1. Impact of claims management, treatment, and rehabilitation on recovery and return to independence Liz Cairns, Manager Serious Injury Service, ACC, NZ

2. Making research part of your DNA Case study of how to get better client outcomes at the same time controlling costs & liabilities How research was applied & continues to be used to inform strategic and tactical decision-making

3. Why should insurers listen? Learn how research can be used to: –Identify what’s proven to work and where there’s slim evidence that something works as intended –Avoid wasting money re-inventing the wheel –Get things done faster –Get a better return on investment

4. Why should researchers listen? Learn how : –You can make a difference –To be part of the solution, not just describing the problems –Leverage your intellectual capital by partnering with insurers

5. NZ’s Accident Compensation Scheme

6. No fault Covers everyone in NZ including workers, non-workers, & tourists Any kind of personal injury caused by an accident (including assault, medical mishap, mental injury) Funded through insurance premiums (workers, employers, car owners), fuel taxes, and government appropriations NZ’s accident compensation scheme

7. Client mix DisabilityLong termShort term Rehabilitation & recoveryLifetime support Back strain Multiple injuries Persistent pain Sprains & strains Cuts & bruises Broken bones Traumatic brain injury Spinal cord injury Multiple amputations Severe burns

8. Claim volumes Claim volumes Annual claim cost=$2.1billion Outstanding claims liability=$20.4billion 27% cost 15% liability 51% cost 33% liability 22% cost 52% liability Short term claims Medium & long term claims Disability claims Data as at 30 Jun 2011, costs, & liabilities

9. Spinal cord injury 38% Severe & moderate traumatic brain injury 58% Other 5% Injuries involved in disability claims Data as at 30 Jun 2011

10. Case study Achieving better independence & participation outcomes for clients Achieving sustainable growth in costs & liabilities

11. Situation 30 June 2007 Liability blow-out Isolation & dependence Accelerating rate of growth in average cost per disability claim: 4.2%in 2005 5.8%in 2006 14.3%in 2007 Low participation rates in community activities & employment: BestTypicalNZ Spinal80%40%18% Brain injury56%35%9%

12. Drivers of cost growth Single biggest driver of cost & liability growth

13. Strategy Identifying the problem Selecting solutions

14. Problem diagnosis Generalist case management Over-reliance on attendant care No understanding of liability Poor accountability for liability or performance Assessment practices Assessors & suppliers driving our business One size fits all Diffuse accountability No alternatives Managing the service gateway

15. Selecting solutions Clear vision of where we needed to get to: 1.Stabilise growth in costs to a sustainable rate 2.Improve client outcomes: increase participation 20032004200520062007200820092010 Cost per claim Sustainable growth rate

16. Selecting solutions Strategy was a road map of what we needed to do to get there: –Disability model/philosophy –Evidence-based approach to: Assessments Decision-making about human assistance packages Service outcomes –Specialist case management –Alternatives to attendant care –Deliver claims liability knowledge & liability driver understanding

17. Implementation Person-centred planning Evidence-based practice Alternatives to attendant care Client segmentation & case management specialisation Outcomes focus Performance reporting

18. Person-centred planning in action Where will these supports come from ? What supports are needed ? Community Employer FamilyACC Client Other funders School 1.Home/living 2.Work/education 3.Leisure /recreation 4.Community access Participatory goals Participatory goals  Treatment   Rehabilitation   Treatment   Rehabilitation 

19. Person-centred planning Maximise independence & participation Linked to evidence-based practice Assessment Alternatives to attendant care Case management Reporting

20. Assessment Best in class, objective assessment tools & methods

21. Alternatives to attendant care Short-term, outcome- focused services: –Supported Living –Supported Employment –Youth transition

22. Alternatives to attendant care Short-term, outcome- focused services: –Supported Living –Supported Employment –Youth transition Equipment solutions: –Smoke alarms & sprinkler systems –Personal alarms –Short-rise lifts

23. Case management specialisation In-house specialists Disability experience Located in clients’ communities  local knowledge Reflected in case loads Competency based

24. Claim liability knowledge Historically, this knowledge was limited to those concerned with funding & pricing for premiums Now integrating liability into decision-making about sustainable levels of support & service

25. Outcomes focus Information for clients –Emphasis on living an everyday life –Focus on clients’ goals, not “entitlements”

26. Outcomes focus Purchasing disability support services –Services already existed in disability sector, but not previously accessed by ACC –ACC a relatively small player but regarded as cash rich  purchase for outcomes Interventions must achieve an outcome –Evidence of need for intervention –Episode-based funding –Episode tied to a client goal –Standardised outcome measures  Impact on costs

27. Efficiency and effectiveness reporting Performance reporting model INPUTS Clients: Demographic & complexity indicators Finance: Infrastructure Services to clients OUTPUTS What is provided: E.g. episodes of service, hours of service, exceptional responses, plans completed OUTCOMES Impact on client’s lives: To person-centred objectives Evidenced by evidence- based measures Processes Compliance audits, satisfaction surveys, dispute rates, etc

28. Putting it all together…

29. Results Client goal achievement Employment participation Actuarial release

30. Results Achieved a delicate balance –$820 million contribution to actuarial release –61% of clients achieving or exceeding their self-directed goals –22% in part-time or fulltime paid work Cost Outcomes

31. Role of Research Past Present Future

32. Past Problem identification: –Statistics on cost & liability drivers –File reviews to determine impact different case management models –International comparisons on use of human assistance (attendant care) –Evidence base for efficacy of interventions, such as: Supervision to manage problem behaviours Music therapy – Client and staff forums

33. Present Selection of solutions: –Selection of assessment tools: Selection criteria was they had to be internationally researched, valid & reliable, easy to administer –Service development: Literature search on behavioural interventions led to creation of Behaviour Support Service Online surveys of suppliers & staff informed strategic development of existing Disability Support Services

34. Present continued… Development of decision guides: –Consultation with expert clinicians adapted NSW spinal cord injury guidelines for NZ environment –Statistical modelling of FIM data & attendant care hours led to development of predictive model Development of communications –Client advisory group aided content development for Fact Sheets –Client focus groups guided content of DVDs –Client interviews & advisory group provided accessibility solutions for website

35. Present continued… Selection of outcome measures: –Similar selection criteria to selection of assessment tools –Linked to client objectives & used to monitor client goal achievement –Used for supplier performance feedback Client satisfaction –Independent research measures client satisfaction with service delivery –Used to drive operational tactics & service quality improvements

36. Present continued… Rapid response Evaluation of business-critical services TBI and Spinal Strategies being informed at the outset by evidence and ‘best theory’ Development of decision support resources for spinal cord injury management in the community Development of relationships with international practitioners in applied research

37. Future Horizon scanning –Relevance of new technologies Do they help clients to achieve their objectives? Do they give the insurer an acceptable return on investment? –Advances in medical treatment Is there enough good-quality evidence of their widespread effectiveness? Should the insurer be an early adopter or fast follower?

38. Future Responding to developing issues –Health status of people with disabilities Existing co-morbidities Impact of aging –Skilled labour shortages in the disability sector Current workforce is aging Where will replacements for the current workforce come from?

39. Conclusions

40. Research helped us… Define the problems we faced & identify the root causes we needed to concentrate on Select solutions faster, without needing to re-invent the wheel Achieve consistency in decision-making

41. We are using research to… Measure our progress Manage our suppliers’ performance Effectively communicate with our clients & stakeholders Develop better interventions Improve the quality of our services Keep abreast of new technologies, medical advances, & future challenges

42. We have partnered with… Our in-house researchers Best practice treatment & rehabilitation practitioners Academics & health researchers - locally & internationally Market researchers

43. Research is a tool It will be used by insurers as long as it.. –Continues to be useful –Remains practical

44. Questions?