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An insider's guide to choosing a rehabilitation provider.

An Insider's Guide To Choosing A Rehabilitation Provider

Ten years ago the problem was different: Rehabilitation was something that people vaguely associated with disabled war veterans and people who suffered what were euphemistically called "handicaps." The typical understanding of rehabilitation was that it was some kind of effort to teach amputees to walk or blind people to weave baskets. There was little understanding among laymen of either the possibilities or the problems. Rehabilitation rarely touched the average worker's life; when it did, it was handled by public agencies--with a low success rate that was virtually guaranteed by high per-counselor caseloads and generally adverse conditions.

Today, however, rehabilitation is very much a part of our lives. Insurers and employers (as well as local, state and federal governments) understand what rehabilitation does and the need for such services. Whether mandated by law (as it is in a number of states) or voluntarily included as part of the employer's/carrier's workers' compensation claims management program, rehabilitation has become an accepted part of the medical-care/recovery process. This acceptance has led to the appearance of many private rehabilitation providers that have largely supplanted the public agencies in dealing with injured workers. The companies have the same avowed purpose--to return the injured or ill worker to optimum function and thus to work. How they work toward that goal, and the methods they use, vary along with their rate of success. Given the premise that rehabilitation is not only accepted but necessary, the problem becomes which provider to choose.

What to Look For

How local is the provider's local office? Does the company operate from a distant corporate headquarters, using telephone and mail services only? Are there regional offices? Are there offices in most major cities?

Rehabilitation is not a long-distance service. Whether they are called case managers, rehabilitation specialists or counselors, skilled personnel must be available for personal contact. They must be able to meet with the client, physicians and therapists to assess the patient's condition and the suggested treatment program. They must know the community facilities and resources and be able to deal effectively with the local medical community. They must also be familiar with local business, industry and educational facilities.

The need for a physical presence is very strong. Without it, it is almost impossible to gauge an injured worker's fear of job interviews or returning to the place where he was nearly killed. The clammy hands and ashen face cannot be seen through telephone wires.

The company should provide a full range of services to the client and not just what is available. The most obvious example is medical case management. This service is essential in dealing with catastrophically injured workers or those suffering from severe job-related illnesses. Burn victims should be in well-equipped burn centers; patients with head trauma or spinal-cord injuries should be moved expeditiously to the appropriate regional centers. While most rehabilitation workers are aware of such facilities and can make appropriate recommendations, effective case management requires a great deal of attention and a high degree of specialized experience and expertise. In short, it requires a qualified case manager.

The assessment should be thorough. The case manager should evaluate the client's home situation and the amount--or lack--of support provided by the family and assess the client's motivation to return to work. The assessment should deal with vocational issues and address the possibility that not only disability but the client's age or outdated skills may severely restrict his or her return-to-work options.

Some services should be offered in-house. The company should perform its own testing, work evaluations and computerized transferable skills analyses. Ideally, testing should be done by the provider's own personnel. The use of outside vendors presents too many delays.

The program should be flexible. Even though the rehabilitation provider offers a full range of services, not all clients require every one of them. A worker who is set to return to her own job does not need a transferable skills analysis. Automatically running batteries of tests on every client is unnecessary and costly. It is possible to purchase only components of the program that are necessary or desired. Some accounts may request limited rather than full-scale evaluation/services; the rehabilitation program should be customized to provide only the components that meet the client's and the account's preferences and needs.

The provider's depth of experience and areas of expertise should be determined early. In addition, the company should be discriminating in the cases it accepts. It is important to remember that not every injured worker requires rehabilitation. Dealing with a company that accepts every case indiscriminately is a guaranteed way to waste money.

Although using a well-established company with a known history and good reputation is generally a safe way to do business, younger companies should not be dismissed simply on the basis of youth. Sometimes the newer provider offers additional services or a fresh viewpoint. If the company measures up well to all the other criteria, there is little reason not to take a chance. In this context, it should be remembered that experience is not synonymous with expertise; it is unfortunately possible to do the same thing every day for a dozen years and still not be very good at it. In any event, references should be requested--and checked when received.

The provider should also be familiar with the given state's laws and lines of coverage. Although the essence of rehabilitation is the same, no matter what the coverage, the services must be provided in compliance with the applicable laws. Current knowledge is especially important in workers' compensation cases, where the laws governing the rehabilitation process are subject to periodic legislative changes.

Case managers are the people who will deal with the injured or ill workers, and how they deal with them is crucial. Their background, training and experience should be checked for appropriate licensing and certification. Other benchmarks to look at when considering the appropriateness of case managers are, advanced degrees and specialty training.

Case managers must be able to communicate with their clients in language that the clients can understand, whether it is French, Chinese, Russian, a Vietnamese dialect, or a home-grown regional patois. Trying to explain procedures or technical terminology is often difficult when both people speak the same language. It is impossible when neither person understands more than a few words or phrases of the other's language. Instructions that are not understood cannot be followed, and ill or injured clients should not have to cope with the additional problem of not being able to make themselves understood. If the case manager does not understand or speak the particular language, a translator should be called.

Different cultures and their customs, values and ideas must also be dealt with. Among some groups, retraining for a less physically taxing job may be seen as yielding to weakness. The inability to provide for one's family may be considered a personal disgrace rather than the aftermath of an accident. Case managers should be cognizant of cultural differences and not belittle them in an effort to work around them. While case managers should not empathize so strongly with their clients that they lose objectivity and effectiveness, sensitivity to differences among people is essential.

Caseload size varies greatly from one company to another. Eighteen to 22 clients, however, seems to be an optimal number. More cases than that may spread the case manager too thin to be either effective or efficient (this has generally been the case in public rehabilitation agencies). The danger is that the overloaded case manager may miss clues to the worker's physical or emotional condition that will affect the outcome of the case. Additionally, the case manager may not have sufficient time to research alternative/better resources or to provide essential follow-through. Conversely, if there are too few cases, the care tends to be too aggressive. The case manager with a very small case load may look for too many new resources, recommending unnecessary services and destroying the continuity of treatment. Either extreme is costly and avoidable.

Prompt company response is essential for good case management. It is essential not to make the worker wait needlessly long for services. Delay negatively affects the entire rehabilitation process and the worker's attitude. Too often, injured workers whose rehabilitation starts late or seems to take too long fall into a "disability rut." They become discouraged and stop trying, or they become comfortable with being disabled. Without prompt and appropriate aid, these workers may not get better. A further problem is that injured workers who do not receive assistance promptly tend to become angry with the insurer and employer. In our increasingly litigious society, this is asking for expensive trouble. If the company promises one-day contact, the contact should be made within that period.

Defining Success

Taking into consideration the definitions and constraints set forth by the various state laws, it is important to see how closely the provider's definition of success matches the carrier's and employer's definition, what the claimed rate of success is, and whether the actual performance statistics support the claims.

Not every worker can regain full pre-injury function. The rehabilitation provider must be able to deal successfully with all the levels of recovery from the worker who returns to the same job with the same employer for the same pay, to the one who spends the rest of his or her life in a sip-and-puff wheelchair. Most workers who require rehabilitation services fall into the very large gray area between those two extremes; for them, success is measured by how much function is really possible and what they are able to accomplish.

Case managers should always be closely supervised. Supervisors should have a wide background in rehabilitation and supervision should be an ongoing process. This is not only a matter of making sure the case managers do their jobs correctly but of helping them to do so. When case managers run into problems they cannot solve, help at a higher level of expertise should be readily available. The effectiveness of the supervision has much to do with the company's definition of quality and the procedures that ensure it. Whether the case managers' work is monitored weekly, biweekly, or following every client contact is less important than the type of review and followup. Internal reporting and monitoring procedures should be realistic and workable, and the account's only awareness of them should come from the quality of the product.

Reporting Procedures

Reports are the only way in which the insurer or employer can find out what is happening to the client, and too much unnecessary detail is as bad as too little. The insurer should specify the format, amount of detail and frequency of reports. He should also make sure they are received as requested. The reports should follow the specified format by explaining the diagnosis, prognosis, therapies and progress in language that can be understood. They must address the client's motivation, his or her home situation and any additional factors that bear upon the case and its outcome.

Management information reports should give accounts detailed information on every referral, from the number of cases referred to the number closed and the reasons for the closing; from the length of the case to its outcome. They should provide the account with data on the results of the intervention, the numbers of people who returned to their original or other jobs and the amount spent versus the amount saved. These data provide the account with evidence of how effective the dollars spent on rehabilitation are. Such reports should be sent monthly, no less often than quarterly. The reports must be readable and literate. Invoices should be presented on a schedule that has some relationship to the listed services and which is acceptable to the insurer or employer.

Continuity is important. No client relishes the thought of explaining his or her problems to a new face every month, and the probability of success diminishes with each repetition. The negative effect on the case's outcome is exacerbated by loss of efficiency as the second or third case manager on the case tries to read and understand the previous case manager's notes. High turnover may be a sign that the company has internal problems that prevent effective work.

Cost is a key area and one that is often misinterpreted. Insurers or employers looking at the projected cost of rehabilitating an injured worker sometimes see only the dollars that will be spent immediately. Although no one wants to spend money on unnecessary goods or services or to overpay for routine services, it is important not to overlook long-term gain by focusing only on short-term costs. The greater cost in rehabilitation is not the dollars paid to the rehabilitation company or medical provider; it is what is paid out instead in benefit payments.

On the other hand, prices should be competitive. A company that charges far below the going rate may be trying to establish itself by cutting prices initially and raising them in the future. It may also be charging less because it does less. There may be fewer services offered--or employees may be underpaid, underskilled, or both. A low hourly rate may also be compensated by an increase in the number of hours or by the performance of unnecessary and time-intensive services. Prices that are above the norm, however, do not guarantee superior service; they may only indicate a high overhead or a very high profit margin. The company's fee structure and estimated costs should be examined and costs negotiated when and where possible.

Howard Goldfarb is director of vocational services for CRS Care Corporation, a provider of rehabilitation and medical cost containment services.
COPYRIGHT 1989 Risk Management Society Publishing, Inc.
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1989 Gale, Cengage Learning. All rights reserved.

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Author:Goldgarb, Howard
Publication:Risk Management
Date:Feb 1, 1989
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