Case Management

Question 1

What is insurance?

Answer 1

A practice or arrangement by which a company or government agency provides a guarantee of compensation for a specific loss, damage, illness or death in return for payment of a premium

Question 2

What is disability insurance?

Answer 2

Protects individuals from an unexpected illness or accident that leaves them unable to work and earn income

Question 3

How much income does disability insurance replace?

Answer 3

60 to 85% of regular income, up to a maximum amount, for a specified time - unless deemed permanently disabled by a variety of medical professionals

Question 4

How is insurance provided?

Answer 4

Government - “workers compensation”, mandatory in some provinces/industries

Privately Operated (Sunlife, Manulife, etc). - typically provided from here
- STD = short-term disability
- LTD = Long-term disability

Question 5

How is insurance paid for?

Answer 5

employer or if you are self employed you can buy insurance

Employer-mandated in certain industries
- drawback = you are restricted (what you can get, what level of coverage )

Question 6

What is the process?

Answer 6

Injury - rest, recovery and rehab - return to work

Question 7

Who is involved?

Answer 7

Case Manager, rehabilitation consultant, plan member (employee), employer

Question 8

What does a case manager do?

Answer 8

Works as a middleman
Acts as the in-between for employee, employer and any treatment providers involved
Ensures employee is doing what they are supposed to do (resting, rehab), treatment providers are doing things properly and that the employer is providing an opportunity to get the employee back to work

Question 9

What kind of injuries/diseases occur?

Answer 9

Can be acute or chronic
Does not have to be a physical injury

Mental health or addiction
Could be a disease related or unrelated to the occupation
I.e. cancer
Does not have to be work-related

This affects who pays out benefits
If the disease is deemed related to occupation WSIB will cover claims, if unrelated to work a private insurance company usually covers it

Question 10

What are the typical documents required for a claim?

Answer 10

• plan member statement (what happened)
• medical assessment./dr letter
  -WSIB functional abilities form
• lots of paper work (may need to submit multiple claims to multiplecompanies )

Question 11

Do case managers decide on what type of claim can be submitted?

Answer 11

No

Question 12

What types of claims can be submit?

Answer 12

STD - provides coverage for 17 to 26 weeks (up to 6 months)
Not all plans include STD, since other options exist (ex; Unemployment insurance)

LTD - provides coverage for long term (typically 2 years)

Question 13

What is the difference between STD and LTD?

Answer 13

STD
Pays more, but does not last very long

LTD
Pays less, but can last extended periods of time
Potentially forever

Question 14

What are the standards of a Case manager?

Answer 14

1. Initial Assessment
2. Assessment
3. Planning
4. Implementation
5. Evaluation

Question 15

What happens during the initial assessment?

Answer 15

A 1 on 1 meeting to ensure client understand rights and responsibilities

Obtain consent, identify clients needs, get client report, provide options

Question 16

What happens during the assessment?

Answer 16

Sets foundations for planning

Common assessments: specialist, surgeon, physiotherapist, psychologist/psychiatrist, oncologist, PDA, Functional Capacity Eval (FCE), TSA, ERGO, IME (independent medical evaluation)

Question 17

What happens during the planning stage?

Answer 17

Discuss results with client, generate a plan, identify barriers, identify services and choices,
* case manager never comes up with a rehab plan for case members***

Question 18

What happens during the implementation phase?

Answer 18

• Outlines and facilitates agreement upon roles and responsibilities of all parties involved
• Goal = return to own occupation
  If not possible = return to own occupation with modifications
  If not possible = find a new occupation
  Could be another job in the facility

Question 19

What happens during the evaluation stage?

Answer 19

Determine if reassessments are required
Evaluate the progress of the plan and reconfigure/replan when needed
Document quantifiable impact on movements toward clients’ goals
Identify gaps in services/supports
TSA occurs at this point (transferable skills analysis)
Last resort assessments
When someone cannot return to their previous occupation