The white cap faces a new challenge: exploring the changing role of the rehabilitation nurse specialist.

Over a decade ago, the nurses who first entered the disability management field as rehabilitation specialists had the same goal as those working today - to make sure the injured employee received excellent medical care and was returned to the work-force as quickly as possible. However, the jobs they performed chiefly involved monitoring the medical treatment that aimed to restore the patient's physical abilities.

Today, these rehabilitation nurse specialists have extended their involvement, providing comprehensive case management for the injured worker. Many nurse rehabilitation specialists play a crucial role in expediting care of the injured worker and assuring satisfaction of all parties- employee, employer, insurer, and physician- involved in workers' compensation cases.

Widespread Acceptance

Employers have found the rehabilitation nurse to be an effective manager of workers' compensation cases, and insurers look to them as a link that can help return the patient to work. Physicians also are increasingly welcoming their advice and support for out-of-hospital care.

The rehabilitation nurse specialist provides information to the patient about the recommended treatment and any alternatives to the care prescribed, the length of the rehabilitation process, community services, and medical costs.

In addition to providing specific, case-related services, rehabilitation nurses also provide pertinent information to all parties involved with the disabled worker. This includes direct, frequent contact with insurers and employers about treatment patterns, diagnostic tools, costs, and alternative care options. "Rehabilitation nurse specialists are charged with providing a global perspective because the industry wants to receive more broad-based information about healthcare," said Faith Blatt, RN, who has worked in the rehabilitation nursing profession for 11 years.

Judith M. Ellis, RN, CIRS (Certified Insurance Rehabilitation Specialist) agrees. Employers and insurers, she said, are finally noticing the many benefits that rehabilitation nurses offer for management of workers' compensation cases. "In terms of expertise and experience, she stated, rehabilitation nurse specialists provide an excellent resource for expediting the resolution of cases while assuring that the best possible care is provided at the most reasonable cost and most appropriate time."

The nurse strives with the patient and the medical care team for maximum medical improvement - that is, to return the patient to the highest level of physical function and recovery from the injury. At the same time, she must keep in mind the broad goal of the insurance company - to deliver needed services as outlined in the insurance contract in a cost-effective manner.

"It is important that the patient understand that the rehabilitation nurse specialist is an objective party," said Diane Vincent, R.N., a rehabilitation nurse specialist practicing in Portland, Oregon. "She is there to objectively evaluate and assess the patient's needs and report back to the insurance company."

The rehabilitation nurse specialist works with the patient each step of the way, making sure that the patient fully understands his or her situation and is kept informed of all information relevant to the case.

Although initially many patients may greet the rehabilitation nurse specialist's appointment to the case with some trepidation, most grow to welcome-and depend on- the important role played by the nurse in navigating today's healthcare high seas.

"It really helps to have someone in the patient's comer who can also create a positive mood about recovery," added Vincent.

Physician Response

One of the most important patient services provided by the rehabilitation nurse specialist is as liaison with the medical specialists providing care. Many patients, for instance, are hesitant to ask their physicians questions pertaining to their diagnosis and recovery. As a member of the patient's medical team, the rehabilitation nurse specialist may attend medical appointments with the patient and clarify information for the patient.

"Rehabilitation nurse specialists help make the most of the rehabilitation process," said Mark Parker, M.D., a physiatrist in practice at Presbyterian Hospital in Dallas, Texas, who views independent rehabilitation nurses not only as patient advocates but as coordinators and advisors for the rehabilitation process. "They are valuable liaisons between members of the treating team and the patient, the patient's family, and the insurance company." Their strongest charge, he says, "is as an advocate for the rehabilitation process, fighting for their patients to receive the appropriate services, and giving them the support required to achieve the greatest possible recovery from the catastrophic injury."

Dr. Parker acknowledged that while physicians may have initially felt threatened by having an independent party assigned to the case by an employer or insurer, treating clinicians have now developed very satisfactory working relationships with the rehabilitation nurse specialist. These nurses are no longer viewed as outsiders; rather, they are considered an integral part of the medical team.

Because independent nurses who regularly work in disability management are familiar with community resources and agencies, they often are invaluable to the treating physicians because of their ability to link patients with community-based services. Furthermore, they are able to recommend and arrange supportive in-home services to assure a patient's compliance with the treatment regimen prescribed by the physician once the patient is discharged from the hospital.

For physicians, they supply critical information about the patient's job responsibilities and physiological job function that provides a key to establishing a treatment program and a realistic timetable for the employee's return to work.

Nora Francis, director of rehabilitation at Bronson Methodist Hospital in Kalamazoo, Michigan, agrees that acceptance of rehabilitation nurses evolved only after physicians began to understand the full scope of their contributions. Now, she observes, their acceptance is solid.

"At our hospitals," she asserts, especially in cases that involve catastrophic injuries, the physicians are likely to request the assistance of a nurse rehabilitation specialist. They realize that these professionals help to move cases along by making sure that resources are used appropriately and the money is well-spent."

Employers Value Nurses'

Role

Employers, particularly, are realizing the benefits of working with nurse rehabilitation specialists in workers' compensation cases. The contributions of the nurse are especially valuable-and often result in the employee's being returned to work more quickly- if they can be brought in on a case as soon as possible after the work injury.

"Employers are becoming more savvy in their requests to be kept apprised of all factors that affect a return-to-work plan. This includes how the proposed therapy will affect the employee's ability to perform the work after returning to the workplace, and the need for adjustments in the work schedule," said Sara Watson, assistant director of the Institute for Rehabilitation and Disability Management of the Washington Business Group on Health. Al Clark, senior safety engineer for Ford Electronics and Refrigeration in Lansdale, Pennsylvania, oversees the light duty return-to-work programs for that company, which has approximately 2,600 employees. He says that the company's working relationship with rehabilitation nurse specialists "provides a missing element that did not exist before in workers' compensation programs."

"The rehabilitation nurse is a neutral, outside person who can work with the employee and physician to provide a communication link back to the company. Because the employee's treatment is carefully monitored, we now have another opinion on whether the employee's medical treatment is appropriate and adequate, and about the employee's treatment progress," he said. Another positive factor he cited was the nurses' awareness of the specific challenges of working with the industrially-injured employee.

The partnership between rehabilitation nurses and Ford has produced real results. "In the past," Clark stated, "we lost employees because the longer a person is out of work, the harder it is to get them to come back. In fact, since working with the nurse rehabilitation specialists, we have been able to bring back some employees who were long-term disability cases."

Another benefit to the company, according to Clark, is that employing a nurse to oversee the worker's recovery demonstrates the company's concern for the injured worker. "It's common for the injured worker on disability leave to feel isolated from the working circle. Providing a rehabilitation nurse is one way the company can say it cares about the employee's injury and recovery," he said.

Role Continues To Expand

The disability management techniques used so effectively in the workers, compensation and property and casualty markets now are being applied to other healthcare areas and insurance markets. For example, rehabilitation nurses currently handle cancer and AIDS patients as well as other catastrophic conditions such as patients undergoing organ transplants. The need for trained nurse rehabilitation specialists in trauma cases has increased, since advances in successfully treating trauma patients have increased the number of patients requiring rehabilitation services.

The escalating demand for rehabilitation nurse specialists, coupled with an increasing number of nurses entering the disability management field, has underscored the need to professionalize. Since 1984, nurses employed as rehabilitation nurse specialists have been able to obtain the C.R.R.N. credential- certified rehabilitation registered nurse-granted by the Association of Rehabilitation Nurses. Nurses seeking this certification must have a minimum of two years of experience working in this field.

The association has set professional and ethical standards of practice and quality that allow the nurses to be accountable to the medical and insurance community.

The Future

The future is bright for the nurse rehabilitation specialist. Not only are they continuing to serve a very important role in medicine, industry and the insurance community, but their role is ever-expanding and met with increasing acceptance within the medical community.