Jun 1, 2022 | Insights
If you ask anyone to explain the players’ role in any sport, the answer will probably be “score, of course!” But ask an award-winning coach and their answer will likely be different – the end goal is to win.
In the claims world, things are fairly similar. For many companies, the end goal is to get an injured worker back “on the field.” But companies with the best programs don’t stop there. Their goal is not just to get an employee through treatment and back on the job. The goal is to give quality care and effectively utilize available resources to get the employee back to work as soon as safely possible while keeping costs manageable…all while making strides toward better outcomes for the entire program.
With physical therapy playing a larger role in medical treatment and overall medical management costs, companies are already scoring in multiple ways. The number of cases requiring costly surgery and dangerous prescription drugs is going down. Recovery times are also trending in a positive direction. Across the board, physical therapy has paved the way for a better and quicker return to work journey for employees.
So, you might ask: if the shift towards physical therapy has enabled companies to score more in the short term, what does it take to win the big game? The answer? Data and analytics. Historically, a lot of the focus has mostly been on the cost of care. And while collecting data points on cost is pretty straightforward, the industry has evolved into a world where what was previously seen as “soft” savings from treatment quality and patient-centric care are becoming more tangible and as valuable as immediate discounts. To fully get there, companies must harness the power of hundreds of data points collected throughout a patient’s journey.
What does this look like? Here are examples of how you can use data and analytics before, during, and after treatment to help your PT program win.
Heading to the game with a plan
Whether it’s basketball, football, or tennis, players must come to the field prepared. The best athletes don’t just wake up and win championships. They seek the best coaches to get them in the best shape physically, mentally, and emotionally and to help them create a winning strategy.
To put this into a claim’s perspective, let’s take construction worker Mike as an example. While working on a project, Mike fell off a scaffolding and sustained injuries in his shoulder. Following the accident, his primary treating physician found that his injuries did not require any surgery and instead, initially prescribed six sessions of physical therapy.
Now, the easy way to score is to do a quick search of which provider is nearest to Mike and have him complete his sessions there. But winning requires a little more than this. The nearest provider may not necessarily be the right fit for Mike. To ensure that he gets the best care, a plan must be put in place even before Mike starts treating.
One effective strategy before sending an employee to treatment is having a consultation directly with the patient. Ideally, the consultation happens with a trained PT expert. In this call, the employee is asked baseline questions about their age, gender, location, injury severity, and chronicity. It’s also important to capture the employee’s psychosocial information at this stage, including their mental and emotional state, relationship with the employer, and their current disposition towards pain and returning to work. With this data, possible return to work barriers are identified and an employee is assigned an in-house risk score of low, moderate, or high. All these inform decisions on treatment. After all, injured workers spend more time with their physical therapist than anyone else, so it’s critical that they are assigned to a provider that best fits their needs.
In Mike’s case, the nearest provider two miles away might be the obvious choice. But if it was found that 35-year-old Mike incurred a rotator cuff injury and was experiencing depression and anxiety as a result of the injury, the best provider may perhaps be one that’s slightly farther but specializes in shoulder injuries. Another consideration is assigning Mike to a physical therapist he might feel the most comfortable with – say, someone of the same age, gender, or race. Moreover, additional data gathered from the consultation may also contribute to him being identified as a high-risk patient, informing the adjuster that this is a case that must be closely watched.
Keeping score and making continuous adjustments
Throughout a game, players are usually seen strategizing with their coaches. Based on how things are going, they evaluate whether to maintain the current strategy or if a change in play is required to move the game in their favor.
Similarly, it’s important to continuously monitor a claim and leverage data and analytics throughout treatment. By aggregating data and pulling key insights, you can employ a more effective, almost instantaneous information exchange across key players in a claim. Adjusters are given actionable insights, in the right format, at the right time so that they can make strategic decisions on what to do next. Employers or anyone looking at a claim from a broader view, on the other hand, are provided with a better picture of how a case is going and is predicted to go. This ensures things stay on track and, in cases where they don’t, additional resources are tapped.
Another effective method is comparing the status of a claim with similar cases and evidence-based clinical guidelines. Data from these cases and guidelines around comorbidities, psychosocial status, and other factors assist in predicting how long treatment will go and additional considerations that should be made. With the right information at their fingertips, a PT partner will be able to run an analysis not just within a particular employer, but across similar injuries, demographics, regions, and providers.
Going back to the example, since initial data has shown that Mike is a high-risk patient, the adjuster might decide to have a nurse case manager reach out to Mike periodically. This would allow close monitoring of his progress. If along the way, he has reached the recommended number of sessions based on clinical guidelines but is still not fully recovered, a clinical review could be triggered. In this peer-to-peer conversation, Mike’s treatment notes will be reviewed and possible actions to make his treatment more efficient can be planned.
Learning for what’s ahead
In most sports, winning one match or game isn’t the end of the story – elite performers want the championship. To continuously stay at the top of their game, players and their coaches take time to review their performance, identify winning plays, and recognize areas for improvement.
Once an individual case is closed, all data captured should be aggregated with data from other claims. From here, one can ask several questions. Was the outcome the same as what was expected? If it wasn’t, was there something unique about this patient? If so, is this something that should be factored in for future cases? What could be done to prevent incurring the same delays and additional costs?
Answers to these questions should feedback both to the predictive model and clinical guidelines, thereby helping teams get a better understanding of how an individual patient treats, paving the way for better predictions, and future-proofing strategy. Additionally, the data collected will give us insight into how providers in the network are doing. This allows us to ensure that providers are following clinical guidelines and providing the best quality of care.
As you gather more data from more claims, the more robust your data set becomes. And with your data and the right PT provider with proven clinical and industry experience, you can build a program that wins.
Getting an injured employee back to work through physical therapy gets you a point on the scoreboard, that’s for sure. But in a world that values not only immediate savings but also quality outcomes and patient-centric care, the industry must take things further. Leveraging data to inform strategy before, during, and after treatment, allows you to ensure that administered care is effective, both in cost and quality. And when you learn to plan ahead, keep score, and adjust your strategy based on learnings, you win.
“How Your PT Program Can Win with Data and Analytics.” WorkersCompensation.com, https://www.workerscompensation.com/news_read.php?id=41084.
Jun 1, 2022 | Insights
When you think about major health conditions affecting society, what comes to mind first? Cancer, diabetes, and heart disease all dominate the collective conversation, and rightfully so. They impact millions of people across the globe and have their own societies, awareness months, cereal sponsorships, celebrity spokespeople, and social media hashtags…the list goes on.
Chronic pain, however, is more prevalent than all three of these conditions combined. Perhaps it’s the pervasiveness or obtuse nature of the diagnosis that makes it a “sleeper pick” in the national conversation. Regardless, it’s a condition many in workers’ compensation know all too well.
Chronic musculoskeletal pain is the leading cause of disability, according to a recent study published in Physical Therapy. And people who try to keep working through pain say it reduces their productivity. Those with chronic joint pain estimate that they lose over two hours a week of productivity, and people with pain in multiple sites say they lose over nine hours a week.
Physical therapy should be part of any chronic pain patient’s regimen. It can relieve pain, increase mobility and flexibility, and guide patients to self-management techniques that work for them.
However, derailing chronic pain is a much better goal.
Preventing acute pain from transitioning into chronic pain has become a top research priority of the Federal Pain Research Strategy (US), prompting physical medicine researchers to analyze “predictors” of this transition.
What characteristics or circumstances indicate that an injured worker could develop chronic pain? Knowing these predictors empowers claims representatives and practitioners to get in front of it and deploy resources to block it.
Published in Pain Reports, the Framework for improving outcome prediction for acute to chronic low back pain transitions analyzed 20 previous studies that examined the transition of acute to chronic pain. Researchers combined the predictors identified in the earlier investigations and divided them into demographic, pain, health status, psychosocial, and individual context domains.
Authors noted some underrepresented predictors in the studies, including the health indicators of physical activity and sleep disturbance, along with alcohol, tobacco, and drug use. They strengthened social determinates of health, adding marital status, household size, and living arrangements to the demographic domain because emerging evidence points to their impact on chronic low back pain. Having Medicaid coverage was a predictor of poorer low back pain outcomes in one study and lower education and income levels decreased the positive effects of psychologically informed stratified care in another.
Since pain itself is a predictor, authors stressed the importance of the clinical history and covering things like the duration of pain, history of previous conditions, and the pain experience (anatomical location, severity, intensity, and impact). One study showed that multiple sites of pain can be predictive of poor low back pain outcomes.
In the psychosocial domain, authors stressed the need to capture negative mood and coping styles along with positive coping skills like self-efficacy and acceptance. They also recommended longitudinal monitoring, i.e., capturing time-varying factors, to track emerging psychosocial impacts.
The individual context domain refers to occupational factors, usually things like job satisfaction and perceived work stress. Framework authors recommended adding measures to capture the patient’s perceptions of receiving care, treatment preferences, and the expectation of having persistent pain.
Takeaways
Practitioners and researchers agree on the predictors of chronic pain, and the Framework research made great strides toward standardizing them. Standardization facilitates research and makes it easier to integrate predictors into electronic medical records.
However, claims representatives do not have to wait for integration to identify injured workers who are at risk of developing chronic pain because many predictive data points already reside in EMR systems. Data on previous conditions, weight, pain duration and location, drug, alcohol and tobacco use, along with anxiety and depression can be mined. Emerging predictors, such as marital and financial status and multiple pain sites could be added to screening tools to improve results.
Early and accurate predictions inform care decisions and drive the best use of healthcare resources early in the claim. For example, less resource-intense methods, such as telerehab and non-pharmacologic care, can be used on the low-risk claims. The high-risk ones need more treatment options and closer monitoring, possibly with nurse case management.
Arranging a consultation with a physical therapist who screens for psychosocial factors is a good starting point. During the consult, the therapist and patient discuss the injury, the pain, and its impact on their lives and ability to work. Consulting therapists also educate the injured worker on their condition, explain the mechanisms of pain and how it transitions to chronic, and help set expectations for physical therapy and relief.
The consultation report should flag barriers to recovery, especially psychosocial factors. Then claims representatives can deploy appropriate resources, such as cognitive behavioral therapy or psychologically informed physical therapy.
Keep in mind that the physical therapist is usually the provider on a claim who sees the injured worker most frequently and spends the most time with them on each visit. Therapists can be early identifiers of issues that cause pain to transition from acute to chronic.
Alternative medicine, acupuncture, and behavioral management therapy may be useful. In most cases, conservative care should be provided first, but some injured workers need injections, pain pumps, or surgical interventions to stop or reduce the pain. The same solution won’t work for everyone, and a nurse case manager can navigate different treatment options to find what works best for a specific injured worker.
While there’s always more to learn, here is what we already know:
Three Steps to Take to Prevent Acute Pain from Becoming Chronic
- Analyze portfolio for claims at high risk of acute-to-chronic pain transition. Closely monitor high-risk claims and strive to reduce or eliminate pain.
- Review and bolster screening tools to better identify predictors of chronic pain development, including negative mood and coping styles, perceived injustice, multiple pain sites, perception of persistent pain, and comorbidities along with marital and financial status.
- Invest in data analytics/predictive modeling technology and professionals or partner with companies who do.
There are many reasons that pain becomes chronic, including delayed treatment, the use of opioids, the intensity of the pain, provider choice, and psychosocial factors. Stopping acute pain from becoming chronic keeps injured workers from spiraling into a lifetime of pain and disability and saves workers’ compensation payers and the overall healthcare system billions of dollars a year.
“Brian Peers: How Do You Keep Acute Pain from Becoming Chronic? Understand the Predictors.” WorkCompWire, 4 Apr. 2022. https://www.workcompwire.com/2022/04/brian-peers-how-do-you-keep-acute-pain-from-becoming-chronic-understand-the-predictors/.
Apr 26, 2022 | Insights
Acute pain has a purpose, chronic pain, not so much.
People feel pain when the brain receives a signal that a disease or injury threatens their well-being. The brain signals a worker that they’ve hurt their back, so they quit doing what caused it and seek relief. With chronic pain, the brain interprets a signal as a threat when there is none.
Physical therapy is the go-to for musculoskeletal injuries and the acute pain they bring. The sooner therapy starts, the better. But what about pain that has gone on for three months or three years? Can physical therapy still help?
Pain is one of the most common reasons that people seek medical care. Severe chronic pain negatively affects physical and mental functioning and diminishes quality of life. It also creates a financial burden for individuals and employers. “Relieving Pain in America,” published by the Institute of Medicine of the National Academies, puts the cost of chronic pain between $560-630 billion a year.
More than 116 million adults in the US suffer from chronic pain, and it seems to affect workers’ comp patients even more than the general population. This is according to a study published in Relational Behavioral Medicine that found that workers’ compensation patients were “generally more distressed and had poorer outcomes than those not covered by workers’ comp.”
Pain is typically considered chronic when it has continued for three to six months. Chronic pain can become a condition unto itself, posing a major barrier to return to work. It can cause anxiety, irritability, and depression, and it is complex and difficult to treat.
Yet injured workers who have chronic pain–even those who have been in pain for years–can benefit from physical therapy.
The main difference in the therapeutic approach for acute versus chronic pain is the balance between education and exercise. When there is a recent injury, therapists focus more on exercise and manual therapy to restore strength and mobility and get the patient out of pain.
Education plays a role in treating acute pain, but it takes center stage when treating chronic pain. Understanding the mechanisms of pain, especially how chronic pain develops, helps patients identify ways to derail it.
When pain goes on a long time, the body develops workarounds for coping. The person’s posture changes, and they may slump or limp. Muscles tighten, trigger points develop, and stiffness deconditioning can occur. Some patients do not feel like moving around, and their lack of activity decreases circulation, weakens muscles, and can affect joint mobility.
These injured workers need more education about the mechanisms of pain, how to relieve it, how move more efficiently, and ideally, how to self-manage it. It’s good to have patients start with a consultation with a physical therapist to discuss the injury, their pain experience, and how it has affected their lives and ability to work. Patients should understand that this course of physical therapy will differ from treatment they had immediately post injury.
This session should include a psychosocial screening even if the worker was screened earlier. Psychosocial factors often develop as pain continues. Some patients come to believe that they’ll always be in pain, never be able to do what they once did, and they lose hope.
Treatment needs to be patient-centric and customized. Combining aerobic conditioning with strength training helps some people, while relaxation and mindfulness work better for others.
Shared decision-making is important. According to an article in the Journal of Manual and Manipulative Therapy, the traditional decision-making process where the provider is the authority and the patient does what they’re told, doesn’t cut it. Collaboration is key.
The therapist will demonstrate strength, mobility and flexibility exercises and apply manual therapy, such as trigger point and myofascial release, spinal manipulation, and dry needling, and explain how they work and their benefits. The patient gives feedback on which techniques help. Together, the patient and therapist decide on the treatment program and set realistic expectations for eliminating or managing pain.
Chronic pain patients learn how their bodies have created workarounds to accommodate injuries and how they led to pain. They see that adjusting their posture or doing a particular set of stretches brings relief. As patients learn the reasons that certain exercises and stretches help them feel better, they become more likely to comply with the exercise program.
There are encouraging success stories of chronic pain patients who have tapered off high doses of opioids and overcome chronic pain through physical therapy. Others learn to accept a level of pain and how to reduce its frequency and intensity. Unfortunately, not every injured worker attains 100-percent freedom from pain.
Consider examining your portfolio of claims for workers in chronic pain and suggest a course of physical therapy. Things change as time goes on, and injured workers who couldn’t accept that they might always have pain may be ready to learn how to manage it.
Ideally workers’ compensation professionals and practitioners will learn to intercept pain before it becomes chronic. Stay tuned for more on this in part 2 of the series!
Mar 10, 2022 | Insights
Chronic pain is complex, costly and widespread – especially for injured workers. In fact, workers’ compensation patients in the U.S. generally experience poorer outcomes compared to those not covered by workers’ comp.
Not to mention the economic impact of chronic pain: direct and indirect costs total about $650 billion. This has prompted clinical practice guidelines and the U.S. Federal Pain Research Strategy to prioritize research on reducing the public health impact of low back pain (LBP) – and physical medicine researchers have begun to analyze the predictors of chronic pain in response. The goal: prevent acute pain from becoming chronic.
In this WorkersCompensation.com article, MedRisk’s VP of Clinical Services & Provider Management Brian Peers discusses key takeaways from a mapping review of 20 studies that have investigated the acute-to-chronic LBP transition. From this review, the authors described a standardized predictive framework to improve prediction of chronic LBP.
The structure used five predictor domains, adding elements in some areas that emerging evidence has revealed impactful on chronic pain:
- Demographics: income, marital status, household size and living arrangements
- Pain
- Health status
- Psychosocial: negative mood and copying styles, and positive coping skills like self-efficacy
- Individual context: perceptions of receiving care, expectations and treatment preferences
“There’s a lot to unpack in this research and much work left to be done. However, this analysis and previous studies have told us a lot,” said Peers. “Early and accurate prediction of the development of chronic pain can guide claims representatives in securing the appropriate physical and behavioral healthcare services in the beginning of the claim.”
Among other key takeaways, Peers pinpointed the importance of patient education in accelerating recovery, addressing psychosocial factors and treating chronic LBP. This is pertinent as psychosocial factors can delay recovery and return to work – and potentially lead to the development of chronic pain. Ultimately, this research supports a rising theme from the past couple of years: early physical therapy (including initial consult and education) produces better outcomes for all patients – but especially workers’ compensation patients.
To read more about the framework for predicting chronic pain, click here – or review the full study here.
Oct 5, 2021 | Insights
Communication is the heart of the relationship between a physical therapist and patient. Here are four guidelines to help improve patient conversations—and create superior outcomes.
After an initial evaluation, PTs will typically prescribe exercises and provide low back pain (LBP) patients with information about their diagnosis, prognosis and plan of care.
A positive interaction between the patient and physical therapist during this evaluation has been linked with reduced pain and disability, as well as a higher satisfaction with treatment. In fact, studies have shown that the initial evaluation process may produce small but significant therapeutic effects related to pain, fear-avoidance and functional measure of mobility and sensitivity.
But this is only true if the therapist successfully delivers the advice and the patient receives and retains the intended message.
Unfortunately, there are cases in literature that show inconsistencies between a PT’s self-assessment and a patient’s perception. This is not just a communication breakdown but a risk to the patient’s overall care.
For example, patients with spinal problems need to understand that back pain is generally benign and activity is key to recovery. If they do not perceive this message, they have a higher risk of disability and lower treatment satisfaction 6 months after treatment.
In a study published in Wiley Physiotherapy Research International, all patients remembered the PT’s first piece of advice, with diminishing retention for the second and third pieces of advice. Simultaneously, PTs underestimated success of message delivery in the first and second items of advice and overestimated success for the third.
While the disconnect may have been marginal in this study, there were a number of factors at play that enhanced the patient-therapist interaction. Based on this research, here’s what can be done to ensure PTs successfully communicate and patients actually listen.
How to Make Sure Patients Listen: Four Guidelines
#1. Use Shared Decision Making
Shared decision making is a consultation process in which a clinician and patient work together to make a health decision. It involves discussing options, benefits and harms and considering patient values, preferences and circumstances.
Taking a collaborative approach of the clinical evaluation and involving patients throughout the diagnostic process helps ensure that the patient understands what the provider recommends—thus bolstering retention of advice and exercises.
#2. Prescribe Simple Exercises
It’s one thing to retain a provider’s advice for managing LBP. It’s another to actually follow it.
Patients are more likely to participate in exercise programs that consider their preferences, circumstances and past exercise experiences. With that said, patient adherence improves when providers prescribe:
- A limited number of exercises
- Simple yet effective exercises
- Exercises that are easy to include in daily life
#3. Address Patient Concerns
A patient’s worries, fear-avoidance, individual beliefs and experiences with LBP can negatively impact their prognosis and overall treatment outcomes.
For example, a patient may be influenced by a family member’s experience with similar pain.
It’s important to have a dialogue about these concerns and then develop specific and reasonable management strategies that addresses a patient’s worries.
#4. Identify & Address Patient Expectations
Finally, patients come into physical therapy with a set of expectations.
For the most part, patients expect specific, tailored exercises. They also expect investigations that lead to a diagnosis and an explanation of what actually caused it.
Opening a dialogue about these expectations—and addressing them—will further improve communication and patient outcomes.
Conclusion
Patient-therapist communication is critical and it all starts at the initial evaluation. As the industry continues to prioritize patient-centric care, it’s important to engage the patient from the beginning to ensure that they hear and understand the diagnosis and treatment.
Because when patients remember what PTs tell them, they are more likely to adhere to exercises and see improvements with their LBP.
MedRisk’s patient-centric approach to managed physical medicine starts with its PT Consult service: a consultation between an on-staff PT and the patient in advance of treatment. PT Consult prepares patients for what PT is like and the physical benefits it brings, such as strength, pain relief, mobility and recovery. There is a screening for any psychosocial factors that could impact recovery and the consultation helps set the patient’s expectations for therapy and what the recovery journey may look like, establishing a positive mindset as they get ready to start with their MedRisk provider.
Supp, G, Schoch, W, Baumstark, MW, May, S. Do patients with low back pain remember physiotherapists’ advice? A mixed-methods study on patient-therapist communication. Physiother Res Int. 2020; 25:e1868.
https://doi.org/10.1002/pri.1868
