WorkCompWire
Full article on: workcompwire.com
Shannon Ford, MA, CRC, SVP, Case Management, Paradigm
and Brenda Calia, MHSA, VP, Case Management Delivery, Paradigm
When it comes to quality assurance in case management, are we measuring what matters? Take, for example, a scenario in which a case manager misses documentation deadlines, yet the injured worker successfully returns to work long before expected. Compare that to another scenario, where the case manager has timely and flawless documentation, yet the injured worker lingered in disability months past medical guidance. While it may be necessary for case management, the current state of quality assurance doesn’t always tell us the full story.
Which case was higher quality? Most scorecards will tell you it’s the second one in each instance.
Too often in this industry, we find ourselves facing this issue. For decades, audit scores, documentation timelines, and cost containment have stood as proxies for quality. But as we’ve just demonstrated, metrics do not always match outcomes. In an industry that should put people before process, it’s essential to reimagine how we define, measure, and pursue quality.
Finding the human element in quality assurance
Without a doubt, case management plays an important role in cost containment for workers’ compensation. By managing cases efficiently, insurers and employers can minimize unnecessary medical expenses, reduce disability durations, and lower the risk of litigation, ultimately resulting in less overall spending. To do this, case managers are expected to perform a multitude of roles, including coordinating care, facilitating communication, directly managing costs, and supporting return to work throughout the recovery process.
Like other service-oriented positions, quality measurement and assurance in case management is intended to help stakeholders evaluate performance, monitor outcomes, and drive continuous improvement. To be effective, these processes must be calibrated not just for business needs, but also for the impact on the people they are helping. This is especially true in workers’ compensation case management, where the ultimate outcome—and the most significant cost savings driver—is helping injured workers recover their health and return to work in a timely fashion.
Focusing disproportionately on administrative metrics and filing deadlines can disconnect quality measures from the outcomes case managers are expected to achieve. In fact, according to Paradigm data, a review of more than 20,000 cases showed wide variance in audit scores, but little variation in return-to-work outcomes. This wide disparity shows us that key elements aren’t being captured in audit processes that are often reactive and based on misaligned benchmarks.
How quality measurement became disconnected from outcomes
To create quality assurance models that more accurately reflect the outcomes we’re trying to reach, we need to examine the contributors that led to these disconnects. Case management grew rapidly in the 1980s in response to rising healthcare costs. And as usage increased, more payers demanded audits to ensure they were getting a return on their investment and the results they expected.
However, the tools and processes used to do this were not necessarily always aligned across vendors or with best clinical practices. As the industry grew from sentiment-based scoring methods to more quantitative measurements, it has created disparate guidelines designed to meet a wide range of complex customer variations instead of our common shared goals.
Reflecting on the opening example, even though the first case manager scored poorly on an audit due to late documentation, the scorecard didn’t reflect her real accomplishments: intervening early, preventing unnecessary surgery, and ultimately helping an injured worker return to work in a timely fashion. In contrast, a case manager who passes an audit with flying colors can just as easily miss the early red flags that can prolong a claim and cause skyrocketing costs.
Rethinking quality through a human-focused lens
While timelines and accurate documentation are important, the quality measurement process needs to be calibrated more closely to this bigger picture of care outcomes. By focusing on core principles and shared goals, it is possible to develop a definition of quality that elevates care, reduces costs, and truly helps people.
Effective case management quality measurement needs to be able to account for:
- Outcome-based metrics: Return-to-work timelines, reduction in disability duration, and improved injured worker satisfaction are essential measurements of success for any case.
- Human connection: Finding metrics that accurately reflect the “how’s” of care delivery—advocacy, empathy, trust, guidance and education—that are foundational to case management, successful recovery, and return to work.
- Expanded scope: Incorporate perspectives such as injured worker engagement, adjuster satisfaction, and care continuity into evaluations.
Developing effective quality standards should reflect the perspective of injured workers as human beings and not just claim numbers. Quality standards should also measure the “how” of recovery, as much as the result, to close the gap between the scorecard and the outcome.
Measuring what matters—the important role of data and technology
Instead of working against people-centered quality standards, there are fantastic opportunities for data and analytics solutions to create audits that more closely reflect actual injured worker experiences and outcomes. One great example is using predictive modeling to flag complex cases within 24 hours of injury, enabling earlier, proactive intervention. By focusing more on early response and intervention, quality assurance can correlate more closely with positive outcomes for injured workers.
On the human connection and injured worker engagement front, there are a wide range of digital tools available that can track sentiment, engagement, and real-time recovery trajectory. Analyzing this data can help us leverage actual human feedback to help case managers better understand how to build trust with injured workers and advocate effectively. Finally, we can also use data to show the holistic impact of the case management profession, comparing the outcomes of cases that did and did not receive case management involvement.
Although sometimes depicted as working in conflict with the human side of case management, technology can instead be a powerful amplifier. By identifying when and where human intervention is most needed and effective, we can turn data into usable insights that enable positive transformation over the long term.
Measuring true quality and outcomes
Historically, quality assurance programs in case management focused heavily on compliance and documentation standards, auditing whether forms were completed, updates were timely, and checkboxes were marked. But as the industry has evolved, this prescriptive model is no longer sufficient.
To deliver on our promise of health and productivity, we need to work together as an industry to develop programs that go beyond checking boxes—and directly support better outcomes, reduced claim durations, and higher value care.
About Shannon Ford
Shannon Ford, Senior Vice President of Case Management Solutions, is responsible for Paradigm’s Case Management Solutions suite of products, serving as a client ambassador and leading a team of skilled case management professionals. Shannon has been a driving force of success within Paradigm’s case management team for the past 11 years. She’s an accomplished leader with over 25 years in case management. She has a proven track record of guiding her team to generate the very best outcomes for patients, payers, and providers.
About Brenda Calia
Brenda Calia, Vice President Case Management Delivery for Paradigm, has been in the workers’ compensation industry for over 35 years. She has led national teams in providing quality services in a wide spectrum of managed care services. As a passionate advocate for quality, today, Brenda’s teams focus on the support of case managers, with emphasis on internal and external quality and outcomes, client implementations, and administration.
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