Batteries Not Included

A case management perspective:

A catastrophic claim can cost millions.  We have a team of professional, clinicians, diagnostics and an arsenal of resources to manage a cost-effective outcome.  What happens when the injured worker comes without coping skills, a pre-morbid history you do not have access to, and an aversion to intervention? How do you identify that a variance or sentinel event may be genetically pre-determined creating an indirect causally related condition that requires savvy case management.

Mr. “Smith” is a 29 year old shot on the job.  He sustains a SCI resulting in paraplegia.  The history you have available to you says he lived alone, independent, military background, attending college, with family support.  He flies through inpatient rehab ahead of schedule and is preparing for discharge to the community.  Without warning, he becomes despondent, suicidal, and is unsafe for discharge.  Counseling is called in and determines he has major depressive disorder.  The injured worker is discharged with 24 hr attendant care and an antidepressant.  He and you have left the confines of an interdisciplinary environment.

As a case manager you must use critical thinking skills to put a new interdisciplinary team in place, and fast.  Mr. Smith needs medication management from a psychiatrist to start. He should continue with counseling.  Close communication is required from all parties including attendant care to monitor and assess the situation.  The treating physician must be aware of treatment plan and support the expectation for improvement.  Mr. Smith’s “new” baseline is not a cost-effective solution to his long term needs, but some may be tempted to think his needs are being met.

Mr. Smith responds to medication and is no longer suicidal however, develops secondary and avoidable complications such as a UTI and skin issue. A good case manager would start to suspect depressive disorder is not the only thing going on.  Collaboration with post-acute interdisciplinary team reveals behaviors that are self-defeating. Poor communication from the injured worker seems avoidant in nature.  A neuropsychological exam can help identify severity of adjustment disorder and possible underlying AXIS IV diagnosis.  In Mr. Smith’s case, an underlying personality disorder has been exacerbated.  The case manager must now add behavior management to coordination of care.  Behavior?!

How can behavior management be the responsibility of Worker’s Compensation?  How can it not!

In this case, the risks of life-threatening secondary complications proved to be the result of “batteries not included”.  Mr. Smith needs what I like to call an “accountability plan”.  His inability to want to get out of bed, attend outings and appointments, eat, catheterize himself properly, and check his skin now becomes a shared responsibility.  Orders are requested from physician for attendants to 1) have patient out of bed by 8am, 2) have him to appointments on time rain or shine 3) review his catherization technique, and 4) document his daily skin checks.  Accountability is also  placed on attendants to show measurable functional gains and document “non-compliance” that will have consequences for the Mr. Smith.  A behavior plan is put into place with the help of neuropsychologist to prioritize goals and limit anxiety for Mr. Smith.  Mr. Smith participates in this process and agrees to 3 primary goals 1) no UTI’s, 2) no skin issues 3) be compliant with appointments and participation. This plan is shared with counseling, psychiatry, physicians, therapists, and internal post-acute case manager.  Consents are signed in order to protect Mr. Smith’s privacy and establish who “needs to know”.  This included family members who needed to be a part of the rehab process and his support system.  Interestingly enough, family was able to confirm what was now known and to the extent and duration Mr. Smith has struggled emotionally, and what triggers had been present in the past.  Every member of Mr. Smith’s support system is now able to provide consistent approach to help him better manage his behavior.  The accountability plan over a reasonable amount of time will shift from less responsibility on the attendants and more on the injured worker.  Mr. Smith’s ability to cope with his circumstances improves and he is able to be weaned from services.  Everyone has the right to self-determination, his decisions and his clear understanding of consequence improved compliance.   And while a pre-existing behavior/personality trait can often “scare” the payor, clear information/understanding about a behavior/personality makes things moving through the system easier.  Additionally in this case, the Mr. Smith’s pre-existing personality tendencies/behaviors were simply identified and acknowledged as pre-existing.  There was no added expense/exposure to the payor, as Mr. Smith was being treated for the injury related depression and the identification of the personality tendencies/behaviors was part of the evaluation/counseling process.

Once the issues were identified and the accountability plan was implemented, the case moved along much better.  We were also able to more quickly and effectively identify times when the injured work would/could decompensate  because of stressors.

“Batteries not included” is a chronic condition that can de-rail a potentially good outcome.  Communication, collaboration, and critical thinking skills are key. How we react to an injured worker’s behavior and personality are just as important as how we react to their injury.

Contributing Authors

Kari Williamson, RN, BS, LNCC, CCM and Neile Manning, BSW, C-SWCM