1. Center of Occupational Health & Education (COHE) COHE at UW Medicine Valley Medical Center of the Puget Sound Providers 2014-2015 Annual Training

2.  Each Center of Occupational Health & Education (COHE) is a contractual partnership between the Department of Labor & Industries (L&I) and healthcare organizations. ◦ Facilitate the implementation of occupational health best practices during the early phase of a claim. ◦ Promote collaboration between stakeholders (Labor, Business, Unions, Providers, Insurers) involved in a worker’s injury or illness.

3.  COHE Claim ◦ WA State Workers’ Compensation State Fund claims ◦ NOT: Federal, Self-Insured, Tribal or Out of State Workers’ Compensation claims.  Claim filed with a COHE provider and/or COHE provider is the attending provider on the claim.  Resources focused on claims within the first 90 & up to 180 days of claim being filed.

4.  Reduce Worker Disability  Improve Employment Outcomes  Promote Patient Satisfaction  Enhance Clinical Efficiency

5.  COHE at UW Medicine Valley Medical Center of the Puget Sound – est. 2002  COHE Community of Eastern WA – est. 2003  COHE at The Everett Clinic – est. 2007  COHE at UW Medicine Harborview Medical Center – est. 2007  COHE Alliance of Western WA – est. 2013  COHE at Group Health Cooperative – est. 2013

6. Best Practices Based on evidence Designed with provider input Focused on reducing disability & improving outcomes Incentives Provider Training Orientation & best practices training Regular feedback Access to resources that will help them better manage an injured worker’s recovery Health Services Coordination Resource focused on coordination & return to work Community Outreach Community communication & involvement Program advocates Broad provider, employer & labor involvement in quality improvement

7.  Establish Mechanism to Identify High Risk Cases for Long Term Disability  Develop Procedures for Coordinating Care  Implement Quality Procedures & Best Practices  Foster Communication between Providers, Workers & Employers  Offer Training & Mentoring in Occupational Health Best Practices to Participating Providers  Provide Feedback to Providers on their Performance

8.  Substantially prevented long-term disability, reducing costs by an average of $480 per claim & lost work time by an average of four days.  Savings continue to accrue three to four years after the claim is filed, even though the current COHE intervention occurs during the first 90 & up to 180 days of the claim.  Claims treated by COHE providers resolve faster ◦ Faster resolution may be due to COHE Best Practices preventing some medical-only claims from becoming time-loss. (Wickizer, et al, 2007)

9. 1211109876543210 0 20 40 60 80 100 % IW Receiving Disability Payments Time-Loss Duration (months) Early Intervention Period Focus of COHE Activities

10.  Over 240 Providers ◦ Chiropractors ◦ Emergency Physicians ◦ Family Physicians ◦ Nurse Practitioners ◦ Physician Assistants ◦ Specialty Providers  Neurology, Occupational, Orthopedics, Podiatry, Physical Medicine & Rehabilitation  Around 5,500 Claims Annually

11. Center of Occupational Health & Education (COHE)

12.  Report of Accident (ROA) ◦ Timeliness  To L&I within 2 business days of initial office visit  Speeds up processing & adjudication of claim  Strong association between time from injury to receipt of claim at L&I and substantially longer duration of time loss  Must use current ROA forms available from L&I  80% benchmark

13.  Must complete each box to avoid delay in claim adjudication

14.  Claim is initiated at L&I by the completion of the ROA.  Missing information may unnecessarily delay the adjudication of the claim, delaying treatment and payment for services.  Must use objective diagnoses – pain is not valid diagnosis for Workers’ Comp claim.  When the ROA is received at L&I within 2 business days of the initial office visit, you receive higher payment for completing this form.  L&I processes COHE claims twice as fast as non- COHE claims.

15.  When determining whether to file a claim for a patient: ◦ If patient asks you to file a claim, you must regardless of your opinion as to it’s work- relatedness.  Indicate on the ROA that the claim is work-related or not.  Inform the patient that inappropriate filing of a claim can cause delays in payment by other insurers. ◦ Claims should be filed even for minor injuries. ◦ Fear of retaliation by employer.  Inform patient that the law protects them from discrimination for filing a claim.

16.  Conditions Due to Specific Incident ◦ Worker states they were doing a specific activity at a specific time and then hurt themselves.  E.g., worker lifted a heavy box and immediately felt a pop/pain in their back.  Worker has one year from date of injury to file claim.  Occupational Disease Claims ◦ Claims due to repetitive use/trauma E.g., worker lifts heavy boxes repeatedly throughout day and has worked in that particular job for several years. Worker has two years from date of onset to file claim. ◦ Have worker complete L&I Occupational Disease Work History forms. ◦ Review work history to determine which jobs/activities contributed to worker’s current symptoms & condition.

17.  Determining Work-Relatedness ◦ Depends on a variety of factors (medical, legal and administrative) ◦ May be difficult to determine ◦ In box 7 on the ROA, you are required to answer yes/probably or no/possibly  By law, a claim can be accepted only if the provider states the condition is work-related “on a more probable than not basis” or greater than 50% certainty, e.g., yes/probably. ◦ For condition to be work-related, the industrial injury or exposure must be a “proximate cause” of the diagnosed condition.

18.  Activity Prescription Form (APF) ◦ Complete at first office visit ◦ Complete with any work status change  Gives claims manager & employer information on the tasks worker can do.  Better chance of worker returning to work in a timely manner.  Claims manager uses form for time loss certification & treatment authorizations.  HSC uses the APF to facilitate return to work efforts with employer. ◦ 80% benchmark

19.  General Section ◦ Patient stickers may be used, as long as all the requested information is provided. ◦ Either ICD codes or written diagnoses may be listed in the diagnosis box. ◦ Providing this information will ensure the form gets into the correct claim file. ◦ Including the provider’s name and the visit date is important for billing purposes. General Info Injured Worker’s Name:Visit Date:Claim Number: Doctor’s Name printed: Date of Injury:Diagnosis:

20.  Released for Work Section ◦ If released to job of injury without restrictions, skip to “Plans” section. ◦ Objective medical findings are needed to certify time loss or loss of earning power benefits. ◦ Consider releasing to light duty even if significant restrictions, when medically appropriate. ◦ Be realistic on “to” dates. Required : Released for work? Check at least one Worker is released to the job of injury without restrictions on (date): ____/____/____ Skip to “Plans” section below. Worker may perform modified duty, if available, from (date): ______/_______/_______ to _______/_______/_______ Worker may work limited hours: ______hours/day from (date): ______/_______/_______ to _______/_______/_______ Worker is working modified duty or limited hours Please estimate capacities below and provide key objective findings at right. Required: Key Objective Finding(s) Worker not released to any work from (date): ____/____/____ to ____/____/____ Prognosis poor for return to work at the job of injury at any date May need assistance returning to work Capacities apply 24/7, please estimate capacities below and provide key objective findings at right.

21.  Released for Work Section Cont’d ◦ Must include at least one “key objective finding”. ◦ Examples of objective findings are:  Limited ROM  Decreased strength  Swelling  Muscle atrophy  Do not include subjective complaints such as pain, tenderness or fatigue. ◦ Be specific with date ranges.

22.  Estimate What Worker Can Do Section

23. ◦ Enables employers to identify potential light/ modified duty positions. ◦ Complete with assumption that light/ modified duty is available. ◦ Check as to how long the current capacity will last or if are permanent. ◦ Estimate based on provider’s clinical opinion.  Conservative estimates are acceptable. ◦ MUST be completed even when worker is not released to work.  For worker to understand what should physically do and not do to enhance recovery.

24.  Estimate What Worker Can Do Section ◦ Only address restrictions applicable to claim covered condition.  Boxes left blank will be considered as not restricted. ◦ “Other instructions” could include need to elevate limb periodically, no use of left arm, no overtime, etc. Be specific. ◦ Note to claims manager is intended to help you draw the their attention to an issue, i.e. “need authorization for…” Also has space for new diagnosis and opioid prescriptions.

25.  Plan/Sign Section ◦ Quickly/briefly establishes plan for rehabilitation. ◦ Succinctly indicates whether patient is progressing. ◦ Comments are strongly encouraged. ◦ Identifies what should happen next.  Alerts claims manager to actions needed, e.g., impairment rating exam schedule, Independent Medical Exam needed, claim closure. Required : Plans Worker progress:  As expected / better than expected.  Slower than expected. Address in chart notes Current rehab:  PT  OT  Home exercise  Other_____________________________ Surgery:  Not Indicated  Possible  Planned Comments:  Next scheduled visit in: _______ days, _______weeks.  Treatment concluded, Max. Medical Improvement (MMI) Any permanent partial impairment?  Yes  No  Possibly If you are qualified, please rate impairment for your patient.  Will rate  Will refer  Request IME  Care transferred to:________________________________  Consultation needed with:___________________________  Study pending:____________________________________

26.  Two-Way Communication with Employer ◦ Return to Work Options Discussed Provides timely communication between APP and employer. Contact employer if worker is current off of work or is expected to be off work. Provides information to employer regarding worker’s restrictions, ability to work light/ modified duty and treatment plan. ◦ 25% benchmark

27.  Ways to Meet Best Practice #3 ◦ Call employer at or after the initial office visit Be sure to bill for phone call and use appropriate modifier. Can be secure voice mail left for employer. ◦ AP contacts HSC who completes Initial Evaluation & Coordination (IEC) For IEC, HSC is required to make 3-point contact: AP, worker and employer. ◦ Job description signed by AP Be sure to bill for review of job description. ◦ Stay-at-Work benefits paid Requires APP signature on light duty job description.

28.  Assessing Barriers to Return to Work ◦ Barriers Assessment Exam ◦ Referral to COHE Advisor for Barriers Assessment Exam ◦ Medical Case Conference ◦ Consultation with COHE Advisor ◦ Currently no benchmark For informational purposes only

29.  Barriers Exam ◦ Completed by APP or COHE Advisor that includes:  Medical history  Physical Exam  Diagnoses, assess capabilities/stability & calculation of impairment  Review of all barriers preventing return to work  Develop future medical treatment plan  Documentation in detailed SOAP-ER note

30.  S: subjective complaints  O: objective findings  A: assessment  P: plan  E: employment issues  R: restrictions to physical activity

31. Center of Occupational Health & Education (COHE)

32.  Set expectations for injured workers regarding return to work.  Help avoid administrative claim delays.  Eliminate barriers to care.  Facilitate communication with all parties.  Establish & maintain communication with employer.  Enhanced payment for services if provider meets the Occupational Health Best Practices benchmarks. ◦ Scorecards are published by L&I on a quarterly basis.

33.  COHE Project Directors ◦ Jaime Nephew, PT, DPT, MBA, FACHE ◦ Grace Casey  COHE Medical Directors ◦ Scott Morris, MD ◦ Karen Nilson, MD  COHE Advisors ◦ Wide variety of disciplines represented  COHE Health Services Coordinators (HSC) ◦ Ellen Hull, M.Ed., CRC ◦ Heather Latvala, M.Ed., CRC ◦ Kathryn M. Visser, M.Ed., CDMS

34.  One-on-one training ◦ Promote occupational health best practices ◦ Provide training for nurses and other office staff  Assist with return to work coordination ◦ Even missing 3 to 7 days of work can increase disability and a long-term earning capacity. ◦ Research has shown that a worker remaining on payroll during recovery has a greater chance of full recovery and a higher family income while recuperating.  Evaluate potential barriers to return to work early to prevent ongoing disability

36.  Identify claims that are at risk for long-term disability.  Intervene on claims that need HSC assistance.  Track claims to ensure early return to work services, care coordination and improved clinical outcomes of injured workers.  Act as a liaison, on behalf of the provider, between injured worker, employer and L&I.  Help employers, providers and injured workers navigate the Workers’ Compensation system.

37.  Renton Worker Survey ◦ As satisfied as on key satisfaction measures of:  Quality of Care  Coordination of Care  Overall Treatment Experience ◦ Better employment outcomes  55% more likely to return to same employer  65% more likely to be working at time of survey

38.  Renton Provider Survey ◦ 75% indicated they have improved ability to treat Injured Workers ◦ 74% are satisfied with their experience ◦ 70% reported improved ability to communicate with employers ◦ 50% stated they are more willing to treat Injured Workers

39. Center of Occupational Health & Education (COHE)

40.  Please see attached COHE Provider Quiz 2014-2015 Microsoft Word document for instructions and to complete the quiz.