Claims and injury management

Overview

Research confirms a strong link between effective early intervention and positive recovery and return to work outcomes for workers following an injury.

This guidance outlines how to actively identify and manage the risk of delayed recovery and work loss across four key domains:

• Personal
• Workplace
• Healthcare
• Insurance and system.

Tailoring action and support to the worker’s needs, and clear communication about claim and return to work processes in the first few weeks following injury, establishes trust between the insurer, a worker and their employer to optimise recovery and work outcomes.

Factors influencing return to work outcomes

Factors with moderate to strong evidence of influencing return to work outcomes are summarised under four key domains. The evidence¹ supports the four domains as:

Personal – includes biological, psychological, behavioural and social factors relating to a worker

Workplace – considers the working environment, relationships, design, support systems and how a workplace accommodates return to work

Healthcare – includes the provision of treatment and rehabilitation

Insurance and system – includes claims agents, insurers, regulatory authorities and factors relating to the workers compensation system.

A focus on optimal outcomes for workers means a focus on early intervention. Early intervention involves actively coordinating all stakeholders from the first conversation to the point of developing an injury management plan, including:

• early and supportive contact
• assessing risk for delayed recovery
• matching actions to identified risks (injury management planning)
• equipping and supporting the worker to drive their own recovery
• supporting the employer to provide suitable work
• a coordinated multi-domain approach to ensure work focused outcomes.

A consistent and high-quality early intervention approach enhances worker, employer and stakeholder experience and outcomes.

^{1 Collie, A., Lane, T., Di Donato, M. and Iles, R. August 2018. Barriers and enablers to RTW: literature review. Insurance Work and Health Group, Monash University, Melbourne, Australia.}

Early, supportive contact

Early, supportive contact with a worker and their employer in the early days of a claim is critical in setting direction and is the first opportunity to commence case management planning.

Under section 43(4) of the Workplace Injury Management and Workers Compensation Act 1998 (1998 Act) an insurer must contact the worker, employer and (if appropriate and reasonably practicable) the worker’s doctor within three working days of being notified of a significant injury.

In making contact, the insurer is to:

• demonstrate conduct in line with SIRA’s Customer Service Conduct Principles
• seek to understand the worker’s individual situation and circumstances
• ensure compliance with privacy obligations
• set tailored expectations about frequency and method of agreed contact
• clarify rights and obligations of the worker, employer and providers.

Early, empathetic engagement with a worker has been shown to have a significant positive impact on return to work outcomes.  An insurer’s early contact with the employer should also encourage ongoing, constructive engagement between the employer and the worker.

Identifying risk factors for delayed recovery

Effective risk assessment is an important part of effective early intervention and high-quality case management. Risk assessment involves comprehensive and systematic consideration of all risks known to influence recovery and return to work.

For workers likely to have a significant injury, insurers should gather information about risk factors for delayed recovery across all four domains (personal, workplace, insurance and healthcare).

SIRA has provided a template Checklist for Insurers: Risk factors for delayed recovery and return to work – short version to assist in gathering information about modifiable risk factors. A more comprehensive version of the SIRA checklist is also available that includes indicators of potential risks, prompting questions to guide conversations with workers, employers and providers, and potential matched actions (Checklist for Insurers: Risk factors for delayed recovery and return to work – full version). Some insurers may have an in-house risk assessment tool that provides an equivalent approach.

Insurers should analyse the information gathered to:

• appropriately allocate and/or prioritise the claim
• identify key risk factors most likely to affect recovery and work outcomes, and
• consider and plan matched actions to minimise the effect of injury and optimise capacity and recovery.

Information about risk factors should also be used to tailor the claims management and return to work process to meet the worker’s needs and circumstances.

The initial information collection and analysis process should commence as soon as possible to inform and enable early action and support.

Matching actions to risks

Following the identification of risk factors that may delay recovery, insurers should:

• match appropriate actions to address specific risks identified
• collaborate and co-ordinate with the worker, employer, and treating medical practitioner and other providers where appropriate, to agree and implement matched actions to inform the injury management plan, developed in line with Standard of practice S12. Injury Management Plans

Every effort should be made to identify worker goals and supporting actions as soon as possible. Planning and decision making should be in collaboration with the worker and employer, and the treating medical practitioner and treatment providers where appropriate.

Further information about developing an injury management plan can be found in Insurer guidance GN 3.5 Injury management plans.

Equipping and supporting the worker

Equipping and supporting a worker to take an active role in their recovery can positively influence their response to injury, engagement in the claims and return to work process and recovery outcomes. This includes ensuring workers:

• are provided with accessible information about the claims and return to work process, including the health benefits of good work
• know their rights and responsibilities, what to expect from others involved in the process, and expected timeframes
• are supported to participate in planning, setting meaningful goals, and making informed choices about the most direct path back to work and the timeframes and supports required to get there
• understand their injury, symptoms and self-management strategies they can use to facilitate recovery.

Workers are more likely to achieve positive health, social, economic and recovery at work outcomes if the case management process is tailored to their individual needs using a person-centred approach

A person-centred case management approach means allowing people’s values, beliefs, circumstances and needs to guide how services and supports are designed and delivered enabling people to participate meaningfully in decisions that impact them in partnership with their support team.

The table below outlines key differences between a best practice person-centred, and system or organisation centred approach.

^{Table adapted from National Disabilities Practitioners (NDP). 2016. Factsheet What is a person-centred approach?}

For workers with a significant injury, insurers are to adopt a person-centred approach and:

• maximise a worker’s input to their recovery
• consider the worker’s capabilities, preferences and goals.

Note: Section 45(2) of the 1998 Act requires insurers to develop an injury management plan in consultation with the worker ‘to the maximum extent that their co-operation and participation allows’.

Supporting the employer

Many workplace factors have been shown to predict and influence return to work outcomes following injury. These include a positive workplace culture, strong return to work systems and capability, perceived support from supervisor and co-workers, and the provision of suitable work to support recovery.

A key part of an insurer’s role involves supporting employers to appropriately and effectively prepare for, respond to and manage work-related injury and illness. Section 43(3) of the 1998 Act requires an insurer to take appropriate steps to ensure that employers are aware of requirements under the injury management program, and their obligations under Chapter 3 of the 1998 Act. Insurers should ensure that employers have a return to work program in line with SIRA’s Guidelines for workplace return to work programs.

Insurers are to support employers to:

• facilitate a supportive relationship between the employer and the worker
• identify and provide suitable work
• access services required to address work related risks or barriers.

Insurers must also keep the employer informed of action planned or taken under an injury management plan to enable their cooperation and participation.

Coordinated, multi-domain approach

Return to work and recovery outcomes are optimised when stakeholders work together, and support is coordinated across all domains (personal, workplace, insurance and healthcare).

It is the role of the insurer to ensure all aspects of injury management (treatment, rehabilitation claims management, employer practices and return to work) are coordinated and integrated to optimise outcomes.

This involves:

• ensuring everyone involved understands the benefits of recovery at work and factors known to influence recovery and return to work outcomes
• establishing meaningful goals with the worker and employer, and sharing this information with others involved in supporting recovery to align expectations about action and timeframes
• monitoring response to treatment and liaising with the worker and providers if treatment is not contributing to achievement of the worker’s goals and outcomes.

Review

A worker’s risks and barriers to return to work vary throughout the life of a claim, therefore regular review of the assessment and planning process is required based on a worker’s risks, needs and changes in circumstances. This allows the insurer to identify any new or emerging risks and review effective control of risks previously identified.  A review may also identify any delays in reaching milestones and the need for more intensive management or a changed approach.

It would be expected that a review involving repeating the risk assessment and planning process would be undertaken prior to updating a worker’s injury management plan. Insurer guidance GN 3.5 Injury management plans provides information about when a plan may be reviewed, noting that a review of the injury management plan may not result in a revised plan being issued.

Capabilities and personal attributes of case managers

Case managers need a range of capabilities and personal attributes to be successful in delivering high-quality case management. These include:

• strong communication and problem-solving skills
• ability to collaborate with diverse stakeholders
• commitment to ongoing professional development
• empathy
• resilience
• emotional intelligence.

Case managers responsible for complex claims often require formal qualifications or significant prior experience to manage these claims effectively. Insurers should consider how best to achieve this within their internal and external resources.