Catastrophic Case Management
Catastrophic injuries or illnesses can strike at any time. S & H Medical Management Services, Inc. is your source for goal-directed, timely and cost-effective catastrophic case management services. The S & H goal for RN catastrophic case management is to provide an immediate, mutually beneficial (to both the injured worker/recipient and the claims handler) response, ensuring facilitation of the medical care required to return this injured worker/recipient to a productive life.
S & H CAT Care is performed by registered nurses experienced in trauma, orthopedic or neurological injuries. At a time when information is scarce and the family, the employer and the adjuster require a connection to real-time information, the S & H CAT Nurse is there to facilitate the needed communication, assess if treatment is timely, aggressive and is being provided at an appropriate facility! Many times the initial contact with the family made by the S & H CAT Nurse is the first contact the family will have with an employer or adjuster representative.
The S & H CAT Nurse is there to keep all parties focused on the goal of a safe and timely return to work and/or appropriate utilization of resources.
The nurse works closely with all parties to ensure communication and appropriate care during the first critical hours and days following a catastrophic injury coordinating if necessary, a transfer of treatment to a Center of Excellence. S & H is available 24 hours/day - 7 days/week.
Call 630-226-5036 when catastrophic case management is required.
On-Site RN Case Management
Sometimes referred to as full or field case management. Usually will include (with account authorization) three point contacts, with the employer, physician and injured worker. The Nurse Consultant will typically meet with the injured worker and the physician, and coordinates care as authorized by the referral source. A safe and effective return to work is facilitated through communication with all involved parties.
Utilization Management & Coordination of Utilization Review
You cannot be treated for a non-work-related accident or condition without your group health carrier implementing utilization review. If you go to a hospital or medical caregiver for non-work-related problems, someone somewhere is looking at the costs and approving what is necessary and reasonable. Implementation of UR in non-work-related settings isn't by accident; it is done because the cost savings are enormous.
S & H Medical Management believes that UR when done well, is a strong alternative to an IME. However, why spend the time and expense for your cases to go through the previous models for UR?
S & H Medical Management Services, Inc. has developed a 2 prong approach to ensure your utilization of UR is appropriate, time-sensitive and cost-effective. First, S & H Nurse Consultants utilize the Medical Disability Advisor to research if the treatment & RTW guidelines meet evidence based medicine (EBM) guidelines. Second, if it appears treatment or RTW is outside EBM guidelines, S & H has partnered with a peer review organization to perform the actual UR.
Our partner for UR is URAC accredited and licensed to provide W/C UR in all 50 states! This partner is a truly independent source for UR, and utilizes objective EBM practices and provides literature reviews as part of their reports. The reviews are conducted by physicians the first time! A definitive answer is available regarding approval or denial, without having to go to the “second or third tier”.
Turnaround time can be as quick as 24 hours, no later than 72 hours. Specialists and sub-specialists can be engaged for the initial review, should the RN and client determine this is the best approach. Referrals are made online – again minimizing turnaround time! S & H has negotiated special pricing with our UR partner.
One Time/PRN appointment coverage
Also referred to as a Task Assignment. The RN confirms attendance of the appointment with the physician and the injured worker. The RN attends the appointment to obtain the information specified by the account. The report to the account following the appointment can be in the form of an email, or dictated report, depending on the account requirements.
Limited Assignment
Typically entails review of Medical Records, scheduling an Independent Medical Evaluation, documenting the questions to be asked of the physician in a letter format, ensuring the attendance of the injured worker, coordinating retrieval of all diagnostic studies and meeting with the physician and possibly the injured worker, at the time of the examination. A report is provided to the account, and the need for any ongoing services is addressed with the account before proceeding with ongoing services.
Telephonic Medical Case Management
Provided by our RN staff for a prescribed period of time. Task assignments may be utilized when appropriate to facilitate file movement. Telephonic services are provided for workers' compensation, STD/LTD & Health Insurance. We also provide TCM global services.
Integrated Absence Management Program
As part of an integrated absence management program, S & H Medical Management Services, Inc. can help you reduce your STD/LTD claim costs by providing quality, cost effective vocational and medical case management services. These services are designed to a ssure the insured receives timely medical care, assist your employers in developing effective return to work programs, obtain documentation to verify the medical necessity of the requested LOA and provide vocational support to both the claims examiner and the insured with respect to issues of employability and return to work assistance.
It is critical that as soon as an individual enters a claim for STD, the treating physician, employee and employer work together to effect a positive recovery and eventual return to work. The S & H Nurse Consultant will utilize nationally recognized parameters when addressing these issues with the physician. The physician will be requested to provide functional capabilities at each appointment.
Health Insurance Case Management
The principles of case management that make the S & H Medical Management Services, Inc. Nurse Consultant successful in providing case management in the W/C, STD & CAT Care™ arenas, are also utilized with S & H Health Insurance Case Management.
The S & H Health Insurance Nurse Consultant utilizes a Case Management Model focused on the recipient/patient. The end result is medical care that is appropriate and of the highest quality. The goal in this process is for the client/patient to obtain this care, while preserving the recipient/patient’s health care dollars for future needs, whenever possible. This collaborative process is accomplished through assessment, planning, implementation, coordinating, monitoring and evaluating.
The S & H Health Insurance Nurse Consultant communicates with the recipient/patient, family, providers, ancillary services, insurance companies and employer, if appropriate. An initial assessment is performed, utilizing the S & H specially-designed format, and the S & H Medication Adherence Assessment™ based on CMAGII guidelines.
Medical Records Analysis
Also referred to as Medical Legal File Review for Causation, is performed by our RN staff. The Nurse Consultant contacts the account prior to documenting findings, to ascertain the specific reporting format to be utilized.
Negotiation of DME and Home Health Providers/vendors
A service that is routinely performed by our RN consultants as a component of On-Site RN Case Management, but can be performed as a stand alone limited service.
On-Site Job Analysis
The RN can perform an on-site job analysis (including video if requested) to assist in addressing causation issues or to delineate the functional requirements of an injured worker’s position for usage in designing a structured physical therapy rehabilitation program.