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Treating an Injured Person and Not a Claim: Why Injured-Person Centered Care Is Essential for Driving Better Outcomes in Workers’ Comp

May 9, 2022 · Optum Workers' Compensation

In the workers’ compensation industry — and honestly in health care writ large — injured-person care can often feel very transactional. The medical model used by so many organizations limits an injured person’s care choices and focuses on their deficits and not their abilities.

These practices create a singular focus on the injury, rather than treating the whole person, which can lead to prolonged hospitalizations, serious health issues and increased treatment costs.

“At the heart of every claim is an injured person,” said Tron Emptage, chief clinical officer for Optum Workers’ Compensation. “We must think about care as the right medication and the right treatment at the right time, for the right duration and for the right individual.”

Instead of providing transactional care that focuses on the injury, Optum Workers’ Compensation focuses on treating the whole person by taking into consideration psychological and social factors that could put their case at-risk for turning into a long-term, high-cost claim. This approach often helps injured persons return to their pre-injury level of function faster and it can save on claims costs in the long-run.

 

What Is Whole Person Care?

In the past, many in the workers’ comp industry have focused solely on treating the injury. If a person has a broken ankle, they’ll focus on treating that injury and ignore other factors — like comorbidities or a history of addiction — that could affect their recovery.

Whole person care, by contrast, focuses on identifying and maybe even mitigating psychological and social risk factors alongside the physical conditions of the injury.

“We try to put the person at the center of their care,” said Dr. Kathleen Fink, Associate Medical Director for Optum. “We try to treat the injury and make sure that everything from prescriptions to ancillary services to specialists that may be needed are coordinated so that they get the best recovery.”

When most people in the industry think of whole person care, they tend to think about it in relation to catastrophic injuries. But it’s just as relevant for an injured person who only needs a prescription or has a minor injury or no lost time.

“We still have to have safety checks in place to be able to say, ‘Okay, is this appropriate or not appropriate?’ ” Fink said.

“Maybe someone is on a blood thinner that’s going to have an interaction with a certain prescription, so they need to take something else. Or maybe someone has a pinched nerve in their back. In some cases, something like an anti-inflammatory drug or an oral steroid might be appropriate. But if they’re having surgery, a steroid might impede healing.”

That’s why it’s important to keep the injured person at the center of their care from the very beginning.

“We’re always thinking about return-to-work, return to function and settling the claim,” Emptage said. “Keeping the injured person at the center of all of that is really important. We do our best to keep that in mind throughout all of the programs we develop and processes we put in place.”

Additionally, the pandemic has thrown into focus the benefits of considering mental health for both injured persons and providers since depression, burnout and fear can cause care delays. An injured person who was fearful of getting sick may have delayed treatment to avoid going to the hospital and coming in contact with the virus. In other cases, health care organizations may have faced staff shortages after doctors and nurses quitting due to burnout, resulting in long waiting times for appointments.

“Wellness is obviously important for the injured persons, but it’s also important for the people taking care of them,” Fink said.

These mental health factors existed before the pandemic. Consider an injured person who is fearful of reinjury. They may avoid doing their prescribed physical therapy exercises because they’re afraid of pain or of aggravating the injury. In these cases, wellness programs and counseling sessions may go a long way in helping sure they remain on track in their recovery.

“We’re not treating an injury in a vacuum,” Fink said. “From wellness programs to behavioral health specialists to coordination of care, I think these are all things that we’re looking at.”

 

Protecting Injured Persons, Saving Money

Keeping the injured person at the center of everything isn’t just good for an injured person’s recovery, it can also help reduce costs by identifying potential complications early on in the life of a claim.

“Our predictive analytics programs and risk scoring take into account several factors, not just injury-specific data and that really helps us identify those injured persons that are at highest risk for developing long-term, high-cost claims,” Emptage said.

“We have found the proxy for overall medical spend can be pharmacy utilization,” Emptage said. “By helping identify those areas where they may need additional assistance, even if it’s not from the data itself but a trigger from pharmacy.”

Emptage and Fink pointed to Optum’s opioid safety program as an example of how proactive, whole person care can reduce complications later on in a claim. As part of the program, a team at Optum works with providers and educates injured people on alternatives to pain medications.

The company also has a clinical outreach program that educates prescribers on treatments that are more in-line with state or nationally recognized guidelines. All of these initiatives help ensure that an injured person gets on the most effective course of treatment from the very beginning of a claim.

“If we put the injured person at the center of the care and focus on what that injured person’s needs are, we end up with a more effective plan of care,” Fink said.

 

The Optum Focus

At Optum Workers’ Compensation, whole person care is a priority from triage to the day a claim closes.

Its Single Risk Score triage program uses demographic data and predictive analytics to identify claims that could benefit from a whole person care approach from the beginning. That way, they can avoid complications down the line.

The company also works to coordinate care between all of the parties involved in the claim. VitalPoint®, Optum’s technology portal, provides claims professionals with information to help with more informed pharmacy or ancillary services decision making.

It also maintains injury-based formularies, which allows a pre-approved list of appropriate medications to be dispensed at point-of-sale. This helps injured persons get the right medications, at the right time.

“Our technology helps drive decisions at the point of sale, point of care, even before a claims professional needs to get involved again to bring access as quickly as possible,” Emptage said.

All of these services work in tandem to help provide whole person care to an injured person, with the hope of getting them back to their pre-injury level of function as quickly as possible.

“We are able to tap into some of information directly from our analytics that can help us identify if there are issues or questions. Those things really help us allow the injured person to also be an active participant in their own care,” Fink said.

“We know that when an injured person feels that they have a sense of control over their own care, we get better outcomes.”


Tron Emptage, Chief Clinical Officer, Optum Workers’ Compensation

Dr. Kathleen Fink, Associate Medical Director, Optum Workers’ Compensation

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