A Healthesystems publication

Fall 2014

Missing the Big Picture? Holistic Patient Management

While the workers’ compensation industry has made efforts toward a global or holistic approach to patient management, there remains continued opportunity for innovation and improvement. A comprehensive, integrated set of tools and strategies can effectively address the fluctuating medical needs of the injured worker while containing costs. 

The goal of treatment in injured workers is straightforward — to restore function to the patient, thereby enabling return to work. But the path to getting there is often complex. The course of a patient’s condition is rarely, if ever, a straight one. A step toward improvement can be countered with a setback. Complicating factors, such as comorbidities, adverse drug reactions or psychosocial influences, may cause an unexpected diversion from the treatment plan.

Maneuverability Along the Continuum of Care

Successful outcomes rely on a treatment approach that can course-correct with equal flexibility. The ability to maintain synchronicity with the needs of an injured worker by delivering the appropriate treatment at any given point of the care continuum is the key to success.

This means recognizing when to intervene, and applying the appropriate level of intervention. The right information is needed in order to make the best treatment decision, and the complexity of the case determines the intensity of service required to uncover this information. No two patients are alike, and each will require different levels of intervention over the course of their condition. The ability to adjust accordingly, to focus the highest intensity of service on the most complex claims and tailor back for less complex ones, enables the highest level of quality care across the spectrum.

Continuum of Care: Intensity of Service Corresponds to Fluctuating Risk Level

Adopting a Holistic Approach

The ability to deliver a flexible and customizable approach to patient care requires a more holistic view than historically has been performed. For example, too often, clinical analysis and recommendations are based on a single aspect of a patient’s medical profile — such as their medication history. But applying a one-dimensional measure of evaluation simply leaves too much ground uncovered to make the most informed treatment recommendation at a given time. There are many variables within a patient’s history, aside from drug regimen, that a prescriber may be overlooking or even unaware of that can impact safety and effectiveness of the treatment regimen. Consider a patient successfully managed on Vicodin — until it’s discovered that their liver enzymes are dangerously high. A review of their drug therapy may uncover if any other acetaminophen-containing products are part of the mix. But it won’t uncover the bout of Lyme disease the patient had six years prior that contributed to underlying liver damage. This type of critical data can only be found by digging deeper. Therefore, additional evaluation strategies are needed to obtain a more complete picture of the patient in order to understand the full context of any clinical decisions.

However, improvement in care doesn’t just mean doing more. It means doing better. Application of these multiple strategies is only effective when part of an integrated approach. Collectively, the information is out there, but fragmentation of knowledge among stakeholders renders it useless, as no one party has consistent visibility into the overall patient. This becomes dangerous as medication decisions are being made based on assumptions or partial information. The absence of key information, even just one piece — a comorbidity, a potentially fatal drug-drug interaction — can lead to negative consequences. At best, treatment ineffectiveness. At worst, hospitalization or even death. The left hand must know what the right hand is doing in order to ensure the safety and well-being of the patient.

Services Along the Care Continuum

Integrating Clinical Knowledge With Technology

Healthesystems’ comprehensive suite of clinical and analytics services supports a holistic approach to patient management by providing solutions across the continuum of care, from automated interventions, including prior authorizations, medication plans and alerts, to enhanced clinical decision support.

Based on program outcome results, Healthesystems identifies that approximately 8 to 9 out of 10 claims are lower severity and can be efficiently and effectively managed through lower-intensity services offered by Healthesystems’ innovative technology solutions and analytics tools.1 The remaining population represents highly complex claims that drive the majority of spend, although they represent a small portion of patients. For this reason, these patients are recommended for a more customized, comprehensive clinical assessment to uncover potential complicating factors such as the presence of comorbidities or psychosocial and behavioral concerns, indicators of nonadherence, or prescribed drug therapies that may be inappropriate for their medical needs. While an initial review of their medication profile may prove valuable in identifying these potentially high-risk patients by uncovering the presence of high opioid use or dangerous drug combinations, this information is just the tip of the iceberg. An analysis of full healthcare records reveals a much larger picture, and often uncovers underlying concerns that impact the medication regimen and overall treatment plan:

Is the patient showing signs of nonadherence to therapy?
Did the doctor note lack of improvement based on the current treatment regimen? 
Was a urine drug screen conducted?
More often than not, the answer to these questions is yes. 

In fact, approximately 3 out of 4 claims evaluated through Healthesystems’ enhanced clinical decision support services revealed a complicating factor beyond the original prescription concern.

Complicating factors most commonly identified during medical history review:

The presence of each of these may pose a direct or indirect threat to treatment outcomes — threats that would not have been uncovered in a review of prescription history alone. For example, a urine drug screen — which was identified in a least half of reviewed cases — may indicate potential abuse. A next step would be to evaluate the results of this test, and determine what actions should be taken based upon those results. 

Comprehensive clinical analysis offers critical insights that can help change the trajectory of a claim. In approximately 70% of claims reviewed, more than one complicating factor was present within an individual claim, further compounding the complexity and subsequent risk.1 Now that these complications have been brought to light, action can be taken:

Quality Care Leads to Quantifiable Outcomes

A customized and patient-centric approach to care that prioritizes safety and appropriateness of treatment will positively influence health- and cost-related outcomes over the long term. Identifying opportunities for intervention early in the course of a patient’s condition and taking action to address potential threats can help manage snowballing costs resulting from symptom progression, new or existing comorbidities, unnecessary or potentially dangerous medications, and increased number of physician office visits and hospitalizations. It is these factors — factors that can often be prevented or proactively addressed — that can drive costs across an entire population; typically less than 10% of injured worker claimants are responsible for 70-80% of drug spend. Even just one complicating factor can have a significant impact. Consider the effect of comorbidity on outcomes; a study of injured patients with comorbid depression were less likely to return to pre-injury function and/or work status when compared with their non-depressed counterparts.2 Proactive management of complicating factors such as comorbidities, psychosocial issues, or nonadherence can have a measurable impact on cost; and for this smaller but very complex population, the effort and resources put into comprehensive evaluation and subsequent clinical decision-making can translate into exponential payoff. 


To learn more about how Healthesystems' enhanced clinical decision support is changing the way clinical intervention has historically been conducted and delivered, visit www.healthesystems.com/insights




1 -Data on file. Healthesystems 2014.
2 -Richmond JD, Guo W, Ackerson T, et al. The effect of post-injury depression on return to pre-injury function: a prospective cohort study. Psychol Med. 2009;39(10):1709-20.
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