessment makes sense.

Drugs and Complex Care Cases
People with complex or long-term injuries are usually taking multiple medications, often two or three narcotics. There may be a mainstay pain killer and another for breakthrough pain. Patients often take Tylenol and muscle relaxers containing acetaminophen, which is known to cause liver problems. The type and quantity of medications taken tends to increase as people get older; medication for cholesterol, blood pressure, and depression are common among the 40+ group. Older claims should be reviewed every six months to a year to identify drugs that interact poorly with each other or that negatively affect bodily systems.

Proactive assessment and management of claims involving wounds are particularly important. Odd things, like the pressure of a tucked-in sheet on a person's toes that prevents healing, can be detected in a thorough in-home assessment.

Wounds and fractures often take longer to heal than they should. Bariatric chambers, nutritional improvements, changes in prescriptions, and patient and caregiver education can save thousands of dollars in wound care. The claimant may need a low-air loss mattress with tubes that have tiny holes that bleed out air slowly to keep the skin dry. Air mattresses create less pressure against the skin than foam and circulating air keeps the skin away from moisture, facilitating faster recovery. Yes, assessments usually produce recommendations for equipment or treatment, but the cost of these therapies pales in comparison with the costs of hospitalization and 24-hour care that can occur when symptoms go untreated.

Another good reason to proactively manage long-term cases is the emergence of new technologies. Better products may have been introduced to the market since the employee was injured. Frequently, new technology or equipment can reduce the hours of home health nursing care or the level of caregiver required. Advances in medical equipment such as beds that turn patients over without someone waking them up and physically turning them can eliminate overnight care altogether. New equipment can often reduce the level of care from a 24-hour RN to a 12-hour-a-day LPN and a 12-hour-a-day CNA.

In one case, utilizing a ceiling-lift system that enabled a single caregiver to transfer and position a patient, and changing the medication schedule so that all medication administration takes place between 7 a.m. and 7 p.m., allowed for a reduction in the level of care and the number of caregivers, saving the carrier more than $195,000 annually.

Finally, perhaps the best reason to regularly assess complex cases is the need for re-education. Over time, patients adapt to their conditions and some stop working out, using prescribed equipment or agreeing to therapy. Physicians and nurses will not pursue aggressive treatment when a patient refuses.

It is essential that the assessment involve an in-home visit by a qualified assistive technology specialist or nurse. In-home reviews reveal environmental issues such as family dynamics or smokers in the patient's room that work against the patient's recovery. If the patient does not like the sound of a low-air loss mattress, refuses to use it, and the caretakers give in, then the wounds do not heal and wound V.A.C. and other therapy go on and on for years. One family created a diva out of the claimant, insisting that nurses remove their shoes when entering the room and that they not wake the claimant for respiratory therapy. Of course, he developed respiratory infections and was constantly checking into the hospital at $9,000 a day.

Educate and Assist
Claims managers might as well prepare for resistance. Many long-term care claimants dislike change and actively fight it. Often, their families and other caregivers prefer the status quo. Providers and payers can fall into the "let sleeping dogs lie" trap. Some doctors and nurses freeze at the first sign that the patient is refusing care.

This is when the home health care professional needs to transform into a super educator. It is essential to demonstrate how the equipment, treatment or other therapeutic change will speed recovery, enhance quality of life, and extend a person's independence. That—along with controlling the costs of claims—is the whole purpose of proactively managing a long-term claim.

Proactive claims assessments and management on complex claims are the keys to preventing dormant files from exploding into costly and life-threatening medical episodes. Taking the "squeaky wheel" analogy to another level: It is the squeaky car that gets the oil, but it is the car that is out of oil and does not squeak that ends up needing a full engine replacement. Proactive assessments on long-term claims guide and refine treatment plans to mitigate or prevent the impact of age-related or drug-related conditions and prevent costly complications.

Special Reports /

Proactively Managing Long-Term Claims

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