The goal in handling a workers’ compensation (WC) claim is to restore the injured worker to maximum medical improvement (MMI) and return the worker to the workplace. Past blog posts have discussed major issues in achieving success toward this goal, including comorbidities and opioid addiction: Managing Outcomes Through Value-based Healthcare Providers, Addressing the Opioid Epidemic, and Return to Work Programs. In some way, each of these posts touches on an issue that is gaining attention as a major barrier to successful claim outcomes—psychosocial issues.
The interaction of psychological and social factors with biological factors was first introduced 40 years ago. The importance of addressing psychosocial issues is clearly rising to prominence—a Google search of “psychosocial model in WC claims” yields 544,000 results, with recent articles reporting it as a top barrier to successful WC claim outcomes.
The term “comorbidities” is used to describe medical conditions that interfere with treatment of the work injury. These may include cancer, previous orthopedic injuries, obesity, cardiac condition, or high blood pressure that needs to be addressed before a surgery can take place; and those that delay healing, such as diabetes. Medications to treat these pre-existing conditions can interfere with the treatment of the WC injury. The adjuster should be aware of these medical conditions when referenced in the history portion of the reports provided by the treating physician.
Mental health condition comorbidities include pre-injury diagnoses such as depression, anxiety, mania, post-traumatic stress disorder, and alcohol/substance abuse. Psychosocial issues/risk factors may be more difficult to identify, often becoming first known to the adjuster through conversation with the injured worker or nurse case manager. The adjuster may learn that the injured worker is under high stress due to family life, ongoing financial issues, other stressors that increase anxiety, or a lack of coping skills. An injured worker may limit movement for fear of pain or aggravating the injury. There may also be logistic issues with treatment, such is the case when the injured worker who requires care also functions as a caregiver themself and can no longer perform that role. In other words, daily life has plenty of challenges without layering injury and disability on top of it. Understanding the psychosocial factors can help to identify variables that influence a patient’s willingness to adhere to prescribed treatment regimens.
Adjusters skilled in active listening and communicating with empathy are critical in understanding the whole person, including their fears and beliefs, and then identifying claims that need specialized intervention to support the recovery of the injured worker. The individual case determines which resources are appropriate; however, family support, formal support groups, mindfulness interventions, cognitive behavioral therapy, and health and life skills coaching are just a few resources that can contribute to a successful outcome. Check with your TPA for their insights on a holistic approach to claims and the use of behavioral health specialists.
The Old Republic Risk Management Claim Department provides oversight of the claims handled by the Third Party Administrators (TPAs) selected by our Insureds. Claim Specialists liaise with the TPA Adjusters and Insureds to provide guidance on the management of serious claims. The Claim Department is based out of our corporate office in Brookfield, WI.