By: William Zachry, Rudy Flores and Dick Turkanis, M.D.

A recent comprehensive study released by the Workers Compensation Research Institute showed a strong association between prompt provision of appropriate Physical Therapy (PT) and positive outcomes for back injuries. The report suggested that the potential benefits of early PT should be considered when planning care for these injuries.  One can extrapolate that there may be positive outcomes from timely and focused PT for other musculoskeletal injuries as well. 

"Positive Outcomes" are defined as maximum recovery and return to work. Though there are challenges in the workers' compensation system to providing timely and quality PT, there are best practices which, if followed, will help improve access to, and delivery of, quality care and enhance the likelihood of Positive Outcomes.

Best Practices focus on timely and accurate communication, using state-of-the art technology, between the injured worker, the PT provider, the referring doctor, the claims administrator, the managed care nurse, and the employer – ensuring that the entire treatment team is committed to achieving the same goals.  

Best Practices means treating each team member with respect and consideration, especially the physical therapist.  Timely approvals of treatment requests and prompt, accurate and fair reimbursement for work well done on the part of the therapist help foster that relationship.  PT providers should be viewed as valuable assets in the care of injured workers, so they will want to offer work comp services in their practices.

The Employer's role in communication

1. All claims should be reported immediately to the claims administrator.
2. If one exists, a copy of the physical job description should be shared with the treating physician and physical therapist.
3. The existence of light jobs or modified duties should be shared with the treating physician.
4. The employer should be aware of treatment or PT appointments and attempt to avoid scheduling work duties during those times.
5. The employer should work diligently with the injured worker and front-line supervisors to ensure compliance with any job restrictions.

The Treating Physician's role in communication

1. The preference of the referring physician regarding which PT provider might be best fit (personality and skills) to take care of the injured worker's injury should be communicated to, and followed by, those directing patient care.
2. Great communication can be facilitated by an automated referral system to the PT provider utilizing the latest technology.  
3. The referral to the PT provider should include a clear medical history and the reason for the referral, as well as the specific goals for recovery. 
4. Depending on the jurisdiction, the physician should also make sure that the necessary authorizations are in place.

Claims Administrator's role in communication

1. The claims administrator should aggressively look for ways to promptly approve treatment requests.
2. If treatment requests are denied the explanation should be based on evidence-based medicine guidelines and easily understood by the injured worker as well as by the physician and the physical therapist.
3. If the denial for treatment is based on a denial of compensability the explanation should be promptly conveyed to all parties, so no treatment is provided inappropriately. 
4. The claims administrator should convey approvals for both the number of treatments approved as well as the timelines within which they should be provided.
5. The claims administrator should routinely review the appointment statuses of all their claimants (using an online portal can improve the ease of this activity), and to respond to any delays or requests for information or assistance from other teams members.
6. The claims administrator should promptly pay for services which were provided. 
7. If there are any billing disputes the reason for the dispute and the proposed method of remedy should promptly be conveyed to the provider.
8. When the claim is settled or closed, the claims administrator should convey the final results (permanent disability levels and any future medical treatment awards) to the treating physician.

How best to communicate with the Injured Worker 

1. Quality communication with the injured workers can be facilitated by using the latest technology that is easy for the worker to use and understand.  It is a reasonable assumption that 100% of the workers have and use cell phones, thus the communication process with the injured workers can be through text or voice reminders for appointments.  Communication should be HIPAA compliant and in the language which each worker understands and regularly uses to communicate (native language).
2. The injured worker should have a system and technology that provides the name of the physical therapist, the location, date and time of the appointments.
3. The system should provide all specific instructions to the injured workers concerning current Covid-19 protocols.
4. The system should be a source of information for the injured worker on self-care and follow up care or activity limitations prescribed by the doctor or the physical therapist.
5. If there are transportation issues, the system should provide information for access to reimbursements for transportation expenses.
6. The system should also facilitate communication by providing the email, text or phone numbers of the physical therapist and treating doctor if the injured worker has any questions concerning their care and follow-up.
7. After their PT visits, it is important to ask the injured workers for their opinion of their care and about the technology which they are using.

The Physical Therapist's role in communicating with the Injured Worker

1. Prior to the first session, the physical therapist should communicate directly with the patient the expectations of how long sessions will take and what to expect during the sessions.  
2. At the first session, the therapist should spend time getting to know the injured worker to determine if there are any comorbidities or psycho-social obstacles to achieving recovery.
3. At the first session, the therapist should provide a careful, thorough and realistic explanation of the treatment which has been prescribed, set an expectation of recovery (timelines and levels of recovery), and detailed descriptions of why the patient is performing both passive and active actions to maximize recovery.
4. At every session, provide an explanation of why that session of PT should not result in re-injury (or how to avoid re-injury).
5. At every session, set an expectation on how much effort the patient will have to exert and how much pain may be expected (both during and after the session). 
6. At every session the Physical Therapist should explain that the patient may experience "good pain" which is a necessary part of recovery.
7. At the end of each session, the Physical Therapist should make sure that the patient understands the exact nature and extent of any PT homework that needs to be performed.
8. At the last session, make sure that the patient is fully aware of the extent of recovery and, if needed, how much is still needed to fully recover, plus what homework may still be needed.
9. At the last session the Physical Therapist should provide insight concerning physical activities which will avoid reinjury or protect the worker from aggravating the injury.

The Physical Therapist's role in communicating with the Claims Administrator and Referring Physician

1. Optimally, using the latest technology, the Physical Therapist should keep the treating doctor and the claims adjuster informed about all scheduled, missed and completed appointments.
2. An online appointment portal should be viewable to the physician's staff so there are no conflicts between doctor (doctor's office) and therapy appointments.
3. After each PT session, the physical therapist should promptly deliver an easy-to-read update to both the claims administrator and the referring physician concerning progress made and if there are any noticeable obstacles (physical, or psycho-social) which may delay recovery.  
4. After the final session, the therapist should provide a report to the doctor and the claims administrator outlining the work which was performed as well as the appropriate measurements (range of motion, on injured and uninjured parts of the body), any discernible atrophy, strength of grip, and ability to perform physical job-specific requirements.
5. Ideally the reports to the physician should be automated and flow directly into the physician's medical record system.
6. If there are any concerns over the treatment, progress or billing, HIPAA-compliant technology should be used to facilitate questions and replies between all parties.
7. All bills to the claim's administrator should be automated, timely and accurately coded

How to include the Nurse Case Managers in Communication 

If a nurse case manager is assigned to the injured worker, that person should have access to the same information that is provided to the injured worker and the same reports and information which is provided to the claims administrator and the treating physician (utilizing the same online communications software.)

The Physical Therapist's role in communicating with the Employer

1. If a physical job description exists, a current copy of the physical requirements of the job should be reviewed by the physical therapist before therapy begins.
2. If the employee is on light or modified duties, ask the employer if there are any treatment scheduling issues which may assist the employer to maintain their business, while facilitating recovery.
3. If the employee is on light or modified duties, the physical therapist should discuss with the employer what physical activity can be performed while the employee is on the job that will help the employee recover.
4. Keep the employer notified of all upcoming scheduled appointments and whenever any appointments have been missed.