Case management in occupational rehabilitation: Would the real case manager please stand up?

Case Management in Occupational Rehabilitation 1 Running Head: CASE MANAGEMENT IN OCCUPATIONAL REHABILITATION

Case Management in Occupational Rehabilitation:

Would the Real Case Manager Please Stand Up?

Dianna T. Kenny PhD

Director, Work and Rehabilitation Research Unit

Faculty of Health Sciences

The University of Sydney

In Australian Journal of Rehabilitation Counselling, 1995, 1, 2, 104-117

Key words: case management, role conflict, occupational rehabilitation

Address for correspondence: Dr Dianna Kenny, Department of Behavioural Sciences, Faculty

of Health Sciences, The University of Sydney, PO Box 170, Lidcombe, NSW, Australia 2141.

Telephone: 61 2 646 6644 Fax: 61 2 646 6540

This research was funded by a grant from the WorkCover Authority of New South Wales,

Australia (Grant No 30 303 010)

Case Management in Occupational Rehabilitation 2

Abstract

Key stakeholders (injured workers, rehabilitation co-ordinators, rehabilitation providers,

treating doctors and insurers ) in the occupational rehabilitation process were interviewed to

gain their perspective concerning the degree to which case management was viewed as the

organising principle of post-injury management and to whom this role was most frequently

assigned. Findings indicated that there were differences in stakeholder perceptions about who

should fill this role for the injured worker, with the majority of each group claiming case

management as their proper role. In contrast, 35% of the injured workers interviewed stated

that they either did not have a case manager or that they case managed themselves. Although it

was argued that rehabilitation co-ordinators are suitably placed to act as case managers, they

were nominated least by injured workers. Three vignettes of successful case management were

presented and recommendations for policy and practice were made.


Case Management in Occupational Rehabilitation:

Would the Real Case Manager Please Stand Up?

Case management of injured workers following workplace injury is viewed as a critical

feature of occupational rehabilitation programs in several countries (Morrison, 1993).The

emergence of case management as a central organising principle in the provision of

rehabilitation services has arisen because of the complex nature of the rehabilitation process

and because of the large number of stakeholders involved with the client throughout the post-

injury phase.

Case management has been defined as "a set of logical steps and a process of interaction

within a service network which assure that a client receives needed services in a supportive,

effective, efficient, and cost-effective manner" (Weil & Karls, 1985, p 2).

The essential elements of case management are "assessment of need, service planning, service

co-ordination and linking, and the monitoring and continuous evaluation of the client, of

service delivery, and of available resources" (Weil & Karls, 1985, p x).

In recent studies assessing the benefits of a case management approach, conflicting results

have been reported. For example, Blum and Mauch (1990) reported benefits of case

management using the rehabilitation nurse in the role of case manager, in the form of cost

reduction, higher return to work rates amongst injured workers and decreased litigation. On the

other hand, Greenwood et al. (1990) found that neither the costs of injury nor the amount of

time lost from work decreased with an early intervention case management approach compared

with routine claims management. However, the quality of the case management was not

assessed in either study, thus making interpretation of the results difficult. Further, little

attention has been paid to the team dynamics in case management, with the result that

stakeholders often have difficulty understanding the roles, responsibilities and perspectives of

other participants. Where disparate and conflicting values exist, such as the basic conflict

Case Management in Occupational Rehabilitation 4 between profit and safety in occupational rehabilitation (Williams & Thorpe, 1992), dilemmas

arise in practice which cannot be resolved at the practitioner-client level. Tarvydas & Cottone

(1991) advocate structural and policy change as the appropriate level of organisational

intervention that would need to be targeted to resolve such dilemmas.

Different countries practise different methods of case management. For example, in the

Netherlands, a team of experts provide joint case management to injured workers. In Germany,

however, the case management function resides in the physician who is responsible for

assessing the needs of injured workers and for arranging rehabilitation if necessary (see for

example, Bockting & Hulsman, 1990; Dean, 1990). In Australia, each state is responsible for

the provision of workers' compensation benefits and rehabilitation to its injured workers. In all

workplaces within the state of New South Wales, for example, employers are required to

establish a workplace rehabilitation program which is developed in consultation between

workers and employers. Part of this program involves the appointment of a rehabilitation co-

ordinator in workplaces which employ more than 20 workers, whose function is to provide

information to the injured worker, liaise with key personnel such as the worker's supervisor and

treating doctor, and to negotiate suitable duties. The rehabilitation co-ordinator may also be

involved in referring to specialist occupational rehabilitation providers (eg, Commonwealth

Rehabilitation Service) for assistance in, for example, workplace modification, development of

upgraded return to work programs or vocational redirection.

Although rehabilitation co-ordinators are in an ideal position to take on the role of case

management for the injured workers in their workplaces, difficulties exist in the rehabilitation

co-ordinator role. Two main reasons have been proposed (Kenny, 1995c). Firstly, there are

currently no requirements within the legislation for the rehabilitation co-ordinator to possess a

set of minimum competencies for the position. Nor are there currently any pre-requisite

qualifications and the person can be selected from among existing staff at the workplace. The

Case Management in Occupational Rehabilitation 5 second difficulty pertains to the conflict of interest which arises for persons occupying this role,

as they are simultaneously employees who owe allegiance to their employers and advocates for

injured workers whose needs do not always coincide with those of their employers. In a series

of studies involving in-depth interviews of injured workers, difficulties with the rehabilitation co-

ordinator were one of the most frequently cited problems (Kenny,1995a; Kenny, 1995b).

Injured workers complained that the rehabilitation co-ordinator was often temperamentally

unsuited to the position, did not understand the requirements of the job, had insufficient

authority within the workplace to serve an advocacy role for the injured worker and was often

unable to implement appropriate workplace modifications. The difficulties identified in the role

of the rehabilitation co-ordinator imply a gap in service provision, in particular, in case

management of injured workers at the worksite.

The aim of this study was threefold: firstly, to describe the current practices of case

management within the post-injury period for injured workers; secondly, to determine which of

the key stakeholders in the rehabilitation process perceived their role as case manager; and

thirdly, to ascertain who was perceived by injured workers to fulfill the role of case manager in

the post-injury period.

Method

Subjects and sampling

Subjects comprised a group of 49 injured workers from the Newcastle/ Hunter regions of New

South Wales, who were drawn from a study population provided by the WorkCover Authority

(see Kenny, 1994, for sampling details), and key stakeholders who operated in the region and

who had employed (n=23 employers) or who had serviced the study group. Either insurance

claims officers or claims managers from each of the major workers' compensation insurers in

the region were interviewed (n=14), as were representatives from each of the accredited

rehabilitation providers (n=19). From the 23 workplaces, 14 rehabilitation co-ordinators were

Case Management in Occupational Rehabilitation 6 interviewed. From a list of 12 treating doctors in the region who had at least 25% of workers'

compensation claimants in their caseloads, nine agreed to be interviewed.

Interview

An in-depth semi-structured interview protocol was developed for all stakeholders, based on

a review of the rehabilitation literature pertaining to the identification of relevant variables which

impact on return to work, on the Workers' Compensation Act (1987) and on policy documents

and brochures for stakeholders developed by the WorkCover Authority of New South Wales.

Only the results of the questions related to case management are reported in this study. The

principal question asked of each of the stakeholders was, "With respect to occupational

rehabilitation, what are your roles and responsibilities as an insurer, a treating doctor, a

rehabilitation co-ordinator, a rehabilitation provider?"

Analysis

Interviews were conducted by the author, a trained research assistant and two contract

interviewers. These same four people also coded the interview transcripts which were tape-

recorded (with permission) and transcribed verbatim for coding and analysis. Thematic

categories, specifically, whether a statement about perceived roles constituted a case

management function, based on the definition and list of essential elements provided by Weil

and Karls (1985), were developed. Inter-rater reliability for assignment of interviewee

statements to thematic categories was assessed at 94% (range 90% to 97%) for five

transcriptscoded independently by each of the four coders (one from each stakeholder group).

Results and Discussion

The role of the insurer

Only two of the 14 insurers interviewed did not perceive case management to be their

primary role. Of the 12 insurers who nominated a case management role, eight identified

multiple roles for themselves, most of which could be subsumed under the case management

Case Management in Occupational Rehabilitation 7 umbrella. For example, one insurer perceived his role to be simultaneously an administrator, a

"watchdog", and a case manager. Other specific roles identified by insurers included supporting

stakeholders, monitoring, and liaising. The need to adopt multiple role functions was

perceived by insurers to arise out of a system which required them to serve multiple clients

simultaneously. These included the WorkCover Authority to whom they are directly

accountable, the employer who pays premiums and the injured worker who has entitlements

under the Act to Workers' Compensation.

Administrative functions included paying wages, processing claims, paying claims and

handling inquiries from injured workers.The support role was identified as "giving assistance to

the employer", "doing whatever we can in assisting the main players in helping to get this person

back to work"; "our role is to support all the other parties involved - employer, injured worker,

rehabilitation provider and doctors."

Insurers were aware that they were in possession of information not readily available to

other parties but which would be of assistance to them. Insurers who identified the role of

communication/liaison as important did so because they perceived that no other conduit

existed. One stated that "insurers get a lot of medical information not generally passed on to the

rehabilitation provider." Another identified the liaison role of insurers as critical, that is, "we

pass on all relevant information between the parties." Monitoring included "monitoring by

medical and vocational evidence the suitability of the plans presented by rehabilitation

providers." Other monitoring functions focused upon the progress of the graded return to work

of the worker, the progress of suitable duties and the outcomes of retraining programs.

Case management was the most frequently identified role. This role was primarily

conceptualised as one of involvement in the identification of those workers who required the

services of a rehabilitation provider, the initiation of those services and subsequently the

provision of guidance and assistance in the rehabilitation process.

Case Management in Occupational Rehabilitation 8 The role of the treating doctor

All doctors identified treatment of the injury as their key function. Seven of the nine treating

doctors interviewed were emphatic about their role as case manager of the injured worker.

They perceived this role to entail a number of functions, including referral to medical

specialists, occupational therapy, physiotherapy, rehabilitation providers and even solicitors.

Doctors took on this role because of their perception that "no-one else would do it." One

doctor expressed his role succinctly - "I am the captain of the ship. It is my job to co-ordinate

the whole show." Below are typical comments from doctors about their perceived role in the

occupational rehabilitation process.

You provide total care . . . you have the role of co-ordinating services. In the country, it is

not as easy to access global rehabilitation services. We have to co-ordinate their seeing a

physiotherapist or an occupational therapist . . . or sending them to an appropriate

specialist.

My primary role is to treat and manage the injury. My second role is case manager and

to assist with the overall approach by all parties, specialists etc, and my third role is to be

patient advocate.

Three doctors commented on the complexity of the rehabilitation system and the variable

quality of services provided. For example, one doctor reported that, "I have to guide my injured

worker clients through the whole confusing system because there are a plethora of

rehabilitation providers out there who are not supplying the goods." Another stated that "There

is an enormous amount of money being wasted on rehabilitation providers . . . the main

problem is that they do not have a sufficient comprehension of the workplace." This comment

notwithstanding, none of the doctors perceived liaison with the workplace as part of the

function of their case manager role. The comment below generally summarises the doctors'

position on this issue.


I use private occupational therapy firms to liaise between me and the employer, because,

you know, I don't have any direct contact with the workplace. I'll ask the Occupational

Therapist to look at what sort of suitable duties they have. I'm fairly specific in what I want

when I send someone back...I make the decision and supervise the whole thing.

Both of the doctors who did not perceive their role as a case manager identified patient

advocacy as their main function. This entailed "ensuring that the patient's needs were met, for

example, getting an insurer to move on a patient's file;" or "if there is some problem, like the

insurer has rejected an application for physiotherapy, I will ring the insurer and talk to them

about it."

Seven of the nine doctors clearly stated that their principal responsibility was to the patient.

My main role is to relieve pain . . . to get them back to near normal . . . sending them

back to the workforce is important . . . but I don't see myself as having responsibilities

beyond my patient. I forget that they are workers' compensation. They are basically my

patients. The relationship exists and it continues.

The role of the rehabilitation co-ordinator

Unlike other stakeholders, rehabilitation co-ordinators did not use the language of case

management. However, many of the responsibilities cited by the 14 rehabilitation co-ordinators

interviewed included case management functions. Their responsibilities in decreasing order of

frequency (numbers in parentheses), were as follows:

(i) to keep the employer informed about the number of injuries, rehabilitation plans and

progress of cases (7)

(ii) to assess the rehabilitation plan and to organise the services of a rehabilitation provider,

if necessary (7).

(iii) to assist the injured worker to return to work as soon as possible (5).

(iv) to control the costs of injury for the employer (4).


(v) to advise and educate the injured worker regarding their entitlements under the

legislation (4).

Other responsibilities cited by at least three rehabilitation co-ordinators were to keep their

employers up-to-date on changes to the legislation; to ensure that the worker did not return to

work too early, thereby risking an aggravation of the injury; to show concern and to be the point

of contact for the injured worker.

Rehabilitation co-ordinators were asked an additional question regarding conflict of interest,

as follows: "Do you experience any conflict of interest in meeting your obligations to both your

employer and to the injured worker?"

Six of the fourteen rehabilitation co-ordinators experienced role conflict. The conflicts were

related to budgetary pressures or to management's difficulty in understanding the full

circumstances of a case. Below are some examples.

Everyone is so budget conscious. We are under a managed fund system and we are being

told constantly to keep the cost of individual claims down, so when you are lobbying to get

assistance for the injured worker in the form of a rehabilitation provider or equipment or

aids, which require you to spend more money, it is a conflict.

Sometimes protecting our liability may mean it is detrimental to the employee. Being a

self-insured company puts me too close to the costs of accepting a claim.

Management feel that some rehabilitees are not genuine, and I agree with them. But I

have to take into account both the physical condition and the emotional outlook on the

injury. We had a young bloke who was emotionally upset about a love affair, after having 3

months off for a bad back. It took me a long while, daily, to stop management from

terminating him.

The five rehabilitation co-ordinators who did not experience a conflict of interest cited

management's commitment to occupational rehabilitation as the major reason for harmonious

Case Management in Occupational Rehabilitation 11 relations. Below are some examples. "I am rather lucky . . . I have the respect of both workers

and management. Management give me their full co-operation. And time off for training"; "I

am lucky with this company. They don't pressure you. They let you work honestly."

I don't have conflicts because we are all moving in the same direction. My company is very

responsible and caring about its employees . . . safety is a priority . . . they have more safety

equipment than I have ever seen. They are very aware of their legal responsibilities.

Three of the rehabilitation co-ordinators were ambivalent about their position in the company.

"It's funny . . . I think the supervisors see me as being for the injured workers. The workers see

me as a company man and I see myself in the middle. Neutral."

The role of the rehabilitation provider

Rehabilitation providers are, for the most part, independent practitioners in service delivery

related to rehabilitation of workplace injury. A small proportion of providers are owned and

operated by insurance comapnies. The professions represented include occupational therapists,

physiotherapists, psychologists, vocational counsellors and rehabilitation physicians.

Rehabilitation providers must obtain accreditation from the WorkCover Authority of New

South Wales to practise. They have joint responsibility to insurers, to whom they submit their

plans for payment, to employers, whose workplaces they are servicing, and to the injured

worker, whose rehabilitation they manage.

Up to 1992, 8% of injured workers, on average, were referred to accredited rehabilitation

providers (Kenny, 1994; WorkCover Authority of New South Wales, 1992). However, the

number of claims referred to a rehabilitation provider in the period 1993/1994 rose to 18%

(WorkCover Authority of New South Wales, 1994). In this sample, derived from a study

population taken from the 1991/1992 database, 18.4% workers had been referred to

rehabilitation providers, reflecting the intentional sampling bias towards the more seriously

injured and/or workers with more time lost. Rehabilitation providers answered the question

Case Management in Occupational Rehabilitation 12 only for the subgroup with whom they had contact.

Eleven of the 19 rehabilitation providers interviewed stated that the case management

approach was the central organising principle of management of injured workers. This meant

that one professional from within the organisation was appointed as case manager at the time of

referral and maintained this position with respect to the worker until the case was closed. The

responsibilities cited for this role included initial assessment, development of a rehabilitation

plan, referral and liaison with specialists and other stakeholders, monitoring costs of treatment

and negotiating with the insurer.

It is possible that the remaining nine rehabilitation providers interviewed who did not

explicitly mention case management as the operating principle, assumed the case management

approach as a given, as WorkCover's accreditation system requires that they operate on a case

management principle in order to achieve accreditation. Their responses to the question

implied a case management function. These included monitoring the progress of the injured

worker, assisting the injured worker to be actively involved in his/her own rehabilitation,

maintaining the dignity of the injured worker, and liaising with the workplace, the insurer and

the treating doctor.

Once an injured worker was referred to the rehabilitation provider, providers perceived

themselves to be the case manager for that worker, the central point of contact between the

workplace, the insurer and the treating doctor. Below are some verbatim responses from

providers which highlight their case management philosophy.

Case management in our organisation means referring a case to a designated

professional who is responsible from beginning to end; responsible for arranging

services, for keeping clients informed, for documenting, for monitoring costs and for

liaising with other stakeholders.

Normally the Occupational Therapist would manage the case and do all the liaison with

Case Management in Occupational Rehabilitation 13 other parties such as consultants and referrals. If the employer can't accommodate the person

(ie, provide suitable duties), s/he is then referred across to our rehabilitation counsellor.

Although these comments imply a case management function in relation to other

stakeholders in the system, accreditation guidelines do not require providers to assume such a

function, which may more properly be occupied by the rehabilitation co-ordinator or the

treating doctor at the time of the initial contact with the provider.

Case management from the injured workers' perspective

Injured workers were asked the following question, with probe, "After you were injured, who

was responsible for your case management? Probe: Who advised you about procedures,

treatment and return to work plans?"

The 49 workers interviewed came from 23 workplaces. Each of their employers were also

interviewed and the results of their interview have been reported elsewhere (see Kenny, 1995b).

Of interest in this study was the fact that there were 12 workplaces which employers stated had

a rehabilitation co-ordinator but which injured workers stated either did not have a co-ordinator

or that they did not know whether there was a rehabilitation co-ordinator at the workplace. To

resolve the discrepancy, employers were contacted for clarification. In most cases the problem

arose because the person designated as the rehabilitation co-ordinator was also employed in

some other capacity in the workplace, such as pay clerk, receptionist, "bosses' wife",

occupational health and safety nurse, or personnel officer and was known to the injured worker

only in his/her primary capacity. Further, rehabilitation co-ordinators do not routinely identify

their co-ordinating role to the injured worker. Table 1 summarises injured worker perceptions

of who acted in the capacity of case manager for them during the period of their injury.

Insert Table 1 here

From the table, it can be seen that more than one third (34.7%) of workers believed that none

of the people with whom they had contact post-injury acted in the capacity of case manager. In

Case Management in Occupational Rehabilitation 14 four cases, injured workers stated that they did not need a case manager because the course of

their injury was straightforward and they were able to return to work without such assistance. In

the remaining 13 (26.5%) cases, the injured worker was not contacted by any-one (9) or found

the case management of the person involved to be inadequate, necessitating that they take on

their own case management. One injured worker said, "I did have a rehabilitation provider but

they did not seem to know what they were doing. They put together a return-to-work plan that

had nothing to offer me. In the end, I had to organise things for myself." Another said, "It was

mainly up to me. I did all the ringing up and chasing up. There really is no-one around who will

help you through it."

Seven of the eight workers who were referred to rehabilitation providers identified the

provider as the case manager with the one exception quoted above. This may be the case

because rehabilitation providers use the language of case management and referred workers

were familiar with the terminology. For example, some rehabilitation providers introduce

themselves to the injured worker as "your case manager." The injured workers who identified

the insurer as the case manager were all insured by companies who operated their own

rehabilitation services. Only three workers identified the rehabilitation co-ordinator as the case

manager.

Summary of major findings from the interviews

The majority from each group of stakeholders identified themselves as the most appropriate

group to function in the case management role. In these situations, role confusion arises

whereby each stakeholder may mistakenly believe that other stakeholders are performing

necessary functions or they may vie with each other for case control. This situation leads to

polarisation, competitiveness and conflict between stakeholders and jeopardises a successful

outcome for the client (Kenny, 1995b).

The perception of injured workers was that the case management role was not filled in 35%

Case Management in Occupational Rehabilitation 15 of the sample, and was not adequately filled for half of those (32.7%) who did identify a case

manager. This group felt dissatisfied with at least one aspect of their contact with the nominated

person. The main problematic areas identified were suitable duties, conflict of interest in

service providers resulting in sub-optimal management, and rivalry between stakeholders.

Key issue: Suitable alternative duties

Workers most at risk of post-injury difficulties are those who require suitable alternative

duties, and are hence in most need of a case manager. The provision of suitable alternative

duties may be pivotal in determining the course and outcome of attempts to return to work

(Kenny, 1994), as the following example illustrates.

A severely injured slaughterman in an abattoir, who had lost the use of an arm, described

his experience as follows. He said that the rehabilitation co-ordinator

. . . tried to give me suitable duties, if that's what you call it. They gave me a job looking

after lockers in the work area. Then they got me folding up other blokes' clothing in a

laundry with women. . . . Here I was a leading hand and they got me folding clothes. Every

other bugger who walked past me would say, "Nice to see you working in the women's

quarters, mate." It pissed me off. . . . I walked out because of what I was copping out there.

The provision of inappropriate duties may be likened to employed people working in what

they perceive to be unsatisfactory jobs. Although there is a public perception that "bad" jobs are

preferable to unemployment (Jahoda, 1981), such a view is not supported by the available

evidence. Two recent large scale studies of unemployed young people clearly demonstrated

that those employed in unsatisfactory jobs scored in the same low range on various measures of

mental health as those who were unemployed (O'Brien & Feather, 1990; Winefield,

Tiggemann, Winefield & Goldney, 1993).

Key issue: Conflict of interest

Some workers were unhappy with providers owned by insurers because, "You are put under

Case Management in Occupational Rehabilitation 16 the thumb . . . you do as she (ie, rehabilitation provider) tells you or you go nowhere. But then,

she was under the thumb (of the insurer) and it goes down the line and it is bad."

In cases in which key stakeholders experience conflict of interest, as has occurred with some

of the rehabilitation co-ordinators interviewed in this study and some of the rehabilitation

providers who are owned by insurance companies, optimum service delivery may be

compromised by the constraints which arise in trying to serve two clients.

Key issue: Rehabilitation Co-ordinator as case manager?

When a case manager was identified, the rehabilitation provider was most frequently cited

as the case manager, but for the 92% of injured workers who were not referred to rehabilitation

providers, there was not a systematic process for ensuring that each worker had a case manager.

The finding that many workers were unsure about the existence of a rehabilitation co-ordinator

in their workplaces and that only three workers identified their rehabilitation co-ordinator as

their case manager indicates that incumbents in this role do not currently have a sufficient

profile in their organisations to adequately serve their clients. They, above all other

stakeholders, are in the best position to occupy this role, but currently appear least equipped to

do so.

Case vignettes

Case management perceived by 16 of the workers interviewed to assist in their return to

work are summarised below in three case vignettes demonstrating the different forms that

successful case management currently takes in the Workers' Compensation system.

Case 1: Hans, a 45 year old contract diesel mechanic for a large manufacturing industry

suffered severe muscle and ligament damage to his right arm and shoulder. Following

surgical repair, he was referred by the orthopaedic surgeon to a physiotherapist, who took

on the role of case manager. Hans described his role thus: "He worked out an individual

program and made sure I had mobility in the shoulder and strengthened the muscles. He let


my GP (ie treating doctor) know what was happening. We decided together when I was

ready to go back to work. ....When I went back to work, my physiotherapist came with me

on the first day. The bosses have to understand that you can't do the same things straight

away. They should be told by some-one else, not the worker, what is wrong and what

treatment you have had and what the restrictions are. I had no problems going back to work

because I still had a place to go back to. The physiotherapist smoothed the way, educated

the bosses. It was a year before I could work as much as I did before. Now I can do

anything."

Case 2: Jill, a 24 year old medical intern in a paediatric ward of a large public hospital

suffered two lumbo-sacral disc herniations. Although there were some difficulties

experienced in her transition back to work, related to the type of work she was offered post-

injury, Jill was fortunate in receiving the appropriate support, both medically and

administratively. She found her rehabilitation co-ordinator to be both "knowledgable and

sympathetic", and her rehabilitation physician "was willing for us both to plan my

rehabilitation and return to work." She was referred to a rehabilitation provider by her

employer (via the rehabilitation co-ordinator) four weeks after her injury, and described her

case manager as . . . "able to give me a lot of direction as to what I was supposed to do. She

(the case manager) talked to the physiotherapist and to the rehabilitation physician and then

worked out a coherent plan. My return to work plan was a joint decision between all the

treating health professionals and me. It worked well because of this and also because I had a

good registrar (immediate superior) who was supportive.

Case 3: Darren, a 26 year old tyre fitter with a large firm, suffered ligament and cartilage

damage to his left knee, which required surgical repair. Although Darren made several

attempts to return to his former position, his injury was aggravated with each return to work

attempt. His employer wanted to terminate him and referred him to a rehabilitation


provider for retraining. Darren described his experience with the provider: "We put our

heads together and discussed what I'd like to do. They told me what was possible and what

wasn't. I settled on a business operations course at Tech . . . Then I went on the JobCover

Scheme1, which the provider organised for me and now I am an Assistant Manager of a

(different) tyre company."

Each of the three successful cases presented above demonstrates how effective a case

management approach can be if appropriately applied. In the first case, the worker was

fortunate to have been referred to a private physiotherapist who was willing to assume a case

management function, to the point of accompanying the worker to his workplace on his first

day back at work after his injury. This action was, in the opinion of the worker, pivotal to his

smooth transition back to work. The second case demonstrates the ideal functioning of the

team approach to case management, where a number of stakeholders move in and out of the

case management role depending on the needs of the client. Adequate information exchange

and sufficient competencies in each of the stakeholders ensured this worker's successful return

to work. The third case, in which referral to a rehabilitation provider was the "last step before

termination", appropriate case management resulted in retraining and re-employment,

preventing the bleaker alternative of long term unemployment for this capable and motivated

worker.

1The JobCover Scheme is an initiative of te WorkCover Authority of New South Wales, designed to provide incentives to employers via premium exemptions for 12 weeks, to employ workers who have bee rehabilitated or retrained for another position following workplace injury/illness.

In the current system of occupational rehabilitation in New South Wales, authority and

responsibility for care of the injured worker is shared by a number of stakeholders, and each

Case Management in Occupational Rehabilitation 19 stakeholder perceived the major function of case management to reside in his/herown

profession. Their differing perceptions raise an interesting question about the definition of case

management for each of the stakeholders interviewed, with each stakeholder implicitly defining

the "case" differently. For example, for the insurer, the "case" is the workers' compensation

claim; for the treating doctor, the "case" is the injury; for the rehabilitation co-ordinator and the

rehabilitation provider, the "case" is the return to work outcome and for the injured worker,

who is the "case", the overriding need is to be treated with care and respect, to be kept informed

and to be involved in treatment and management decisions. In some circumstances, it is

appropriate and necessary that the responsibility for case management shifts throughout the

person's recovery. In the case of Jill, each of the stakeholders case managed their part of the

case to the mutual satisfaction of the both the client and employer. The difficulty which needs

to be addressed in this multiple case manager model is how the system can ensure a smooth

transition in function between stakeholders, and how to reduce the risk of over-servicing the

client and managing the associated costs involved.

Clear policy and practice guidelines and education about these, together with clear

assignment of roles to key stakeholders need to be established for this central role in injury

management.


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Case Management in Occupational Rehabilitation 22 Table 1

Injured worker nominations of case management role

Case manager

Number

%

No-one/myself

17

34.7

Rehabilitation Provider

8

16.3

Treating doctor

6

12.2

Company doctor

5

10.2

Insurer

4

8.2

Medical specialist

3

6.1

Rehabilitation Co-ordinator

3

6.1

Physiotherapist

2

4.1

Solicitor

1

2.0

Case management in occupational rehabilitation: Would the real case manager please stand up?

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