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Check for mental illnesses that can impede recovery
Psychiatric problems are frequent comorbidities
Case managers are the center of the universe when it comes to spotting psychiatric problems that can impede recovery and return to work, asserts Barton Margoshes, MD, chief medical officer for CIGNA Group Insurance, based in Bloomfield, CT.
"The case manager is the only person who can coordinate the information among the doctor, the patient, and the employer. Nobody else makes contact with all three," he says.
Case managers can get subtle and not-so-subtle information from all three parties involved in return-to-work disability cases and put together a comprehensive picture of what's going on.
Many times, the physician may not have an understanding about what's going on in the workplace or the patient's life at home. He or she is looking only at the back pain or other condition, Margoshes adds.
"The worst thing that can happen is that a patient is being treated for low back pain and the orthopedist knows nothing about what is going on at work. Our case managers play a pivotal role in making sure we uncover the hidden issues," he says.
Case managers are at the forefront of CIGNA's holistic approach to managing the care of members covered by group disability insurance, Margoshes says.
The CIGNA group disability insurance program is separate from the plan's workers' compensation program and is for people who do not get hurt on the job but suffer the same kinds of injuries and illnesses and face the same return-to-work issues.
"We take a holistic approach, looking for not only a psychiatric condition but also another medical condition that could impede return to work," he says.
Psychiatric problems are very common among people with disabilities, Margoshes says.
He cites statistics published in Managed Behavioral Health News that 65% of people with disabilities have multiple impairments and 40% have a behavioral health comorbidity.
"If you look at them through blinders without determining if there are other things going on, you're going to miss something. That's why we use our holistic approach, as opposed to the impairment approach, and perform a comprehensive evaluation of the individual," Margoshes says.
Screening for factors that can impede recovery is an integral part of any case management activity, Margoshes says.
"These kinds of things are not always evident, but if someone is having a difficulty with treatment or return to work, it can mean that post-traumatic stress disorder (PTSD) or another psychiatric or medical condition is unrecognized," he says.
For example the first six months following the terrorist attacks of Sept. 11, 2001, CIGNA experienced a 7% increase in psychiatric disability claims.
Many of the claims were for PTSD or a severe, long-lasting reaction to a stressful event.
The increase in cases was just a temporary bubble, but it created a greater awareness of psychiatric disabilities, their effect on the workplace, and the need for early treatment, according to Margoshes.
Now, as members of the armed services reserves return from active duty on Afghanistan and Iraq and go back to work, it is possible that PTSD cases may crop up, he says.
"It may present as a physical problem but in fact, they may also have a psychiatric condition," Margoshes says.
PTSD can be a single diagnosis that causes a disability or an unrecognized comorbidity that complicates another diagnoses, Margoshes says.
PTSD can occur in the workplace. That's what happened Sept. 11.
Someone who is a victim of a violent crime or something less dramatic also can suffer from the condition.
It's common for people who have PTSD to have problems at work. They may be having problems concentrating. Their productivity and quality of work suffers. For the first time in their lives, they may get a bad appraisal. Their employer reports interpersonal conflicts with co-workers.
"The case manager looks for clues as to whether something else is going on and that this individual needs help," Margoshes says.
At CIGNA, the claims case managers and nurse case managers work together. The insurer's psychiatrists and other medical directors consult on the more difficult cases.
"There is a coordinated approach between our clinical team and our claims administration team," Margoshes says.
The case managers do a quick screen for psychological issues on almost every group disability case.
"Our case managers don't just look at an individual based on diagnosis alone. We probe and search for other things going on in their lives that may affect their recovery.
They find out a lot from talking to the patient, asking if they are having any problems at work," Margoshes says.
For instance, someone may be on disability because of low back pain but may also have PTSD or another psychiatric condition that delays recovery and return to work.
"The most important part of helping someone with a psychiatric disorder is early intervention and identification," Margoshes says.
There are two ways to identify patients with psychological disorders: The easy way is if they already have a diagnosis and are in treatment. In this case, the nurse case manager works with the patient, physician, and employer on return-to-work issues .
In the more difficult cases, the psychiatric disease is not readily apparent but the case manager picks up cues that the patient has more than just physical problems.
Most conditions have a "predictable recovery trajectory," Margoshes says.
The case managers have a good idea how a patient's recovery should go and when he or she should be able to return to work.
When the patient isn't improving with appropriate treatment or is getting worse, the case manager probes to find out what other issues could be causing the problems.
Another clue that something else is impeding recovery is if the diagnosis keeps changing. Maybe the patient first complained of back pain, then switches to neck pain or pain in some other area.
"Maybe something was missed on the diagnosis or maybe the doctor was not aware that something else was going on in the person's life," Margoshes suggests.
For an example, a member has a primary diagnosis of low back pain and doesn't seem to be recovering. The case manager looks for other issues that may affect recovery, speaking to the employer, the physician, and the patient.
"When we get cues that this person may be having workplace difficulties or family issues or financial issues, these are a red flag that maybe something else is going on," Margoshes says.
Throughout the course of the disability, the case managers maintain contact with the member on a regular basis.