5 months ago
The Post-Acute Care Facility Equation for Success
By Linda Colsen, SVP of Product Management, One Call
When an injured worker can’t go straight home following discharge from a hospital or medical facility, it adds another layer of complexity to the claim. Where do they stay? How long will they stay? Will it be the right care for their injury? Who will manage their care?
Claims staff working with an injured worker who isn’t ready to go home following a hospital discharge have to find answers to these difficult questions – and quickly.
The injured worker requires time-sensitive post-acute care at a skilled nursing or rehabilitation facility; however, steering to a facility that best suits their clinical needs – without overtreating – and provides appropriate quality of care can require hours of back-and-forth conversations with the hospital and facility, and ultimately result in awkward negotiations. When all is said and done, was the negotiation a good one? Was the best facility chosen for continued recovery?
While in-patient post-acute care is estimated to be a billion-dollar cost center within the workers’ compensation industry, the selection of facilities is relatively unstandardized, and costs are widely unmanaged. In-patient rehabilitation providers and skilled nursing facilities are trained to adhere to Medicare protocols, rather than the norms of the workers’ compensation industry, leading to inconsistencies in timely claims processes, such as authorization, medical updates, and invoice documentation. As a result, workers’ compensation payers encounter difficulties influencing and managing the care injured workers receive at these facilities – from both a quality and cost perspective. And with heavy caseloads, devoting the time to investigate and evaluate in-patient facilities in detail can take away from other priorities.
The Answer: In-Patient Facilities SolutionsSM
Through One Call’s In-Patient Facilities Solutions program, we place injured workers at appropriate, high-quality facilities where they receive the right care, for the right length of time, at the right cost.
Since the program’s inception in 2015, we’ve built a strong network of skilled nursing and rehabilitation facilities across the country. Facilities within our network range in terms of their benefits, specialties, and treatments available. Working directly with claims staff or nurse case managers, we help select a facility that will best support the injured worker’s needs as prescribed by the treating physician. From there, we create seamless transitions for injured workers by providing valuable insights into care progression and foresight into the next stages of treatment and recovery.
But just how do we manage all these details?
Key Ingredient for Success: Care Navigators
Leave complicated care coordination to the quarterback on One Call’s team – the Care Navigator. Care Navigators specialize in coordinating complex cases with many moving parts. Whether it’s a catastrophic case – such as traumatic brain injuries, spinal cord injuries, or amputations – or a more traditional orthopedic case after a total knee replacement, our team of expert Care Navigators has your back.
Care Navigators carefully review injured worker medical records and documentation. They utilize this knowledge to help claims staff and physicians access the best in-patient facility for their injured worker. Ultimately, Care Navigators’ close coordination with facility staff in combination with our proprietary contractual provider agreements ensure facility reimbursement matches the level of care provided.
Once an injured worker is ready to leave the facility and continue to the next step in their recovery, Care Navigators boost injured worker confidence by coordinating in-network ancillary services for them at home, such as durable medical equipment needs, nursing assistance, and physical therapy appointments.
In-Patient Facilities Solutions in Action
Let’s take a look at an example of how this critical program can lead to impactful results.
Our team received a referral for a young man in his 20s who suffered a severe spinal cord injury. He was told he would likely never walk again.
Working with the physician and claims staff, we identified and recommended a care facility that specialized in his specific injury. We were able to collaborate with the facility to ensure they had the proper equipment – as required by his physician – for his complex therapy plan. Once everything was confirmed, his recovery team at the facility quickly got to work. A One Call Care Navigator tracked his recovery, provided regular updates on his progress, and coordinated transitions throughout the continuum of care.
Ultimately, our team contributed to, and coordinated, a customized recovery plan that placed him in the right facilities to treat his injury as his recovery progressed. And the outcome is awe-inspiring. By the time he was discharged, this young man was walking again, with the help of a walker, and able to live on his own in an ADA-compliant apartment.
While most adjusters and nurse case managers won’t ever have to balance this type of sensitive injury and the associated high costs of care, this story demonstrates how a proactive partner and approach can make all the difference in injured worker and claim outcomes.
When you’re managing the claim for an injured worker who isn’t ready to go home following discharge, put our In-Patient Facilities Solutions program and Care Navigators to work for you. We’ll move quickly, finding answers to timely, important questions that will place your injured workers at the right facility, with the right care, for the right length of time, at the right cost.
To get started, contact our team today.