center of occupational health & education (cohe) cohe at uw medicine valley medical center of...

Center of Occupational Health & Education (COHE)

COHE at UW Medicine Valley Medical Center of the Puget Sound Providers

2014-2015 Annual Training

Each Center of Occupational Health & Education (COHE) is a contractual partnership between the Department of Labor & Industries (L&I) and healthcare organizations. ◦ Facilitate the implementation of

occupational health best practices during the early phase of a claim.

◦ Promote collaboration between stakeholders (Labor, Business, Unions, Providers, Insurers) involved in a worker’s injury or illness.

COHE Claim◦ WA State Workers’ Compensation State Fund

claims ◦ NOT: Federal, Self-Insured, Tribal or Out of State

Workers’ Compensation claims. Claim filed with a COHE provider and/or

COHE provider is the attending provider on the claim.

Resources focused on claims within the first 90 & up to 180 days of claim being filed.

Reduce Worker Disability Improve Employment Outcomes

Promote Patient SatisfactionEnhance Clinical Efficiency

COHE at UW Medicine Valley Medical Center of the Puget Sound – est. 2002

COHE Community of Eastern WA – est. 2003 COHE at The Everett Clinic – est. 2007 COHE at UW Medicine Harborview Medical

Center – est. 2007 COHE Alliance of Western WA – est. 2013 COHE at Group Health Cooperative – est.

2013

Establish Mechanism to Identify High Risk Cases for Long Term Disability

Develop Procedures for Coordinating Care Implement Quality Procedures & Best

Practices Foster Communication between Providers,

Workers & Employers Offer Training & Mentoring in Occupational

Health Best Practices to Participating Providers

Provide Feedback to Providers on their Performance

Substantially prevented long-term disability, reducing costs by an average of $480 per claim & lost work time by an average of four days.

Savings continue to accrue three to four years after the claim is filed, even though the current COHE intervention occurs during the first 90 & up to 180 days of the claim.

Claims treated by COHE providers resolve faster◦ Faster resolution may be due to COHE Best Practices

preventing some medical-only claims from becoming time-loss. (Wickizer, et al, 2007)

12111098765432100

20

40

60

80

100

% IW Receiving Disability Payments

Time-Loss Duration (months)

Early Intervention PeriodFocus of COHE Activities

Over 240 Providers◦Chiropractors◦Emergency Physicians◦Family Physicians◦Nurse Practitioners◦Physician Assistants◦Specialty Providers Neurology, Occupational, Orthopedics,

Podiatry, Physical Medicine & RehabilitationAround 5,500 Claims Annually

Center of Occupational Health & Education (COHE)

Report of Accident (ROA)◦Timeliness To L&I within 2 business days of initial

office visit Speeds up processing & adjudication of claim Strong association between time from injury

to receipt of claim at L&I and substantially longer duration of time loss

Must use current ROA forms available from L&I

80% benchmark

Must complete each box to avoid delay in claim adjudication

Claim is initiated at L&I by the completion of the ROA.

Missing information may unnecessarily delay the adjudication of the claim, delaying treatment and payment for services.

Must use objective diagnoses – pain is not valid diagnosis for Workers’ Comp claim.

When the ROA is received at L&I within 2 business days of the initial office visit, you receive higher payment for completing this form.

L&I processes COHE claims twice as fast as non-COHE claims.

When determining whether to file a claim for a patient:◦ If patient asks you to file a claim, you must

regardless of your opinion as to it’s work-relatedness. Indicate on the ROA that the claim is work-related or

not. Inform the patient that inappropriate filing of a claim

can cause delays in payment by other insurers.◦ Claims should be filed even for minor injuries.◦ Fear of retaliation by employer.

Inform patient that the law protects them from discrimination for filing a claim.

Conditions Due to Specific Incident◦ Worker states they were doing a specific activity at a

specific time and then hurt themselves. E.g., worker lifted a heavy box and immediately felt a

pop/pain in their back. Worker has one year from date of injury to file claim.

Occupational Disease Claims◦ Claims due to repetitive use/trauma• E.g., worker lifts heavy boxes repeatedly throughout day

and has worked in that particular job for several years.• Worker has two years from date of onset to file claim.

◦ Have worker complete L&I Occupational Disease Work History forms.

◦ Review work history to determine which jobs/activities contributed to worker’s current symptoms & condition.

Determining Work-Relatedness◦ Depends on a variety of factors (medical, legal

and administrative) ◦ May be difficult to determine◦ In box 7 on the ROA, you are required to answer

yes/probably or no/possibly By law, a claim can be accepted only if the provider

states the condition is work-related “on a more probable than not basis” or greater than 50% certainty, e.g., yes/probably.

◦ For condition to be work-related, the industrial injury or exposure must be a “proximate cause” of the diagnosed condition.

Activity Prescription Form (APF)◦Complete at first office visit ◦Complete with any work status change

Gives claims manager & employer information on the tasks worker can do.

Better chance of worker returning to work in a timely manner.

Claims manager uses form for time loss certification & treatment authorizations.

HSC uses the APF to facilitate return to work efforts with employer.

◦80% benchmark

General Section

◦ Patient stickers may be used, as long as all the requested information is provided.

◦ Either ICD codes or written diagnoses may be listed in the diagnosis box.

◦ Providing this information will ensure the form gets into the correct claim file.

◦ Including the provider’s name and the visit date is important for billing purposes.

Released for Work Section

◦ If released to job of injury without restrictions, skip to “Plans” section.

◦ Objective medical findings are needed to certify time loss or loss of earning power benefits.

◦ Consider releasing to light duty even if significant restrictions, when medically appropriate.

◦ Be realistic on “to” dates.

Released for Work Section Cont’d◦Must include at least one “key objective

finding”.◦Examples of objective findings are:

Limited ROM Decreased strength Swelling Muscle atrophy Do not include subjective complaints such as pain,

tenderness or fatigue.◦Be specific with date ranges.

Estimate What Worker Can Do Section

Estimate What Worker Can Do Section◦Enables employers to identify potential light/

modified duty positions.◦Complete with assumption that light/ modified

duty is available.◦Check as to how long the current capacity will

last or if are permanent.◦Estimate based on provider’s clinical opinion.

Conservative estimates are acceptable.◦MUST be completed even when worker is not

released to work. For worker to understand what should physically do and

not do to enhance recovery.

Estimate What Worker Can Do Section◦ Only address restrictions applicable to claim

covered condition. Boxes left blank will be considered as not

restricted.◦ “Other instructions” could include need to

elevate limb periodically, no use of left arm, no overtime, etc. Be specific.

◦ Note to claims manager is intended to help you draw the their attention to an issue, i.e. “need authorization for…” Also has space for new diagnosis and opioid prescriptions.

Plan/Sign Section

◦ Quickly/briefly establishes plan for rehabilitation.◦ Succinctly indicates whether patient is progressing.◦ Comments are strongly encouraged.◦ Identifies what should happen next.

Alerts claims manager to actions needed, e.g., impairment rating exam schedule, Independent Medical Exam needed, claim closure.

Two-Way Communication with Employer◦Return to Work Options Discussed• Provides timely communication between

APP and employer.• Contact employer if worker is current off of

work or is expected to be off work.• Provides information to employer regarding

worker’s restrictions, ability to work light/ modified duty and treatment plan.

◦25% benchmark

Ways to Meet Best Practice #3◦ Call employer at or after the initial office visit• Be sure to bill for phone call and use appropriate

modifier.• Can be secure voice mail left for employer.

◦ AP contacts HSC who completes Initial Evaluation & Coordination (IEC)• For IEC, HSC is required to make 3-point contact: AP,

worker and employer.◦ Job description signed by AP• Be sure to bill for review of job description.

◦ Stay-at-Work benefits paid• Requires APP signature on light duty job description.

Assessing Barriers to Return to Work◦Barriers Assessment Exam ◦Referral to COHE Advisor for Barriers

Assessment Exam◦Medical Case Conference◦Consultation with COHE Advisor◦Currently no benchmark• For informational purposes only

Barriers Exam◦Completed by APP or COHE Advisor

that includes: Medical history Physical Exam Diagnoses, assess capabilities/stability

& calculation of impairment Review of all barriers preventing return

to work Develop future medical treatment plan Documentation in detailed SOAP-ER

note

S: subjective complaints O: objective findings A: assessment P: plan E: employment issues R: restrictions to physical activity

Center of Occupational Health & Education (COHE)

Set expectations for injured workers regarding return to work.

Help avoid administrative claim delays. Eliminate barriers to care. Facilitate communication with all parties. Establish & maintain communication with

employer. Enhanced payment for services if provider

meets the Occupational Health Best Practices benchmarks.◦ Scorecards are published by L&I on a quarterly basis.

COHE Project Directors◦ Jaime Nephew, PT, DPT, MBA, FACHE◦ Grace Casey

COHE Medical Directors◦ Scott Morris, MD◦ Karen Nilson, MD

COHE Advisors◦ Wide variety of disciplines represented

COHE Health Services Coordinators (HSC)◦ Ellen Hull, M.Ed., CRC◦ Heather Latvala, M.Ed., CRC◦ Kathryn M. Visser, M.Ed., CDMS

One-on-one training◦Promote occupational health best practices◦Provide training for nurses and other office

staff Assist with return to work coordination

◦Even missing 3 to 7 days of work can increase disability and a long-term earning capacity.

◦Research has shown that a worker remaining on payroll during recovery has a greater chance of full recovery and a higher family income while recuperating.

Evaluate potential barriers to return to work early to prevent ongoing disability

Identify claims that are at risk for long-term disability.

Intervene on claims that need HSC assistance.

Track claims to ensure early return to work services, care coordination and improved clinical outcomes of injured workers.

Act as a liaison, on behalf of the provider, between injured worker, employer and L&I.

Help employers, providers and injured workers navigate the Workers’ Compensation system.

Renton Worker Survey◦As satisfied as on key satisfaction

measures of: Quality of Care Coordination of Care Overall Treatment Experience

◦Better employment outcomes 55% more likely to return to same

employer 65% more likely to be working at time of

survey

Renton Provider Survey◦75% indicated they have improved

ability to treat Injured Workers◦74% are satisfied with their

experience◦70% reported improved ability to

communicate with employers◦50% stated they are more willing to

treat Injured Workers

Center of Occupational Health & Education (COHE)

Please see attached COHE Provider Quiz 2014-2015 Microsoft Word document for instructions and to complete the quiz.