I just had a brief conversation on the phone with a worker’s compensation case manager about a low back pain patient that I saw today.  He was seen by a colleague of mine for the first 3 visits, then transferred to me today.

The patient is improving, however, my colleague gave me heads up on psychosocial aspects as he picked up…basically yellow flags.  These are usually evident in subjective history and can be confirmed with outcome scores.  He exhibited catastrophizing behaviors, fear avoidance behaviors, and dis-satisfaction with job (works at Walmart)….the whole gamma. To confirm our hypothesis in this particular case, we used the Fear-Avoidance Belief Questionnaire (FABQ).

Results:

FABQ(work): 39/42, FABQ(physical): 24/24.

Wow, off the chart numbers!

So, back to my initial story. I told the case manager that he is improving in overall pain complaints and function slowly, but I am very concerned over these factors that I just mentioned (as these usually lead to chronic LBP and inability to return to work).

Her response: Okay, that’s nice. How is his lumbar ROM?

Me: It is better {hesitantly}… but needs more work.

Her: Good, continue and let me know when your authorized visits are up.

Me: Okay…goodbye?

I am not sure if anyone else has run into a conversation as I just mentioned, however, I have quite often in the past.  I do not know if the case managers just do not want to deal with this information I am providing as they do not think it is important, or still think lumbar ROM/strength is indicative of return to work status and overall outcomes?  What do you think?  How have you addressed it?

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9 comments

  1. Those people are mindless. They may be nurses but they follow algorithms that determine the number of visits. If it is not in the algorithm they don’t care. I find that you have to challenge them directly, i.e. ” He has high FABQ scores, don’t you know what that is?”. They usually relent to a few extra visits if thats what you are after. As far as them caring? Good luck.

    1. Good point Jeffre with the algorithms. I do not know them or ever seen them, but we have “algorithms” in regards to CPRs but we don’t follow them completely as you can’t forget the individual in front of you.

      You wonder if the nurses who care stay in clinical practice where the ones who don’t end up in a position like a case manager?

      H

  2. I deal with this on a daily basis where approx 75% of my case load is work comp. Its both frustrating and unfortunate but I feel those that are motivated to return to full duty and are being 100% truthful with me are the minority. It is very deflating when case workers/MD’s/RNs anyone is not picking up on yellow flags that are (usually in my case) documented more then verbalized. Perhaps they are not reading the notes or overlook them. I do not know. Disability index scores/FABQ, inconsistencies of ROM, responses to palpation, etc. I do not have an answer or solution but look forward to what any suggestions we can do to have a larger footprint.

    1. Wow John 75%!? What percentage would you say is that minority (the ones who want to get better)? Would be interesting to know. How do you go day by day knowing this and not wanting to change your patient type?

      It is a challenging task to tackle low back pain as it is, but to add in yellow flags and then worker’s comp or litigation…then that is a tough curve ball to hit.

      H

  3. Hey Harrison,

    I have experienced a similar disconnect issue with case managers in the past. The case managers are compensated for returning patients to work as soon as possible or closing a a case due to maximal medical improvement (MMI). The case manager may feel that your patient will not likely RTW and will need to achieve MMI in order to close the case. The case manager needs the PT to regain as much ROM for the patient as possible. When calculating an impairment rating or disability rating the ROM is the main factor in the calculation. Pain, FABQ, and functional outcome measures do not factor into this equation. This may explain why the case manager is fixed on ROM and not pain or function. Disclaimer, I have worked with many case managers that care for their clients and this does not determine how they manage a case, but I have also worked with case managers that were very focused on closing cases ASAP.

  4. You made the mistake of talking to her about what you care about (the patient’s full recovery) instead of what she cares about (her boss asking her why she approved more therapy when ROM is good). Explain to her that the patient is likely to end up in an emergency “facility” getting “repackaged drugs” if he is sent back to work without addressing the psychosocial elements. She’ll be calling the nurse case manager faster than you can get off the phone.

  5. Good post Harrison. Funny how many hoops you have to go through with WC isn’t it. In Washington, I deal with insurance authorization issues all the time. I would say you would be better served to speak their language and state what ROM/strength/positional tolerance/dynamic strength limitations their are so that you get your authorized visits, but at the same time (unknown to the claims manager) you treat the yellow flags for chronicity. Best of luck with that case

    1. Good points Steve. You are right, you gotta pick your fights and sometimes to get through the day and continue a business, you have to play by the rules.

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