Nurse Case Management
Criteria for Nurse Assignment
• At the time of case acceptance, the injured worker
(IW) has not returned to regular duty on a full-time
basis.
• IW is partially disabled, but the file does not contain
work restrictions.
• The claims examiner (CE) requires information
about continuing services such as home health care,
housing modifications, surgery or additional
physical therapy.
Criteria for Nurse Assignment
Although the ideal time for nurse intervention is from the
date of injury through 120 days, the CE may refer a case
for nurse intervention regardless of the time elapsed since the
injury if:
• Medical evidence does not indicate a return to work (RTW)
date.
• The RTW date exceeds usual disability for the condition.
• The RTW date is extended without clear medical rationale.
Basic Tasks of the Nurse
• Establish a supportive relationship with IW
either telephonically or through face-to-face
contact.
• Secure sufficient information about the
condition and medical treatment plan to
coordinate appropriate medical services which
will expedite recovery.
• Assist the attending physician (AP) and IW in
securing medical services for the work related
condition in a timely manner.
• Monitor IW’s medical condition and treatment
provided.
Basic Tasks of the Nurse
• Assist IW in completing forms and securing information
about medical services available and facilitating RTW.
• Assist IW and AP in obtaining medical authorizations
and expansion of the claim to include additional
diagnosis if appropriate.
• Encourage IW to cooperate with medical treatment and
other efforts to prepare for RTW.
• Provide feedback regarding work restrictions to
employing agency (EA) and verify work status.
Types of Nurses
• Staff Nurse Supervisor – Manages the Lead Nurse and the OWCP Staff Nurses
nationwide.
• Lead Nurse – Conducts research and analysis to assess the efficiency and
effectiveness of the Nurse Program. Makes recommendations for Program
improvements and participates in the development of policies and procedures
for implementation, management, and evaluation of nursing services.
• Staff Nurse (SN) - Manages the contract nurses for OWCP.
• Continuation of Pay (COP) Nurse (CN) - Consists of telephone interaction only.
• Field Nurse (FN) - Assigned when disability has been identified. May be
telephonic only based on the claimant's locale or severity of condition.
• Catastrophic Nurse Assignment - Complex and long term in in nature. Often
involves multiple medical or nursing facilities, and providers.
• Task Nurse Assignment - A specific assignment is identified for FN. Once
completed, nurse will file a closure report.
Nurse Intervention with Rehabilitation Services
“Dual Tracking”:
• CE has the option to take a dual track intervention approach on certain
cases. FN and a rehabilitation counselor (RC) may be assigned at the
same time if there are specific and distinct goals for both.
• For example - FN works with AP to obtain maximum work tolerances;
while RC is evaluating transferable skills or performing an ergonomic
evaluation.
Field Nurse (FN)
• FN is a registered nurse who assists in the management of disability
claims in a number of ways. Unlike CN, FN’s contact is frequently in
person with IW, EA, and medical providers. In some cases, however,
FN’s activity may be purely telephonic in nature due to lack of FNs in a
certain area, or for other reasons.
• FNs provide case management services for 120 calendar days (can be
extended on a case by case basis).
• FNs are instrumental in reducing lost production days (LPD) associated
with a claim.
• Within a week of case assignment FN contacts EA, IW, and AP.
Subsequently, FN contacts CE. FN reports back to CE all information
obtained and recommends future case interventions based on the
information received during these contacts.
Types of information obtained by FN
• Personal Information - identifies barriers to a successful RTW.
• Job History – outlines transferable skills and abilities, which
may be used by EA to create a modified position.
• Medical History -- identifies other non-work conditions that
may interfere with an immediate RTW to some form of gainful
employment, and discussion of current treatment plan due to
the work related injury.
• Nursing Care Plan – outlines potential problems, nurse
recommendations, and nursing planned services for the next
30 days.
Nurse Intervention Process
During the first 30 days:
• FN determines whether AP has formulated a
treatment plan and whether IW’s physical condition
is improving.
• Advises AP of the availability of light duty.
• Once a plan is formulated, FN monitors the physical
progress of IW and obtains RTW date from AP.
Nurse Intervention Process
Contact with EA:
• FN may request to perform an onsite walk through
IW’s work environment to determine the extent (if any)
the job may be modified to accommodate work
restrictions.
• EA may also request this. This has proven valuable in
returning IWs to light duty in a short period of time,
thereby reducing the number of LPDs.
Nurse Intervention Process
• FN works with EA to ensure that the physical demands
of the job are in keeping with any medical restrictions
imposed by AP.
• To ensure that there are no significant barriers to RTW
and verify that RTW occurs on or near the expected
date; FN may request a RTW meeting with IW and
supervisor to review work restrictions.
Nurse Reports
• Nurse Report is submitted to CE every 30 days.
• Nurse Report outlines the progress of IW’s recovery,
contacts with EA, CE, AP, and any obstacles that may
delay RTW/recovery process.
• Nurse Report will outline any progress made with RTW in
a light duty position and/or regular duty position.
• Nurse Report also contains any recommendations for
future case intervention by CE.
Nurse Reports
• If IW does not RTW within 120 days of FN assignment, there
is no significant improvement in the condition of IW, or AP
does not provide a treatment plan, the intervention process
may end.
• FN submits a final case closure report. CE will then
formulate an appropriate plan for future case management.
Return to Work Monitoring
If IW is released to return to work, but does not RTW on the proposed
scheduled date or remains at work less than 60 days, FN will evaluate the
underlying reasons and report to CE.
Evaluation of reasons -
• If the reason is a job adjustment problem (difficulty with EA providing work
within prescribed limitations), FN will notify CE.
• If medical conditions prevent or cut short RTW, FN will contact the physician
for new restrictions and discuss the issues with CE.
• If non-cooperation with FN is an obstacle to a successful RTW, FN will notify
CE via e-mail, telephone call, or an Interim Nurse Report.
Extension of Nurse Assignment
• Extensions of 30-60 additional days may be necessary in some
cases with the approval of the CE:
– to help IW reach a higher level of physical capacity,
resulting (if possible) in return to date-of-injury job
– if work related surgery is necessary
– to ensure that initial RTW is successful
– A follow-up review is then undertaken after the extension
period has ended. As long as the file supports continued
intervention, CE can extend FN intervention period for up
to 180 days.
Extension of Nurse Assignment
• In catastrophic cases, when it is clear that FN services
would be useful for a specific purpose, or it is clear that IW
will RTW within a short period of time, the intervention
process may extend beyond the 180-day limit.
• However, any extension beyond 180 days is done only with
Supervisory approval. The only exception is an automatic
extension provided for an initial return to work monitoring
period of 30 days for regular full duty (or 60 days for light
duty).
Injured Worker’s Responsibilities
• To provide a medical release allowing FN access to
medical information related to the on-the-job
injury.
• To effectively communicate with FN.
• To coordinate communication between FN and AP.
Agency Responsibilities
• To effectively communicate with the nurses in all
phases of the assigned intervention, during the
process and after RTW.
• To allow access to IW’s worksite.
• To provide accommodation and modification of job
duties when restrictions are presented.
Results
• Nurses establish a professional relationship with the IW’s AP,
which will be beneficial towards the goal of a successful
RTW.
• Nurses are “foot soldiers” for EA and CE. Nurses coordinate,
report, and assist in the medical management of cases.
They are out in the field gathering information and medical
evidence that will contribute to a successful RTW or an
expedited medical recovery.
• IW has access to medical care and guidance needed to assist
him/her with a successful medical recovery from the injury
and an expedited RTW.
Results
• Communication lines are open to EA that will
assist them in returning IW to work; thereby
reducing LPDs.
• CE is able to take a proactive approach to
medically manage cases.
• Long term benefits – EA has a healthy, productive
employee back in the work force as well as a
reduction of LPDs and a reduction in long-term
compensation costs.
Questions
A nurse will be assigned to an OWCP case when:
a) At the time of case acceptance, the injury worker has not returned to
regular duty on a full-time basis.
b) The injured worker is partially disabled, but the file does not contain
work restrictions.
c) The claims examiner requires information regarding home health care,
housing modifications, and/or surgery.
d) All of the above
Questions
All of the following are tasks of the nurse except:
a) Assist the attending physician and injured worker in securing medical
services.
b) Issue a final decision on entitlement to medical benefits.
c) Monitor the injured worker’s medical condition.
d) Establish a supportive relationship with the injured worker.
e) Provide feedback regarding work restrictions to the employing agency.
Questions
A field nurse and a rehabilitation counselor may be assigned to
a case at the same time?
a) True
b) False
Questions
Initial field nurse service is usually authorized for 120 calendar days.
During that time they remain in contact with:
a) The employing agency
b) The injured worker
c) The treating physician
d) The claims examiner
e) All of the above
Questions
The field nurse can perform an onsite walkthrough of the injured worker’s
work environment to determine the extent the job may be modified to
accommodate work restrictions.
a) True
b) False
Questions
If an injured worker is released to work, but does not return to work on the
proposed date or remains at work less than 60 days, the field nurse will evaluate
the underlying reasons and report them to OWCP. In this situation, which are
reasons a field nurse usually contacts a claims examiner:
a) If the reason involves difficulty by the employing agency in providing work
within prescribed limitations.
b) If medical conditions prevent or cut short return to work.
c) If non-cooperation with field nurse is an obstacle to a successful return to
work.
d) All of the above
Questions
An extension of field nurse services for 30-60 days may be necessary in the
all the following situations except
:
a) To give the field nurse 60 extra days to complete their closure report.
b) Help injured worker reach a higher level of physical activity.
c) If work related surgery is necessary.
d) To ensure that the initial return to work is successful.
Take Away Tips
1) Although the ideal time for nurse intervention is from the date of
injury through 120 days, OWCP may refer a case for nurse intervention
regardless of the time elapsed since the injury if medical evidence
does not indicate a RTW date; the RTW date exceeds usual disability
for the condition; and/or the RTW date is extended without clear
medical rationale.
2) The nurse with establish a supportive relationship with injured worker,
the treating physician, and the employing agency either telephonically
or through face-to-face contact.
3) The claims examiner has the option to take a dual track intervention
approach on certain cases. A field nurse and a rehabilitation
counselor may be assigned at the same time if there are specific and
distinct goals for both.
Take Away Tips
4) Within a week of case assignment the field nurse contacts the
employing agency, injured worker, and treating physician.
Subsequently, the field nurse reports back to CE all information
obtained and recommends future case interventions based on the
information received during these contacts.
5) The field nurse works with employing agency to ensure that the
physical demands of the job are in keeping with any medical
restrictions imposed by attending physician.
6) A nurse report is submitted to the claims examiner every 30 days. It
outlines the progress of the injured worker’s recovery, contacts with
the employing agency, claims examiner, attending physician, and any
obstacles that may delay RTW/recovery process.
Take Away Tips
7) If the inured worker is released to return to work, but does not return
to work on the proposed scheduled date or remains at work less than
60 days, the field nurse will evaluate the underlying reasons and
report to the claims examiner.
8) Extensions of 30-60 additional days may be necessary in some cases
with the approval of the claims examiner.
9) Nurses coordinate, report, and assist in the medical management of
cases. They are out in the field gathering information and medical
evidence that will contribute to a successful RTW or an expedited
medical recovery.
