case management principles 2787
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CASE MANAGEMENT
PRINCIPLES
WorkCover.Watching out for you.
NOVEMBER 2005
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Disclaimer
This publication contains information regarding occupational health, safety, injury management or workers compensation. It includes some of your
obligations under the various workers compensation and occupational health and safety legislation that WorkCover NSW administers. To ensure you
comply with your legal obligations you must refer to the appropriate Acts.
This publication may refer to WorkCover NSW administered legislation that has been amended or repealed. When reading this publication you
should always refer to the latest laws. Information about the latest laws can be checked at www.legislation.nsw.gov.au or contacting
(02) 9238 0950 or 1800 463 955 (NSW country only).
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CONTENTS PAGE
INTRODUCTION 2
PRINCIPLE 1 CASE MANAGEMENT PHILOSOPHY AND CASE MANAGERS ROLE 4
PRINCIPLE 2 TRIAGE AND SCREENING 6
PRINCIPLE 3 CLEARLY-DEFINED PRACTICES 7
PRINCIPLE 4 PEOPLE MANAGEMENT AND LEARNING AND DEVELOPMENT SYSTEMS 10
PRINCIPLE 5 RECORDS MANAGEMENT 12
PRINCIPLE 6 SOUND DECISION-MAKING 13
PRINCIPLE 7 COST-EFFECTIVE SERVICE 15
PRINCIPLE 8 QUALITY ASSURANCE AND CONTINUOUS IMPROVEMENT 17
GLOSSARY 18
ATTACHMENT 1 THE OPTIMISING MODEL OF DECISION-MAKING 19
BIBLIOGRAPHY 20
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INTRODUCTION
To assist organisations develop their case management approach, this publication outlines the case
management principles WorkCover has developed following a thorough review of available literature, data
analysis from WorkCover systems, and consultation with industry.
When applied to workers compensation, case management means a coordinated and managed approachthat integrates all aspects of injury and claims management, including:
payment of benefits and entitlements
liability determination
treatment
rehabilitation
retraining
factual investigation
claims estimation
investigation of recovery potential
employment management practices eg risk management, return to work programs and occupational
health and safety.
WorkCovers case management framework is a set of clearly-defined practices, underpinned by quality
assurance and continuous improvement. It ensures effective management of a claim from notification
through to finalisation, supported by sound decision-making.
It focuses on cost-effective service delivery and aims to ensure the achievement of timely and sustainable
return to work outcomes and maximum functional capacity. The goal of case management is a timely, safeand durable return to work for injured workers.
Fundamental to the framework is the appointment of a single appropriately qualified person who is
responsible and accountable for actively managing an injured workers claim.
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The framework incorporates eight case management principles:
1. case management philosophy and case managers role
2. triage and screening
3. clearly-defined practices
4. people management and training systems
5. records management
6. sound decision-making
7. cost-effective service
8. quality assurance and continuous improvement.
Through application and further development of the case management principles within their business
models, WorkCover expects organisations to:
approach managing injuries, claims and return to work in a holistic and systematic manner
maximise return to work and health outcomes for injured workers, while minimising risk of re-injury
establish an effective claims management infrastructure with open communication channels
deliver cost-effective case management with a strong focus on outcomes.
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screening
practices
people
records
decisions
cost-effectiveness
quality assurance and continuous improvement
case management philosophy
and case managers role
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PRINCIPLE 1 CASE MANAGEMENT PHILOSOPHY AND
CASE MANAGERS ROLE
Principle
The philosophy of case management integrates injury and claims management with a multi-disciplinary,
holistic, individual and cost-effective approach, and operates within the legislation. A single, appropriately
qualified person is responsible and accountable for active management of an injured workers claim.
The case manager is the principal decision-maker who uses all relevant facts, options and information,
and promotes a working partnership between the injured worker, employer and service providers.
For each case, a management plan is developed in consultation with the injured worker, employer and
other relevant parties. It identifies stakeholder responsibilities and outlines the agreed way forward,
including the return to work goal.
Components
Case manager roles and responsibilities
An appropriately qualified case manager:
is accountable for the entire case and is the primary contact
is accountable for influencing key parties including the injured worker, employer, nominated treating
doctor and other service providers to achieve agreed goals
maintains regular and appropriate contact with all parties to determine the injured workers progress
and possible barriers to progress, or any risks of delayed return to work, recovery and finalisation
accurately determines provisional and ongoing liability
coordinates services and manages providers to achieve identified outcomes through a collaborative
approach to medical treatment, return to work, dispute management, legal matters and other claims
decisions
has up-to-date knowledge of services that will meet the needs of the injured worker and achieve goals
approves appropriate and effective services
is active in the management of the claim and has the authority to direct service providers and key
parties in ongoing achievement of goals and outcomes throughout the claim
regularly reviews all aspects of the claim, including service provision, service levels and
appropriateness of treatment, service providers adherence to protocols and guidelines, ongoing
liability, claim estimations and recovery potential
considers WorkCovers Claims Estimation Manual.
Roles, responsibilities, levels of authority and legal obligations of the organisation, injured worker,
employer and service providers who influence case management outcomes must be identified and
supported by management and training systems.
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Information management and support systems
Relevant, accurate and timely data ensures consistent and up-to-date management of claims, provided
systems and practices are regularly reviewed. Management systems facilitate decision-making and assists
the case manager to:
identify factors as early as possible that place recovery or return to work at risk
record case management activities and actions
identify, diarise and monitor milestones, including capacity to prompt review dates
review activities
retrieve claim details
identify exceptions.
Communication
Clear and accurate communication forms a central feature of case management. The provision of effective
internal and external communication systems support, encourage and direct communication between key
parties.
Key elements of effective communication includes:
provision of information about roles, responsibilities and obligations of key parties to ensure realistic
expectations
confidentiality and informed consent .
application of a customer-focused approach
demonstration of assertive and empathic communication, interview, listening and reflecting skills
consideration of stakeholders literacy levels.
Privacy
Legislation requires that all privacy, confidentiality, consent and security issues relating to case
management be adequately addressed.
Risk management
A risk management approach to the provision of best-practice case management identifies the likelihood of
strategic and operational risks that could adversely affect delivery of case management. It identifies where
systems and practices fail, and allows rapid remedial action to be taken.
Mechanisms to set and review case loads appropriate to the nature of the claim and the competency of
the case manager are required.
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PRINCIPLE 2 TRIAGE AND SCREENING
Principle
Early and accurate identification of the needs, risks and potential barriers to achieving health and return to
work outcomes ensures the focus of management is upon risk factors indicative of poor outcomes.
Categorising claims according to the risk of delayed return to work, long-term disability and delayed
finalisation allows the organisation to quantify, track and prioritise claims activity, and assign claims to a
case manager with relevant skills.
Re-screening throughout the life of the claim facilitates periodic review of risk factors and barriers to
ensure that intervention is effective in mitigating the risk and reducing the impact, and continues to be
relevant to the worker and key parties. These reviews provide evidence to support or refine the screening
system.
Components
Evidence-based systems and practices
Triage is sorting claims into broad categories and making an early assessment about the extent to which
an injured workers return to work and recovery are potentially at risk. Evidence-based systems and
practices for gathering accurate and relevant information are essential to effective triage.
Screening and re-screening is an assessment of risk factors, psychosocial indicators and return to work
barriers. An effective screening tool must be consistent, replicable, research-based and capture data.
Screening facilitates assignment of the case manager with appropriate competencies relevant to the claim,
allocation of resources and prioritisation of activities.
Risk management
Strategies are required to identify, manage and mitigate risk factors and return to work barriers.
Inappropriate action to address these risks and barriers will jeopardise goals, compromise the effective use
of resources, and increase claims costs.
It is vital to establish risk management strategies and evaluate them over a period of time. Screening is
only valuable when accompanied by an accurate response to the risk factors.
Timeframes
Systems must be in place to ensure the case manager performs initial screening of all claims within the
required timeframes, as outlined in section 43(4) of the Workplace Injury Management and Workers
Compensation Act 1998.
Risk factors and return to work barriers vary throughout the life of a claim. Screening occurs on an
ongoing basis, and at pivotal points in the life of a claim, to improve effective management and identify
milestones not achieved. Screening may also highlight a need for more intensive management, or
alternative management. It identifies the impact of intervention on risk factors, changes in risk factors, and
the development of new barriers and new risk factors.
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PRINCIPLE 3 CLEARLY-DEFINED PRACTICES
Principle
Clearly-defined practices reflect case management that proactively moves the claim towards finalisation
and manages the expectations of key parties. These practices support appropriate interaction with key
parties that ensure injured workers and employers receive services in a supportive, efficient and
cost-effective manner. They underpin the delivery of proactive case management that is aligned with the
legislation.
The identified outcome and service delivery of each practice should be attuned to the organisations case
management philosophy. These practices may be performed concurrently, or in isolation, but no practice
should compromise the objectives of the case management plan.
Components
Early contact and assessment
Initial contact must occur within the legislative timeframe. It should involve a comprehensive assessment
to:
establish a positive relationship with each stakeholder and assess their needs
establish facts and analyse information to facilitate sound decision-making
engage the injured worker and identify potential risks or barriers to return to work
identify realistic outcomes
identify resources and interventions required to achieve outcomes.
The case managers contact in the early days of a claim is critical in setting direction and is the first
opportunity to commence case management planning.
Claim finalisation
Claim finalisation requires the case manager to set expectations and explain the benefits of early case
closure to all key parties, based on expected recovery and return to work timeframes. Finalisation does
not mean rushing to finalise a file. Problems may arise. Goals may need to be redefined. At all times,
however, service providers need to be managed proactively and strategies need to be in place to mobilise
the claim to finalisation.
Case management planning
Case management planning is a consultative approach to align expectations with key parties about how
the injured worker will achieve health and return to work outcomes.
Development
The case management plan is an agreement between the case manager, injured worker, employer and,
where appropriate, the nominated treating doctor.
The plan confirms expectations and defines the objectives and responsibilities of all parties. It outlines
the actions required to mitigate risk factors and return to work barriers. The plan establishes measures,
timeframes and review points for achieving each goal and activity.
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The case management plan incorporates the injury management plan, which is defined in the Workplace
Injury Management and Workers Compensation Act 1998. A copy of the injury management plan is
provided to the injured worker, the nominated treating doctor, the employer and provider (if required)
within four weeks of receiving the claim (if the claim is not finalised).
Implementation
Implementation of the case management plan involves the case manager identifying and implementing the
plans actions, and establishing and coordinating services. It includes communication with all key parties
and agreement on expectations.
Implementation requires:
timely and accurate information regarding the goals, outcomes and proposed actions information
that is clear, concise and understood by the recipient
instant response to problems and potential barriers to progress
effective and efficient service delivery.
Review
Active and regular review of the plan implementation ensures that all key parties achieve their goals
and meet their responsibilities, as the injured worker moves toward the identified outcomes. When new
information is received, or circumstances change, a review is essential.
Review of the case management plan involves:
contacting key parties to track progress against outcomes and if necessary realign expectations
ensuring return to work goals remain appropriate
identifying barriers to progress and case finalisation
documenting actions
updating the plan when necessary.
A review requires active, ongoing assessment of the claim, and the plan must always adhere to the Claims
Estimation Manual.
File handover
File handover requires the new case manager to:
review the claim and case management plan
establish relationships with key parties
re-establish responsibilities and commitment of the key parties.
Payment of benefits and entitlements
The case manager must ensure that workers receive their entitlements, employers are reimbursed for
wages paid, and providers receive payments for their services in a timely, accurate manner. This avoids
complaints and disputes and assists early return to work.
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Complaints management
Complaints management includes a customer service focus that ensures early resolution of complaints.
Strategies to resolve complaints are reflected in the case management plan.
Dispute management
Dispute managementincludes integration of the Workers Compensation Commissions timeframes and an
internal review mechanism to monitor and prevent unnecessary disputes. Strategies to resolve disputes are
reflected in the case management plan.
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PRINCIPLE 4 PEOPLE MANAGEMENT AND LEARNING
AND DEVELOPMENT SYSTEMS
Principle
Human resources systems must support recruitment, professional development, training and performance
management to enable full and effective application of case management.
Components
Case manager skills and knowledge
The skills and knowledge of an effective case manager include:
knowledge of:
o workers compensation legislation, including privacy and confidentiality and claims and injury
management
o service provider management
o medical treatment, injury and disability management
o organisational processes and procedures (including records management, health and safety
practices, management of conflict of interest)
leadership skills
decision-making skills
customer focused approach
communication, negotiation and people management skills
self-directed approach (takes initiative and prioritise activities)
team member skills (demonstrates personal integrity and respects the values and experiences of
others)
analytical and problem solving skills
information technology skills
dispute and conflict resolution skills.
Recruit and retain case managers
An organisation should develop an adequate skills base by:
providing sufficient skilled resources to match work loads
assessing the workforce and its competencies
identifying recruitment strategies and employing staff with the appropriate skill set
implementing initiatives to retain staff.
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Case manager support
A performance management system will support the development of case manager skills and identify
practices that provide opportunities for new case managers. The system will include:
objectives and key performance indicators
review and evaluation of performance
skills and competency analysis
professional development plan
training, mentoring and coaching.
Learning and development
To ensure knowledge and skills are developed and maintained, continuing learning and development
programs are essential.
Conferences, seminars, internal training sessions and mentoring programs will enhance the competencies
and skills of a case manager.
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PRINCIPLE 5 RECORDS MANAGEMENT
Principle
The scope of records management includes all communication in relation to a claim. A system must
be implemented that will deliver complete, accurate, timely, secure and accessible information that
contributes to an injured workers claim.
Components
Records management systems
A records management system must comply with legislative requirements for record-keeping. It includes:
case record identification
archive, storage and retrieval procedures
a record of events, including communication with key parties
workers rights to give the authority to release and obtain information,
application of confidentiality and privacy principles to the collection, maintenance and storage of
information.
Documentation
Documentation provides tangible evidence about the chronology of a claim. It includes:
case management plans
notes about conversations with key parties, correspondence about the claim
notes about claims activities, decision-making, expected outcomes
internal and external responsibilities
reviews by senior staff.
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PRINCIPLE 6 SOUND DECISION-MAKING
Principle
Sound decision-making is free of preference and prejudice. It considers outcomes for the injured worker,
the employer, and the NSW workers compensation system. Sound decision-making means considering
options, then acting.
Components
Decision-making model
A decision-making model needs to be clearly understood and consistently adopted by the case managers.
It must be informed, outcomes-focused, cost effective, evidence-basedand meet records management
principles. See attachment 1 for further information.
Sound decision-making
Sound decision-making reflects consistent application of an effective decision-making model in all aspects
of case management.
The case manager makes decisions in relation to liability, purchase of services and resources, reasonably
necessary treatment, and use of expert opinion and assessments.
Accurate and prompt decisions about entitlements to benefits and ongoing treatment ensure that case
management initiatives are not compromised.
A knowledge of available services and access to approved service providers is essential. To progress a
claim, the case manager relies on available resources, recommendations from experts and appropriate use
of the legislation.
Documenting decisions
The case manager must document decisions. Case notes should include:
information for consideration
information relied upon to make decisions
reasons for decisions
expected outcomes of the decision
to whom this information is communicated
the final decision.
Communication
Communicating decisions to all key parties in a transparent and consistent manner will:
facilitate cooperation
avoid confusion
contribute to fewer complaints and disputes
enhance involvement.
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Protocol
To assist the case manager handle complex issues, such as what treatment is reasonably necessary,
protocols need to be developed to avoid misunderstandings between key parties.
Sound decision-making on complex issues will identify escalation points and the potential for mentoring.
Review mechanisms
Mechanisms must be in place to review the appropriateness, or otherwise, of the case managers
decision-making practices for each and every claim, and across all claims generally.
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PRINCIPLE 7 COST-EFFECTIVE SERVICE
Principle
Outcome-focused management of the injured worker and their claim for compensation includes the need
to effectively manage the overall costs associated with theworkers recovery, and determination of the
vocational and return to work goals. There must be effective systems for:
evaluating costs
managing expenditure
assessing outcomes against costs.
To be cost-effective, the service/treatment is likely to make a significant contribution to the injured
workers recovery and their ability to return to work. However, the most cost-effective service/treatment is
not always the cheapest option, nor is the best service/treatment always the most expensive.
Components
Criteria for purchasing provider services
The purchase of provider services is based on qualifications, availability, accountability and ongoing
evaluation of performance.
Service providers are evaluated, selected and re-evaluated to ensure the case manager has ready access to
the most appropriate services.
Costs and outcomes
The evaluation of costs against outcomes is fundamental to decision-making about cost-effectiveness
across provider services.
The case manager requires information about:
the motivational drivers of key parties
the service
costs
outcomes against service provided
previous expenditure, trends
efficacy of requested services.
Access to information
It is important that the case manager has ready access to a variety of information as a minimum, the
profile and contact details of preferred and WorkCover-approved providers.
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Provider management
To ensure cost-effective selection and provision of services, organisations will establish:
regular cost-benefit assessments of provider performance
measures to identify and prevent ineffective and unnecessary services
practices to manage/correct poor service and over servicing
performance and service standards.
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PRINCIPLE 8 QUALITY ASSURANCE AND CONTINUOUS
IMPROVEMENT
Principle
Ongoing review, analysis and evaluation of systems and work practices, tools and resources are essential
for effective and efficient case management. Using the data allows the organisation to identify areas of
strength and opportunities to implement improvement strategies to enhance performance and achievement
of outcomes.
Components
Documented procedures
To ensure consistent case management practice across the organisation, documentation of essential
procedures is necessary.
Review practices, measure outcomes and analyse data
An organisation should implement appropriate techniques to review, measure and analyse the delivery of
objectives across all case management principles. Techniques would include outcome analysis, peer and
self reviews, identification of exceptions and analysis of customer feedback.
Information management systems create a basis upon which to collect timely and accurate data to
undertake analysis of performance, evaluate decisions and assess strategies.
Customer feedback
Quality frameworks incorporate comprehensive complaints management and customer satisfaction
systems. The information is collected and reviewed regularly and used as a source of evidence to
continually improve practices and systems.
Continuous improvement
Continuous improvement involves gathering evidence, turning data and evidence into knowledge and
refining practices and systems to mitigate gaps and implement improvement opportunities.
At an operational level, organisations will adopt a continuous improvement model that ensuresopportunities are thoroughly analysed and strategies planned, piloted, refined and implemented to ensure
improved performance and outcomes.
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GLOSSARY
case management a coordinated and managed approach that integrates all aspects
of claims injury management, including treatment, rehabilitation,
retraining, liability determination, factual investigation, estimation
and employment management practices for the purpose of achieving
optimum results regarding a timely, safe and durable return to work for
injured workers.
case management plan a plan for coordinating and managing all aspects of claims and injury
management it may be an in-house plan.
case record all components of a workers case file, including electronic and paper
records.
clearly-defined practices case management practices that proactively move the claim from
notification towards finalisation and manage the expectations of
key parties to ensure agreement in relation to the purpose, delivery
timeframes and expected outcomes.
claims and injury management activities and practices undertaken to achieve a timely, safe and
durable return to work for an injured worker, within legislative
parameters.
components elements of a principle.
injury management plan a plan for coordinating and managing the treatment, rehabilitation and
retraining of an injured worker to achieve a timely, safe and durable
return to work.
key parties injured worker, employer, nominated treating doctor, lawyer, union
representative, insurer/agent, and other service providers.
risk management the likelihood and severity of potential risks eg. environmental,
social, political, technical, legal, economic and competitive.
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ATTACHMENT 1
This attachment is an example of a decision-making model. A decision-making model needs to be clearly
understood and consistently adopted by the case managers. It must be informed, outcomes-focused, cost
effective, evidence-basedand meet records management principles.
The optimum decision-making model describes how individuals should behave to maximise an outcome.The model involves:
ascertaining the need for a decision
identifying the decision criteria
allocating weights (values) to each of the identified criteria
developing alternatives
evaluating alternatives
selecting the best alternative.
Ascertaining the need for a decision The existence of a problem or, at a point in the defined
practice, a disparity between the desired state and the
actual condition will result in recognition of the need to
make a decision.
Identifying the decision criteria The criteria needs to be identified and, for frequently-made
decisions, defined. The criteria are those factors that need
to be considered in reaching the decision and the desired
outcome. These are ingredients, not options.
Allocating weights to the criteria Allocating weights to prioritise the importance of thecriteria. All criteria may be relevant, but some more relevant
than others some criteria will have a greater effect upon
the desired outcome, and must be given greater weight in
the decision-making process.
Developing alternatives Determining all the options that solve the problem does
not require weighting of alternatives, just identification of
options.
Evaluating alternatives Once alternatives have been identified, the decision-maker
must critically evaluate each one by appraising each
alternative against the weighted criteria the strengths and
weaknesses of each alternative will become clear. This is
best done by listing the criteria, assigning a weight, and
listing the alternatives in a table format.
Selecting the best alternative The best alternative is the highest score and, if the
weightings have been accurately applied, this selection
should lead to the most effective outcome.
Reference:
Robbins, Steven P, Organisational Behaviour Concepts, Controversies, and Applications 4th Edition
New Jersey,Prentice-Hall International Editions 1989
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BIBLIOGRAPHY
Gursansky D, Harvey J, Kennedy R, Case Management: Policy, Practice and Professional Business
Sydney, Allen & Unwin 2003
Case Management Society of Australia,Journal of Case Management 2003
The Australasian Faculty of Occupational Medicine, Compensible Injuries and Health Outcomes Sydney,
The Royal College of Physicians Health Policy Unit
McMillan J, Case Management Systems in the USA, National Centre for State Courts 1998
Roberts DY, Reconceptualising Case Management in Theory and Practice, Melbourne Health Services
Management Research, Research Directions for Case Management 2002
Robbins, Steven P Organisational Behaviour Concepts, Controversies, and Applications 4th Edition
New Jersey,Prentice-Hall International Editions 1989
Related documents
AS/NZS ISO 9001:2000 Quality Management Systems Requirements
AS/NZS ISO 9004:2000 Quality Management Systems, Guidelines for Performance Improvements
AS4269-1995 Complaints Management System Requirements
Case Management Standards 2004 (replaced by Case Management Principles 2005)
Case Management Assessment Guidelines 2004
Case Management Assessment Guidelines 2005
Workers Compensation Act 1987
Workplace Injury Management and Workers Compensation Act 1998.
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