March 2007
Welcome to the HCML monthly rehabilitation news bulletin for March 2007.
Our aim in this bulletin is to give you an overview of what is happening in rehabilitation, and what is contributing either to early returns to work after injury, or causing injuries and other conditions to last longer than they need to.
We welcome users’ comment or suggestions for new subject areas we might monitor. If you would like to know more about HCML please visit our site
Get right
Rehabilitation providers have long told insurers that early intervention is critical to reduce the length and cost of a claim, and ensure a person’s return to fitness. Sarah Preston reveals there is now research to back up this claim.
Insurers frequently request a demonstration of the cost benefit the service rehabilitation providers supply. For a company on the receiving end of this line of questioning it is a source of constant frustration that it is nigh-on impossible to provide insurers with the definitive answer they want.
Providers rarely have access to final settlement figures and it is difficult to prove that rehabilitation has an impact, positive or otherwise, on the final total claims cost. However, there is one aspect of the claims management process that can be analysed, and this enables providers to see if there is any correlation between the actual length of the claims process and the stage at which rehabilitation is introduced. In other words, does the stage at which rehabilitation starts have any impact on how long it takes to complete the rehabilitation phase?
Kynixa looked at 831 files — they included a broad range of clients, including very complex cases and those with only minor injuries — and encompassed motor, employer’s liability and public liability cases — which all had need of some form of rehabilitation.
For some, rehabilitation was introduced within three months of an accident while, at the other end of the spectrum, rehabilitation was introduced for others only after two years had passed.
Within that time range rehabilitation referral times were broken into smaller blocks of time: under three months, three to five months, six to eight months, nine to 11 months, 12 to 17 months, and 18 to 23 months.
The result revealed that when a case was referred within the first three months after an accident, the time in rehabilitation (that is, referral through to discharge) averaged 4.1 months. This was less than half the time needed if the case referred was 18 months old or more. Here the average was 9.7 months.
While there were one or two minor glitches along the time-line, the overall theory was statistically supported — that the longer insurers delay in introducing rehabilitation, the greater the probability of a longer amount of time needed in rehabilitation.
This potentially means it will be longer for injured clients to return to work or at least return to some semblance of their preaccident status. It is difficult to translate this into an absolute cost. However, it is easy to appreciate that the longer a claims file is open, the more money it costs the insurers.
Lessons to learn
So what lessons should insurers draw from this? Quite clearly, the sooner rehabilitation is referred to a specialist provider, the faster the rehabilitation process can be completed to the desired outcome.
Within the overall claim, rehabilitation will save the insurer money — simply because it speeds up the process and can help squash the life cycle of a claim. This should have a positive impact on the final settlement amount, specifically saving on the length of time off work for the claimant. It can also help reduce the hidden costs associated with any claim.
Furthermore, if cases referred within the first three months of an accident need less than half the rehabilitation support for cases referred after 18 months, then it follows that the earlier rehabilitation is introduced into the process, the actual rehabilitation costs themselves will be reduced.
As the British Society of Rehabilitation Medicine stated in 2000, rehabilitation cannot be viewed as a “bolt on” to any claims handling process — it is an integral part of the handlers’ “toolbox” and essential to an efficient outcome.
This is not advocating rehabilitation per se. Rehabilitation is there for insurers to use, selectively, as one tool. The argument here is that when it is appropriate, it needs to be introduced as early as possible.
Research is also possible for insurance clients who want to take their use of rehabilitation on to a higher level. The plan would be to process data information on claims and identify the variables that will help provide a form of risk assessment and indicate how a claim is likely to proceed.
The goal would be to reveal the profiles of people for whom a claim is most likely to progress smoothly — in other words, the process will be fast and efficient. Within the analysis it may be possible to identify the types of people who are most likely to be responsive to rehabilitation and who would respond positively to early intervention.
Such an initiative would allow insurers to more pro-actively manage their claims management processes — and that rehabilitation companies can play a leading role in helping them do so. More insurers now talk about not ‘if’ but ‘when’ rehabilitation support needs to begin.
Equally, as the rehabilitation industry itself becomes more sophisticated in its targeting of rehabilitation, providers will be able to offer the evidence to demonstrate why their services are fundamental to the claims process.
Sarah Preston is head of business development at rehabilitation services provider Kynixa
Mind over matter
Helping employees get back to work is a crucial goal of rehabilitation. However, the medical-only model fails to take into account the psychological aspects of injury that are essential in understanding how to get the injured back on their feet. Helen Merfield provides a prognosis.
A speedy recovery, mitigated risk, a client-centred approach and an early return to work: all these results can be delivered by rehabilitation case management that is well implemented. However, too many people are seduced by a medical-only approach that may ignore the true barriers to recovery. Without considering an individual’s personal belief system and how they react to their illness or injury, the insurance industry may be encouraging longer timescales for recovery.
Common sense might say that medical intervention will directly address the injury and speed recovery. This is true, but the striking realisation gaining momentum across the industry is the importance of self-empowerment to the recovery process. Addressing a victim’s attitudes to an injury or illness can directly reduce recovery times, producing long-term benefits for all parties. One of the biggest challenges for everyone involved in the rehabilitation process is to step away from the traditional series of physiotherapy sessions and embrace new evidence-based case management. To realise true potential, solicitors, insurers and employers must understand the interconnected benefits of considering social and psychological factors that influence an individual, and not separate the sustained injury to a higher priority.
Belief systems
The traditional medical model of rehabilitation emphasises the injury alone; it does not fully appreciate the overall affects on the injured person following an accident. For example, an individual may receive a continued course of treatment by a health professional that addresses the injury. The individual may then develop harmful coping strategies and a misunderstanding of their condition, which should otherwise by quite manageable. Continued medical intervention may reinforce behaviour that continues to emphasis a sick role.
Case managers must work closely with the injured or sick to understand their level of motivation and associated barriers to recovery. What does ‘recovery’ mean to most people? One hundred percent fitness? No more pain? People have different beliefs about what this means, and these ideas can be more powerful than the actual diagnosis in determining recovery. More importantly, it may not only be the individual’s belief system that is important. The projected beliefs of those that interact with them can have a major impact too. For example, the family member who tells them to rest while they put the kettle on, the health professional who is instructed to deliver a pre-paid course of treatment, the employer who prefers their employee to ‘take it easy’ while the liability claim progresses, or the system that financially encourages staying at home.
Back to work
People who have spent a protracted period of time off work — for example, due to maternity leave or redundancy — can find it difficult to re-enter the workplace. This can be due to social obstacles, fear or uncertainty. Those who have been sick or injured may also have to tackle the pressure of a GP who can only sign a sick note for a manageable condition that would actually offer no barrier to safe employment.
Progressive healthcare and improved medical intervention can address the injury or illness, but may not prevent prolonged illness in cases where the barriers to recovery are physiological. Evidence suggests that social and psychological factors are primary determinants in more considerable degrees of disability. For example, many soft-tissue injuries still proceed without rehabilitation — even if the injured is referred for injury management. The application of a medical-only model will fail to provide a full appreciation of the potential complexities of psychological and behavioural trauma that can lead to long-term disability.
A structured approach uniting all parties is more appropriate to quickly identify deep-routed beliefs and coping strategies. Professor Mansel Aylward, architect of the Department of Work and Pension’s Pathways to Work, recently argued “belief drives behaviour”, and that a “major cultural shift is required to enforce research proving work is generally good for physical and mental health”.
By taking a holistic view of an injury or illness, an injured person can change their perceptions, speed up recovery and increase their motivation for returning to work. This is where holistic case management and an integrated approach can help. By directly addressing an individual’s level of pain, worry, or low job satisfaction, it is possible to help decrease a potential spiral into perceived sickness with associated dependency.
As partners in the rehabilitation process, the key message is that rehabilitation case management must work towards guiding an individual back to health through a bio-psychosocial model that considers injury and illness in a wider context. By encouraging self-empowerment, all parties gain an enhanced and cost-effective outcome rather than long-term bed rest and deferred return to work.
The innovative solution is for all parties to start working together more closely to promote early intervention and prevent longterm work loss due to psychosocial factors. This is what the more enlightened insurers and solicitors advocate, helping the injured person gain a better chance of fast recovery, while the insurer benefits from a reduced cost of claim and loss of earnings.
By appreciating the social, psychological and behavioural factors, the market can help the individual better understand their injury and discover the most effective ways of managing their condition. This limits the potential of continued and costly medical intervention with little basis of success, which places an individual’s life on hold.
Surely this is the ultimate rehabilitation case management goal — a client-centred, model that speeds up recovery, mitigates risk and helps an injured person return to work.
The right fit
The rehabilitation sector must start to mirror the NHS in its moves towards a greater degree of specialisation, argues Dr Edmund Bonikowski, as it faces one of its greatest internal challenges going forward
In medicine, the days of the generalist are numbered. This has long been the case in secondary care where, for example, consultants do not simply specialise in orthopaedics but will focus on becoming a knee surgeon or a hip specialist.
The death knell is also being sounded on the generalist in primary care. GPs are being encouraged and incentivised to specialise in specific areas of medicine so that patient care is integrated, vertically, across the healthcare spectrum. It is a completely logical trend - fuelled by science - and is the product of our increased knowledge of disease areas and the array of possible technical interventions, which mean delivery of care to the patient has had to become much more focused.
Rehabilitation providers cannot kick against the system. As patients become more sophisticated in obtaining and marshalling information relevant to their conditions, so clients of rehabilitation companies - and their insurance customers - will start to question the credibility of companies that continue to work through individual case managers who 'cover everything'.
The rehabilitation process certainly works best with one case manager dedicated to each client whose responsibility is to bring various strands together. The case manager will agree goals, uncover the motivational triggers that clients respond to and ensure rehabilitation is co-ordinated, enabling both client and insurer to see that progress is being maintained and monitored. These are the generic aspects of the rehabilitation process.
Delivery mechanism
Case managers are the mechanism through which rehabilitation is delivered. However, by and large, they will not be expert in working with clients who require specialist rehabilitation. Yet for these people, a generic approach will just not do.
The implication of this, for the rehabilitation sector, is that we now need to put greater emphasis on developing case managers who are keen to acquire specialist knowledge and who will become experienced and confident enough to work with consultants and experts in one individual clinical area.
This means placing the case manager at the centre of a multi-disciplinary, clinical and vocational team. The team will include not only consultant physicians specialising in, for example, spinal cord injury, but psychologists, occupational therapists, physiotherapists and vocational rehabilitation specialists - all experienced at working with spinal cord patients.
Five key areas of pathology can be identified where a specialist approach is necessary: brain injury, spinal cord injury, amputation, brachial plexus injury and limb fracture. In addition, some of the common impairments arising from these areas such as pain, particularly chronic pain, mood disorders and mobility problems also require specialist management. The costs of claims in these areas can be enormous and many people, especially if they are not treated correctly, may never work again.
But for brain-injured and spinal cord injury clients, the right - and specialist - rehabilitation case management provider can help minimise care costs, possibly preventing the need for 24-hour supervision.
This is partly because the management of a condition such as brain injury does not follow one single line. It is a complex weave of independent issues that require specialist understanding. It can range from traumatic brain injuries, which leave people in a persistent vegetative state, through to the 'walking wounded' who, on the face of it, appear to have made good recovery but who family, friends, colleagues and employers are well aware are not the people they were.
It is vital that complications are not overlooked. Complications may include changes in personality and behaviour or loss of intellectual functioning - for example, concentration, memory, or the ability to plan - as well as more obvious loss of physical function.
For insurers, these sorts of claims are the most expensive and difficult that they will have to address; there is a real likelihood the claimant may never return to work. Therefore it is important that the rehabilitation provider appoints the right case manager supported by a specialist, multi-disciplinary team that will provide the vital experience and knowledge to work with the client from the start.
Insurers are beginning to understand rehabilitation far better now and in future will demand increasing specialisation from providers. They will want to know about the background of case managers handling individual high-profile cases and will be within their rights to question whether the appointed case manager has the knowledge and experience to handle specific cases in the most effective way.
Recruitment challenge
For example, there would be little point in a rehabilitation company appointing a case manager experienced in working with amputee patients to handle a brain injury case. They will simply not have the knowledge or understanding to prioritise the key issues and chart the best way forward.
The introduction of specialist teams will be one of most challenging internal issues for rehabilitation companies to address in the next few years. It is integral to the development of the rehabilitation sector and its ability to provide the guidance they need.
Rehabilitation companies will need to re-think their recruitment and training strategies of the last few years. To date, they have tended to rely on appointing extremely capable staff but who have little - if any - background in specialist areas of medicine.
However, as insurers become more discerning and capable of comparing the outcomes of cases and settlements, they will soon start to identify areas of weakness within rehabilitation companies and deduce if the right people are being appointed to manage the more difficult cases. A 'one-size-fits-all' approach just will not wash.
Rehabilitation companies must respond. Just as insurers tend to appoint their most experienced personnel to handle the most complex claims, then equally, rehabilitation companies will have to present a structure that demonstrates they understand both the fundamentals and nuances associated with complex conditions.
Dr Edmund Bonikowski is a consultant in rehabilitation medicine and founder of rehabilitation services provider Kynixa.
Clinical governance - The care factor
With insurers increasingly investing in rehabilitation and case management services, Edward Murray explores the issue of clinical governance and the practical difficulties of regulating this sector
Getting a room full of insurers to agree on anything is difficult but adding lawyers, case managers, medical practitioners and claimants into the mix makes things almost impossible. This is one of the problems currently facing the case management and rehabilitation industries. Most people, thankfully, agree that good case management and rehabilitation works to the benefit of all involved but deciding on how to deliver it, as well as its framework, has not been so easy.
The issue of rehabilitation and how to manage it most effectively has come to the fore during the past decade, although the principles behind it have been around for much longer. The NHS and its private sector cousin have long tried to implement high standards of clinical governance, ensuring a systematic approach is taken to providing, measuring and improving the level of care on offer to patients.
As part of this, rehabilitation and its management on a case-by-case basis is key; restoring patients to their former state before their accident or illness is at the heart of everything the rehabilitation industry is trying to do.
In addition, providing effective rehabilitation should ensure that the treatment patients receive delivers the best results possible, as well as it cutting down on the time people are ill. In turn, this should free up resources for other patients, get people back into work as quickly as possible and keep costs to a minimum.
This is not about a system that rushes people through their healthcare but about providing the most efficient healthcare possible, so that it delivers practical benefits for patients and helps insurers, hospitals or claimants avoid false economies.
However, despite this, the complexity of its practical implications makes rehabilitation difficult to implement effectively. Given that rehabilitation is still in its infancy in the UK, it is not surprising that there is no formal regulatory body to oversee it on a national basis or create a framework within which the entire industry should operate.
Richard Boothman, director at rehabilitation firm RTW Plus, comments: "In the UK, rehabilitation does not fit into the clinical governance framework in either the public or private sectors."
He adds that this is not because the theory behind the practice does not hold up but simply because the administrative framework has not yet been established.
This is something that many people are pushing for but, without standards, it is impossible to have a regulatory body to oversee the industry. Without an industry-wide regulatory body in place, it is difficult to create standards to which everyone must sign up to.
Nonetheless, considerable efforts are being made to remedy this and various bodies are trying to gel the rehabilitation and case management sectors into cohesive states of readiness. For example, the Vocational Rehabilitation Association states: "We have set up an education and training task group, as well as a standards task group comprising representatives from across the vocational rehabilitation sector, seeking to address the need for learning, training, qualifications and issue standards that meet the needs of the vocational rehabilitation sector".
However, the association is only made up of voluntary members and, while it can work towards creating benchmarks, it can do little to make sure members reach them and nothing to encourage non-members to do so.
The case management sector is also considering a similar initiative, with the Case Management Society UK providing industry standards that aim to provide a regulatory framework. Again, the solution is not perfect, but Helen Merfield, chief executive of Health and Case Management, believes it goes some way to making genuine improvements. "CMS UK has standards and guidelines for best practice, and it gets members to self audit," she says.
While this does not guarantee the returns people are making, she believes that those signing up are making a genuine effort to improve standards and differentiate themselves from other organisations in the market.
Mayor problem area
This is one of the major problems insurers face - they know that good case management and rehabilitation firms can deliver huge benefits to their clients in terms of their medical treatment and its results. Insurers also know that this, in turn, will keep their own costs down and improve customer satisfaction, but getting it wrong and putting clients in the hands of firms that are unable to deliver what they promise would destroy all of these benefits and more.
For insurers, the challenge is to find firms to work with that can demonstrate the service, skills and expertise they offer.
Rayne Ward, commercial client director at Medisure, explains: "It is exactly this sort of framework that insurers should seek evidence of when appointing a company or assessing if their existing provider is working to the highest standards. Users of case management or rehabilitation services need to set standards that can be evidenced, so they can be confident that providers are operating in the way that is expected and delivering a quality service."
David Bingham, managing director of rehabilitation firm IPRS, argues that, for rehabilitation providers, the true measure of professional standards comes from whether evidence-based medical practices have been adopted. "Evidence-based medicine focuses on patient outcomes, pulling together published information to feed into more prescriptive treatment protocols. As such, it has a patient's welfare at heart and involves working to agreed guidelines," he says.
However, there are several questions over solicitors' and insurers' ability to assess the case management and rehabilitation providers they use. Rachel Griffiths, spokeswoman for the Association of Mutual Insurers, comments: "Many solicitors and some insurers still have a limited understanding of the services available and whether they will meet the specific needs of their clients."
In the instance of an injured party, she says the roles of rehabilitator and case manager are ones of extreme trust, and the needs of the injured person should be the only priority. To that end, she believes it is vital that the criteria for selection of a rehabilitation provider is stringent.
As insurers become better acquainted with the rehabilitation industry and what it has to offer, they will also become more experienced at understanding their own requirements and assessing the firms that seek to provide for them.
Basil Nally, head of business development at Bupa Recover, believes much of the improvement that will be seen during the next few years will be driven by this knowledge. "In terms of standards, the market is beginning to dictate more of what is acceptable, and rehabilitation providers have to respond to that if they are going to be successful," he says.
Looking at the wider implications, firms will increasingly have to hit certain benchmarks if they want to succeed. "There might not be a regulatory framework in place but, increasingly, there is a market requirement that if you want to remain competitive and meet the needs of clients, then you have to deliver a service that meets certain standards," Mr Nally says.
One of the problems facing those seeking to introduce standards in both the case management and wider rehabilitation sectors is the amount of practices and disciplines that are involved. Rehabilitation is concerned with every aspect of medical care, and case managers have to know their way around these if they are to be effective.
However, for practitioners, each sector of the medical world has its own best practices in