Case Management: FCM or TCM?

What is a Certified Case Manager (CCM)?

Case managers are Medical professionals who do everything in their power to move your claim in the right direction. Their end goal is to see your worker recovered and back at work as soon as possible! They will gather all the necessary information and create a plan to determine the target return to work (RTW) dates and goals for the case.

CCMs are knows as the gold standard in case management. Its popularity arises from the all inclusive certification to the holder. In order for a RN to sit for this exam they must qualify in three areas:

• Licensure or education: they must be a registered nurse or in place have a bachelors or masters degree in nursing, social work or another complementary health related field.
• Employment history: they must meet 12 months of full time case management work supervised by an experienced CCM.
• Character: the character requirement requires the applicant show qualities consistent of good moral decency.

Certified case managers are knowledgeable decision makers committed to act in the patients best interest, therefore providing optimum value for everyone involved. This means a win-win situation for your patients health and your organizations wallet.

What is a Telephonic Case Manager (TCM)?

Telephonic case management is a lot like it sounds. It is patient managed care performed by phone rather than in person. It offers similar benefits to field-based care, without as much personal interaction. It shares the same collaborative process and the same goal and belief that managed care improves recovery and thus gets injured workers back to their jobs with greater success and speed.

Benefits:

• One of the big benefits is having access to this service regardless of geographic limitations.
• Reduction of costs associated with travel.
• One recent study from Carlisle Medical,  found that the average cost of nursing hours was reduced by 40% when handled by a TCM instead of an FCM.

Primarily, the outcomes are more cost-effective for insurance companies. Because this is performed by trained and qualified practitioners such as RN’s, it creates an environment of extensive inclusion of needs-based care that eliminates unnecessary or duplicative costs.

TCM works best when an early strategy of planned involvement is executed. In other words, managing work-related injuries becomes problematic and expensive if there isn’t a plan of how they will be handled before they arise. To meet this need there are many companies that have a TCM nurse staffed in-house. Think of telephonic case management as a thorough and expedited recovery oversight to an injured person. It really is the same as field management, just handled entirely by phone.

What is a Field Case Manager?

A good TCM nurse knows when its time to bring in a FCM, and vice versa. These early injury indicators include:

• Catastrophic injury
• Potential long-term care
• Insufficient communication
• Physician’s treatment plan out of line with evidence-based guidelines (ODG).
• Suspicions of fraud

Catastrophic Case Management

A case is given catastrophic designation generally when an accident leaves the person with life-changing negative impacts and long-term consequences or care that is indefinite.

This type of case is complicated by the severity of the injuries and even the accompanying fear that naturally arises from critical harm. There is a feeling of desperation that comes from a catastrophe. This kind of intensity is why a FCM is brought in so quickly. Case managers overseeing this type of situation have distinguished responsibilities to ensure the highest levels of care are being offered and closely monitored. A physical presence matters in these circumstances to not only provide more personal care, but also compassion for the worker and cost containment for all parties. They usually get involved within the first day of the accident. Then open a flow of communication between the patient, providers, family, and the companies involved.

Often the care relationship can continue for 18-24 months after an accident.

Benefits

• Best at handling cases if there is suspicion of fraud
• Help answer patients questions about treatment plans especially when it comes to long term care cases.

Frequently claimants are unsure of questions to ask their provider or are otherwise apprehensive to agree to certain treatments or recovery plans. When it comes to long-term care this is especially true. Having a FCM with you helps to alleviate these concerns and keep the recovery on track.

When do you need both?

The following case example helps show how these two management options can work together:

A 59-year-old mechanic was at work performing his normal duties. On this day he was climbing on an elevated conveyor belt when he accidentally hit his head on a beam and fell twenty feet onto a concrete pad. He suffered head fractures, hemorrhages, back, shoulder, and knee injuries. He was airlifted to the hospital where he spent a week in the ICU.

An FCM was assigned to provide on-site care coordination. Over the following several months the worker was readmitted to the hospital on multiple occasions for various surgeries and diagnostics.

This man was under the continuous care of 9 specialists. As time progressed. a TCM was brought in to manage the ongoing situation. More leniency could be applied to the case once a care plan had been established and a physical care representative was no longer needed.

Alternatively, if your patient is under the care of a TCM nurse and they start missing their doctors appointments and aren’t consistently responding to phone calls, next steps need to be taken. Their condition may start to deteriorate from this lack of cooperation to their care plan. At this point assigning a FCM will be the next course of action.

Bottom Line

Every case is different, what is important to learn from this example is that both FCM and TCM have an important place in managed injury care and can even be used in tandem. It is not just about cost-containment. It’s about finding the proper management and best care possible. Cost-containment comes by not throwing darts at the wall. It comes by having a plan and investing in the health of the injured worker first and worrying about cost second. In our example, if a case manager was not assigned quickly to help coordinate the proper recovery plan, the costs would likely have skyrocketed. Read more on the pros and cons of a case manager and see if this option is right for you.