Case management

1. Case management Dr Alastair Leckie Consultant in occupational medicine Director, OHSAS

2. Aims • define case management • define case management in OH • outline a project about case management in OH • present early findings • outline possible future developments

3. What is case management? “a goal-oriented approach to keeping employees at work and facilitating an early return to work” • undertaken by a case manager

4. What does a case manager do? • utilise a range of methods and techniques from acceptance to discharge • co-ordinate and facilitate communication between • clients • service providers • employers/workplace • until intervention successful

5. Why does the case manager do it? • rehabilitation • vocational rehabilitation • work is good for you • key feature is a return to work

6. Different models • 1 case manager to 1 worker • information • co-ordination of services • therapeutic relationships

7. Case management as a process • case manager responsible for return to work • case manager identifies key actions • actions aimed at a return to work • Action plan is “owned” by worker

8. Does it work? • Little in the literature • Most effective when (modest evidence) • when used as a method for managing healthcare resource • used to engage with employers

9. What works? • individual skills of case manager • not qualification • not professional background • not therapist

10. Key components • own case manager • tackles obstacles to a return to work • liaises with therapist (but is not therapist) • evidence based interventions • case manager responsible for resources • case manager monitors treatment • case manager liaises with employer - return to work • early intervention

11. Effective case managers • help define health problem • arrange intervention(s) • create an action plan • manages and proactively uses resources • emphasise that a return to work is the goal

12. Further reading • “The costs and benefits of active case management and rehabilitation for musculoskeletal disorders” HSE rr 493 http://www.hse.gov.uk/research/rrhtm/rr493.htm Prepared by Hu-Tech Associates Ltd

13. Why not occupational health nurses? • not trained in case management • ethics and professional role • role as therapists • skills and expertise lie elsewhere • reduced cost-benefits • limited resource

15. Aims • Context • Drivers • Original proposal • Project objectives • Project evaluation • Project timescales

16. Context • Securing Health Together • Healthy Returns • Healthy Working Lives • A Strategy for Workplace Health and Safety in Great Britain to 2010 and Beyond • Efficient Government - Securing Efficiency, Effectiveness and Productivity • Fast-tracking report

17. Securing Health Together • A 30% decrease in the number of working days lost due to work-related illnesses. • That where appropriate, employees off work because of ill health or disability should be informed of the available opportunities for early rehabilitation back into the work environment.

18. Healthy Working Lives • Boosted services aimed at prompt and dedicated rehabilitation of the sick and injured worker • Comprehensive provision of multi-disciplinary workplace-focused services • With regard to NHS employees specifically, the report emphasised the importance of improving the care of NHS staff and of the need to revitalise workplace-dedicated rehabilitation services.

19. Healthy Returns • Aimed to assess the benefits of providing additional healthcare and workplace services to the employed or self-employed absent from work because of illness, injury or disease • Case management model

20. A Strategy for Workplace Health and Safety • Preventing ill health and keeping those at work in work • Promoting rehabilitation and getting people back to work more quickly • Decreasing sickness in the Public Sector thereby enhancing the delivery of Public Services • Doing more to address the new and emerging work-related health issues

21. Efficient Government - Securing Efficiency, Effectiveness and Productivity • All public sector organisations need to have effective strategies for managing sickness absence. These should include firm measures to tackle abuse, but must also address any work-related causes of ill-health, and support staff experiencing illness so that they can return to the workplace.

22. Efficient Government - Securing Efficiency, Effectiveness and Productivity • co-ordinate existing activity - for example in local government and the NHS - sharing knowledge and best practice across the public sector

23. Fast-tracking Report • SLWG – chaired by Chris Pugh • Instead of fast tracking the phrase “Occupational Health Services Extra (OHS Extra)” should be used. • OHS Extra should be an extension of existing NHS Occupational Health Services • OHS Extra should have two components an Employee Rehabilitation Service and early Specialist referral

24. Employee rehabilitation service • Staffing • Physiotherapy • Occupational therapy • Clinical Psychology/Counselling • Key features • Early access to local services • Multiple points of entry via an assessment of need and priority

26. Each Board will be expected to achieve a target of 4% sickness absence in their area by 31 March 2008. • To achieve the sickness absence targets Boards will be expected to follow good HR and occupational health practice in seeking to reduce absence and it is expected that this will be done within the context of positive and supportive practices around Staff Governance implementation and Healthy Working Lives.

27. “We also hope to shortly pilot a dedicated physiotherapy, occupational therapy and counselling service called OHS Extra in Fife and Lanarkshire which is designed to enable staff to get quick access to these services and enable them to remain at work”.

28. OHS Extra • Case management approach • Rehabilitation service for NHS staff • Piloted in 2 sites • NHS Fife and NHS Lanarkshire • Evaluate impact of pilots • Demonstrate suitability of OHS Extra model

29. OHS Xtra - objectives • To • achieve a return on investment thus demonstrating the cost-effectiveness of the OHS Extra approach; • design a scheme which takes account of the experience and lessons learned from the DWP-funded project “Healthy Returns”; • make a significant impact on waiting times in the NHS by concentrating on assisting staff to return to work sooner & to stay at work longer; • produce a model for implementation in the wider NHS.

30. OHS Xtra - methods • Scheme managed by a joint OHSAS/SALUS project manager • Multiple potential routes of entry, (e.g. self-referral, line management/HR/OHS/GP referral) • Client eligibility: • Member of NHS staff • Struggling at work, off work, or likely to be off work with a MSD; • Off work more than 3 weeks with a mental health problem; • Initial appointment with case manager • assess individuals using predetermined tools • Optional onward referral to specialists in occupational health, occupational therapy, physiotherapy and/or CBT • Weekly case conferences with the team, including occupational physician and nurse input.

31. OHS Xtra - evaluation • Eligibility Screen • Participant Information Sheet • Consent Form • Pre-intervention Assessment - biographical Information • Post-intervention Assessment - biographical information • Standardised Measures • Post-intervention Assessment – Clients’ perceptions – Line Managers’ perceptions – Service Providers’ perceptions – Human Resources’ perceptions

32. OHS Xtra - evaluation • Sickness absence figures for the organisations • Client satisfaction data will be collected by the case managers; • Descriptive data on length of absence, time to return to work etc. • More staff resource made available, calculated as a number of non-cancelled appointments/ available man days; • Cost trend data on use of bank staff and overtime payments.

33. OHS Xtra - evaluation • Health economist • Research assistant • External adviser to the project

34. OHS Xtra - evaluation

35. Results I • 555 referrals from mid-March to present • M:F; 15:85 • Average age 42.5 (SD=10) range 19.6 – 57.9 years old • 64% self referrals; 23% from OH; 11% line manager • 60% via telephone • 7% electronically

36. Results II • 73% musculoskeletal problems • 28% psychological problems • 6% other • 64% treated by a physiotherapist • 19% received a psychological intervention • 8% assessed by OT • 1% OH nurse referral

37. Results III • COPM (Canadian Occupational Performance Measure • GHQ-12 • WAI (Work Ability Index) • EQ-SD

38. COPM

39. GHQ-12

40. WAI

41. EQ - SD • Mobility • Self-care • Usual activities • Pain/discomfort • Anxiety/depression All showed significant improvements

42. Qualitative data • HR • Service Providers Almost unanimous in positive feedback

43. Results IV • no evaluation to date of effectiveness of case manager • no cost benefit analysis • no model developed for use in NHSiS

44. Future developments • Case management as an addition to OH within NHS • Case management as a product • Consider in long term absences • Deliver case manager training

45. Summary • case management as a concept • case management in OH practice • early results from OHSXtra http://www.ohsxtra.scot.nhs.uk/