The “Magellans” Navigating Workers’ Comp Care: Nursing Case Managers

Episode Notes

Transcript

Announcer:

Workers Comp Matters, the podcast dedicated to the laws, the landmark cases, and the people that make up the diverse world of workers compensation. Here are your hosts, Jud and Alan Pierce.

Judson Pierce:

Welcome to another edition of Workers Comp Matters. I am your host, Jud Pierce. Today we have a wonderful episode on the subject of nurse case managing and nurse case management services in the workers’ comp context. It’s something that I, as an attorney, I’m still coming to learn about and I’m hopeful that this 30 minutes will bring about some more education on the topic. We’ve got two wonderful guests here from medical and life care.com, the president, CEO, Cindy Bourbeau, and nurse case manager, Annie Barach here to talk to us on the subject and really demystify it because recovery is a team sport and understanding this system is part of healing and fear and anxiety. Do us no good. So welcome Cindy and Annie to our program today.

Cindy Bourbeau:

Thank you. Thank you for having us.

Judson Pierce:

I wanted to have you on because we haven’t touched on nurse case management on this program in some time, and I wanted to ask you first, what is the weirdest misconception about your job?

Annie Barach:

The weirdest conception about our job is that

Judson Pierce:

Misconception

Annie Barach:

We are spies

Judson Pierce:

And by spies, what do you mean? I mean I kind of feel like I know what you’re getting at, but what do you mean

Annie Barach:

That it kind of overshadows the part that we’re there to actually help the patient navigate the system and get them to the best specialist and providers that we can versus where they’re there to report on what they’re doing and not doing.

Judson Pierce:

Okay, so that is one myth that you both would probably agree. You want to retire forever, correct?

Annie Barach:

Yes, yes. The second would be that we can’t work with attorneys

Judson Pierce:

And I would concur with that. You can absolutely work with attorneys. I’ve had the pleasure of working with you, Annie, and you are a tremendous advocate for injured workers here in the commonwealth of Massachusetts. I don’t know if you work in other states as well, but really having someone who can help someone navigate the difficulties in getting care and seeing doctors and where to even go. Lawyers can only do so much of that and I think nurse case managers add a little bit of extra filling to that special recipe we call getting people back to their normal selves. Okay. Now that we’ve cleared your reputation, when are you typically assigned to a claim?

Annie Barach:

Well, that’s a big window, hopefully right away or within a month or two, but there are times when we get claims that are six months a year out or longer, and that’s usually very difficult. It’s like untangling a web.

Cindy Bourbeau:

And so with the more severe injuries, we tend to get called in the day of the injury. So we’re at the hospital when the families waiting to hear what’s happening with their injured worker. So it can be as soon as that or again, when everything else fails after a year of treatment they say come in and solve these problems. And that is more difficult because they’ve already gotten treatment that hasn’t been effective for a long time.

Judson Pierce:

Who typically decides the assignment? Is it the claims adjuster? Is it an attorney?

Annie Barach:

Generally speaking, it’s probably a claims adjuster. Some employees in particular like to have case management on every claim and other times it’s the insurance company that can make that decision.

Judson Pierce:

So you’re juggling a lot, you’re juggling emotions, medicine, logistics. What are some of the hard conversations that you have with injured workers?

Annie Barach:

That they need to be patient. They need to be patient. These things take time and I think that sometimes I don’t fully appreciate or understand that we are trying to get you back as close as we can to your pre-injury state, but that may or may not happen depending on 3020 500 extraneous variables, but we do our best.

Judson Pierce:

What are some of the emotional misunderstandings about recovery?

Annie Barach:

Fear, pain, especially patients that have never been injured before, there’s a tremendous amount of anxiety around that. If they’ve never had a broken bone or torn a ligament or a tendon, it’s the fear of the unknown, which is a great reason to have us on board because we kind of help alleviate those fears and explain things, reeducate them constantly and assure them of what is normal and what is abnormal.

Cindy Bourbeau:

I think one of the hardest things is that patients seem to think that they’re going to be 100% better once they have the surgery and really once the injury has happened, you’re never going to be back to a hundred percent because your body changes. It has to change for most injuries. There are some very minor ones that maybe your back to baseline, but for most they’re not. And for that patient who it’s their first injury, their first injury in their whole life, that can be really traumatic. They just can’t accept that they’re not going to be able to do everything they wanted to do before. So we deal with a whole range of injuries. It can be from simple to very severe. Obviously the severe injuries are the ones that are the hardest to deal with, so having those conversations is part of the process and then helping them through that is a big part of the process and getting them back so that they, even though they have a permanent problem, we’re trying to help them figure out how to live with that.

Judson Pierce:

So there is an impact here on fear and anxiety on the healing process then?

Cindy Bourbeau:

Absolutely. Absolutely. From day one,

Judson Pierce:

I looked at your resume, Anne, and it seems like you have some experience in the correctional field working with inmates and whatnot. You’ve been a nurse for several years. What do you love about your job?

Annie Barach:

Nursing in general or this one in particular?

Judson Pierce:

Nursing in general.

Annie Barach:

Nursing in general. I mean, I think most people think it’s fun to help people and it’s very rewarding. This one in particular, it is unique in the fact that you get the patient and meet them when they’re injured and broken and then God willing, everything goes according to plan and then they’re better and they’ve resumed life and everything that they were doing prior to the injury and that’s amazing because a lot of times in nursing you don’t get that experience. You might see them in the acute stage or in the middle in rehab or when they’re closed to discharge, but you don’t usually get the whole gamut.

Judson Pierce:

Same question really for you, and thank you for that, Anne. Cindy, what do you love most about your job and this one in particular, working with injured workers, having led this professional organization for many years over a wide swath of the Northeast region?

Cindy Bourbeau:

Well, I have very catastrophic cases, so my goal for all my patients is to have the best quality of life and to actually live a life so many of them have. They could be quadriplegics or traumatic brain injuries where they’re impaired and they can’t talk anymore from whatever the injury a fall or a gunshot wound or whatever. And so getting them to the point where they’re the best they can be can take a few years, and then we also work with them for their entire lifetime. So I’ve had patients up to 17 years where we’ve managed their care in the home and make sure that they have a life, they get to do the things that they want to do. They go to their son’s wedding and dance at the wedding as a quadriplegic in a wheelchair, or if they’re a young girl with a hand that’s been amputated because of an injury, getting back into cooking again, which was going to be her career, all those kind of things, helping them achieve those long-term goals and have a good life.

Judson Pierce:

It’s excellent. I mean, you clearly have found the right job for your situation and for your philosophy of life. I mean, I think it takes a great deal of compassion and empathy to be in your situation, right?

Cindy Bourbeau:

Well, yes, and I think that my nurses are all great. They’ve all had patients that are very impaired and minor impaired and they approach them all the same way with humor and getting them through it. So I think it’s great. It’s a great profession to be in for anybody out there who’s looking to get a job in the future. Yeah. Let’s do some marketing here.

Judson Pierce:

We hear in the news at least that there’s a shortage of nurses. Is that what you’re seeing?

Cindy Bourbeau:

Yes. I think when COVID hit, we worked through COVID, some very unique situations, and then after COVID, a lot of people retired, plus baby boomers are retiring, so we’re the largest generation, and so a lot of nurses are retiring and we need people to come into nursing, so I’m always encouraging the young people today to look at it. It’s a great profession and you can do anything in nursing anything, have your own business.

Judson Pierce:

Yeah, yeah, absolutely. Right. Why don’t we take this moment to hear a word from one of our sponsors and we’ll be right back with nurse case management and its secrets unraveled. We’ll be right back and we’re back with our special guests, Anne Barrick and Cindy Bbe from Medical and Life Care Consulting. Getting back to the workers’ comp context, what is the dilemma that you face probably every week on approval versus delay getting caught in between, let’s say a doctor’s requests for certain things and insurers inability to get those things approved forthwith. How do you negotiate that gap and what do you do?

Annie Barach:

Well, one of the main benefits of having your nurse case manager hopefully at your appointments with you is we can kind of preemptively set the groundwork for what’s about to come across that adjuster’s desk or you are as desk and we can kind of amplify how important a certain test or diagnostic of whatever kind is or surgery because we’re there firsthand in the room with them. Again, it’s like that telephone game with if you’re trying to get information from the patient and you’re not there, doesn’t always come across the same way, and some providers are better at documenting and writing notes than others, so sometimes you can help fill those gaps that can expedite an approval for something. So I always try to encourage the patient to have us there with them. Again, not as a spy, but basically to help you.

Judson Pierce:

Right. What about patient’s loved one spouse partner? Do you value them being at these appointments? Do you think it just creates more difficulty if you have more people in the room? I mean, how do you balance that?

Cindy Bourbeau:

I love it. Can I say that this is the patient’s appointment and so it’s not our appointment, so very much the family should be the one who’s in there with them. If there’s a choice between them and us, then obviously the family goes in and then we just talk to the doctor when they’re done, we come in at the end of it. That’s perfectly fine. People can have their privacy if they need it, but being present is so important. We are very fortunate because we work with some great insurance companies, we work with many insurance companies, national ones, some just from Massachusetts, and they really see us as advocates for the patient. So us bringing our professional evaluation actually makes a huge difference and allows us to get approvals or overrides as needed. How

Judson Pierce:

Do you build trust with skeptical patients or skeptical attorneys? I know as a practicing attorney for many years in this area, sometimes I’ve been a little bit surprised with the quote behind the scenes discussions that nurses and doctors may have outside the purview of the patient, the patient’s attorney, and it worries me. It worries me that there could be some implicit or non implicit bias ultimately. Is it fair to the injured worker? How do you build that kind of trust and authenticity?

Annie Barach:

Well, for me personally, I just always remind the patient it’s really they’re making their choices. I’m there to support them, to help them to get things approved. And on occasion, sometimes I’m there to ask some questions, were you truly happy with that experience with that provider just now? And sometimes I say no, and I say, well, are you interested in something else? And they’ll say, yes, and I’ll say, well, let’s do that. But I think it’s to always put the steering wheel back in their hands. I’m not driving this. You are. I’m just here to help you navigate it. I’m like, Magellan,

Cindy Bourbeau:

And I would very much rather have all the conversations in a patient appointment than outside of a patient’s appointment. So I have no problem just talking to the doctor if the patient’s there. I mean, that’s a simple way to solve that problem. There’s nothing I’m going to say that’s going to be harmful to the patient. Nothing.

Judson Pierce:

Do you think the system that we have, and I know we’re dealing here in Massachusetts and we have listeners all across the country and every state’s different laws in the medical aspect of workers’ compensation, but how do you view the fairness of the system to injured workers? Is there some room for improvement there that the legislatures should tend to or do you think the balance is met?

Cindy Bourbeau:

I would like every single case to have a case manager, every single case, treat everybody the same, the same service, the same whatever. I would love to see that happen. I think it would solve a lot of problems actually, and it would get things done so that some of these inefficiencies don’t happen because we deal with so many insurance companies in so many states because we do all of New England. So we’re dealing with people all over the place. There’s good and bad people in every job, people who do their job well, and those who are inefficient. Our job is to get through those inefficiencies and we have ways to do that that we’ve persisted to be able to accomplish what we need to accomplish. Because bottom line is we want the patient better. We want them to be done to have everything they need to get it resolved and to get them better. So we do a lot, and I don’t know if we need to go into details about how we do all that, but we try the best by having a good relationship with everyone. So that includes the adjusters who rely on us, the patients who rely on us and attorneys when they allow us to work with cases like you have in the past. So

That’s much appreciated.

Judson Pierce:

I’d like to just segue into practical advice for injured workers and their counsel, some actionable takeaways here, folks, based on your experience, Ann, Cindy, what should injured workers do immediately after an injury and what are some of the mistakes or pitfalls they can avoid?

Annie Barach:

Report the injury immediately have it documented, because so many times we hear, it happened to me seven days ago, but I thought I’d walk it off or it wouldn’t be that bad. And then everybody gets confused. No one knows what to do anymore. Who knows what happened. Was it really seven days ago? I just tell ’em whatever it is, as small as it is, is just report it that way. There’s something documented that we can always go back to. If you walk it off or you sleep it off in two or three days, fabulous. But on the outside chance that it turns into something more,

Judson Pierce:

At least it’s well documented,

Annie Barach:

Right?

Judson Pierce:

Yeah. I just had a client come to me today as a matter of fact, and his injury was a year and a half ago and I said, well, what took you so long? Did you get hurt and why did you not report? He’s like, no, I reported it. I made out an incident report. And then I said, then what did you do? Did you go see your doctor? No. I said, when did you first see your doctor? A year after the injury, almost to the day. I said, but you were hurting, right? He was like, I was toughing it out. I was trying to tough it out. I was a newer employee there. I didn’t want to make waves. If I had seniority, I might’ve gotten treatment right away and really tried to figure things out. So do you see that type of scenario come about where the employee doesn’t feel safe in terms of his or her situation, employment status, to really dig a little deeper and see doctors and get treatment?

Cindy Bourbeau:

Sometimes. Sometimes that happens. We work very hard with employers even to kind of break down those barriers so that they have a good reporting system and the patients have a place to go identify a place to go to fill out a form and give it to their employer. And sometimes that’s available and sometimes it’s not. But yes, sometimes there are delays like that, and then it’s harder to prove because not only have you delayed reporting it and getting it covered, but you’ve also probably made your problem worse because it’s now a year out and it’s now a chronic issue, which is a whole nother kettle of fish.

Judson Pierce:

Well, thank you. And we will be right back with this interesting program on nurse case management services in just a few moments and we’re back. So when should an injured worker escalate his or her concerns about an injury when they’re a day out, two days out? I mean, it just depends. Every case is different. When really should be the time to see a doctor. Sometimes they don’t even have a primary care. How do they obtain one? Can nurse case managers help with that sort of thing?

Annie Barach:

A lot of employers or will have occupational health that they can go to or an urgent care. If you don’t have a PCP, by all means go to an urgent care and get some sort of documentation that, Hey, I did this today, yesterday, two days ago, and it might not be the perfect provider, but at least it’s a start

Cindy Bourbeau:

Or some kind of acute problem that needs to be treated. And then they’ll usually refer them out. But if they do not refer them out, obviously that’s our role. We want to get people to specialists right away. There’s no sense in treating with your primary or even a health. Long-term specialists are the way to go in our opinion. In my opinion. I should say. I shouldn’t speak for you.

Annie Barach:

No, I agree. I think you don’t. I tell the patients a lot of times you don’t want the doctor who’s treated a knee injury eight times in the last year. You want the doctor that’s treated a knee injury 800 times in the last year.

Judson Pierce:

Yeah, I mean the focus on an issue of an orthopedic nature versus some other type of issue that isn’t really in their treatment style or what they’ve learned. Makes sense. The type of work that you provide and the knowledge that you’ve gained, your institutional knowledge over the years, you’ve probably come into contact with a lot of doctors. Sometimes lawyers are asked by their clients, can you just suggest a doctor? Can you tell me where to go? It would seem to be a little bit more appropriate to have someone in your field who actually knows some of these people make that referral. Am I right? Am I getting to something that you guys have a little black book that we don’t have that you could really help the clients could get some help with?

Annie Barach:

Well, we don’t direct care, so to say, but a lot of times patients are already treating with someone or they’re like, my friend down the street had a hangnail 10 years ago and they really like this orthopedic doctor, and if someone’s really fixated on seeing someone or they’re treating someone, that’s great, we can go there. There are other times where people have asked, I have no idea where to go and what I’m doing. And I’ll usually look where they live and present them with, here here’s four or five different people. Do a Google search, do a review, see what you think, we’ll go where you want. We don’t direct them there, but a lot of times they will ask

Judson Pierce:

And you give suggestions.

Cindy Bourbeau:

We share information as a team, so we keep lists of appropriate physicians for different problems who’ve been good, whether it’s a trauma or whether it’s a hernia, and then we give them a list and then they can choose.

Judson Pierce:

Yeah, absolutely. When I was first practicing, I was told, look, nurse case management is helpful in some ways, and it can also be a little bit of an impairment to the case in general as an advocate for injured workers, I want to see them get better first and foremost. And that is the same goal that you both seem to share. Could you describe to us, again, you do work for insurance companies per se. They pay for your service, but you’re also working for the injured worker as his or her advocate, and that does sometimes create a little bit of a natural tension, does it not? And just to end the program in a sort of uplifting note, how do you guys bridge that tension? Once again,

Annie Barach:

I don’t know that it creates a tension for me personally at all, because if my goal is to do the best I can do for that patient and to get them back to where they were before they were injured or as close as possible, if I’m being the best advocate and I’m actually doing the best job I can do going to happen and everything else falls into place, the rest is the icing on the cake. My goal isn’t running in. They’re like, I’ve got to get them back to one aspect of their life only. That’s not my point. So I think if you’re being the best advocate and the best nurse and the best navigator, then they’re inevitably going to get better.

Judson Pierce:

Yeah, you

Cindy Bourbeau:

Will never get us to say anything other than we’re going to be an advocate for that patient. So we’ve been taken off of cases because we push and push and push and they don’t agree with us, but we will always do that. And I have not personally met, I don’t think any case manager who has not done that pushed to get that done. It’s very discouraging when you’re working with a severely injured patient and maybe you’re working with them for two months or three months and you’ve ’em stabilized and then you get kicked off the case because of it’s a case, right? And it’s a severe case. I get it. But that’s counterproductive to me, and it’s not in the patient’s best interest ever. And I’ve had people scream at me about my involvement and to stop, and that isn’t a good situation either. We should all be working as a team to get this patient the best care possible and get them better.

Even though I’ve been taken off of cases periodically though, I’ve been approached Reapproached afterwards saying, oh my God, we really need help now. Can you help us? Because now this is turned into this problem and they really need someone. So I think if we all keep in mind that we’re working as a team, whether it’s the patient’s attorney, the insurance company, and their attorney, we’re kind of like the middleman. And so in medicine, we’re the middleman because we work in between all of the treating practitioners, which are many, and if they don’t communicate, nothing’s going to work. And that’s what happens. Nothing works unless we’re communicating. So I think that if we work as a medical team, we should be able to extend it to everyone so that we’re all working to get the patient better.

Judson Pierce:

Do you have any involvement with respect to fee disputes? We’ve seen that as attorneys over and over again that the fees are so low and doctors are, they just can’t do it. How do you guys approach that?

Cindy Bourbeau:

I try to develop good relationships between the insurance company and the billing department of whatever the healthcare practice is. I’ve been asked to come in and negotiate fees to try to get everybody closer together, and we’ve been successful with that so that at least the patient can. Now, some systems they set up now are very hard to break into and to get negotiated, but I started nursing in the dark ages, so I’ve done a lot of things that probably wouldn’t have been done by the average case manager now, but we do that all the time. Yes.

Judson Pierce:

That’s great. Well, I just want to wrap up today by thanking you both so much for spending some of your time with our listeners and me. This is a side of workers’ compensation. I don’t think that gets as much attention as it really should because it’s something that benefits all stakeholders in the system, right? First and foremost, the injured worker. If communication, and that was brought up a lot today, can just be more smoothly turned out, then we’re going to see better outcomes. And thank you guys for supplying that help and that guidance and that voice. And I just want to do a shout out to website medical and life care.com where you can find our founder president here, CEO. Cynthia Bbo and nurse case Manager, experienced a ton of experience. Annie Barrick, thank you both.

Cindy Bourbeau:

Thank you for having us and for doing this with us. Yeah, it’s been great. This was great to do. So thank you so much.

Judson Pierce:

Alright, well everyone from here at Lovely Salem, Massachusetts where we record Workers Comp Matters. Recovery is a team sport. Understanding the system is part of healing. And from all of us here at Workers Comp Matters, go and make it a day that matters. Take care.

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