Part 1: Introduction

Accident Compensation Corporation: Using a case management approach to rehabilitation.
As the human face of ACC … Case Managers are vitally important, as they set the tone of the relationship [with the claimant] and have the potential to set and to continue to manage clients' expectations of ACC's services throughout the ACC journey.
(Research New Zealand, Understanding Clients' Expectations of ACC, 2012)

1.1
The theme of our Office's work programme for 2013/14 was Service delivery. As part of this theme, we decided to look at how the Accident Compensation Corporation (ACC) and the Ministry of Social Development manage cases and complaints. In August this year, we published our reports on how these two public entities deal with complaints.1 This report, the third in the series, looks at how ACC uses case management.

1.2
In this Part, we describe:

  • the role of ACC;
  • how ACC uses case management;
  • our expectations of how ACC uses case management;
  • how we carried out our audit;
  • what we audited; and
  • what we did not audit.

The role of the Accident Compensation Corporation

1.3
New Zealand's accident compensation scheme (the scheme) has been running since 1974. It provides no-fault compensation for all New Zealand residents and visitors who have suffered an accidental injury.

1.4
ACC is the Crown entity set up to manage the scheme. ACC's role is to manage the scheme to deliver rehabilitation services to people in a financially sustainable way.

1.5
ACC receives injury claims and co-ordinates the help that people get to return to everyday life as soon as possible. For people who are employed when they are injured, ACC pays weekly compensation to compensate them for the loss of income while they are not working. To pay for treatment and services, ACC collects levies from businesses, motor vehicle owners, and employees. ACC refers to the people it rehabilitates and compensates (claimants), levy payers, and providers of treatment and rehabilitation services collectively as "customers".

1.6
The Injury Prevention, Rehabilitation, and Compensation (Code of ACC Claimants' Rights) Notice 2002 (the Code) was introduced in 2003. The Code sets out how ACC should work with people to ensure that they receive the highest practicable standard of service and fairness from ACC (see Appendix 1).

1.7
ACC must ensure that people are rehabilitated and compensated for any losses from personal injury in keeping with their statutory entitlements. ACC must do this cost-effectively and in a way that promotes administrative efficiency.

1.8
ACC has to maintain a focus on claimants and ensure that they get what they are entitled to under the scheme, while at the same time effectively managing the current administration and claims costs, and future costs, of the scheme.

1.9
However, it is clear that long-term cost management should not be achieved at the expense of quality. A Minister for ACC has said: "Financial stability can only be delivered in the middle and long term through the provision of quality service to claimants and levy payers."2

1.10
In 2012/13, ACC received about 1.7 million claims and spent about $2.7 billion on treatment, rehabilitation, and compensation. The cost of handling all claims was $331 million. ACC has about 3000 staff, of which about 1700 are frontline staff in 25 local offices throughout the country. ACC reported client satisfaction of 68% in its 2013 annual report.3

1.11
We looked at the claims that ACC's local offices manage as cases. Although these claims are a small proportion of ACC's total claims (about 4% of the 1.7 million claims that ACC gets every year), they involve injuries that can have substantial permanent effects on people's lives (for example, traumatic brain or spinal injuries) and the most expensive injuries.

Approach to managing claims

1.12
Simple claims are managed in short-term claims centres (which are separate from local offices). These claims are expected to be resolved in fewer than 70 days. Our audit does not cover these claims.

1.13
Staff at ACC's local offices manage longer-term, more complex claims. These claims are managed using "case management streams". Our audit covers these claims by looking at each stream.

1.14
"Front-end" case managers manage most claims. This is the first case management stream that our audit covers.

1.15
Claims that have been with ACC for more than 912 days are assigned to Recover Independence Service (RIS) case managers. This is the second case management stream that our audit covers.

1.16
At the time of our audit, ACC had plans to reduce the entry threshold for the RIS stream to 365 days. This could mean that people in this stream get earlier focused support and that ACC could better manage the long-term cost of some of their claims.

1.17
Serious Injury Service (SIS) case managers manage people with serious life-long injuries.4 Their claims have to meet specific criteria to enter the SIS stream. This is the third case management stream that our audit covers.

1.18
Local offices manage the RIS and SIS streams, although not all offices have these streams.

1.19
At the start of the claims process, service needs assessors use a scripted telephone call to work out whether a person should be directed to a short-term claims centre or a local office. People are generally managed in the SIS stream after the hospital treating them has contacted ACC.

1.20
As well as the streams based at local offices, ACC has some centrally managed case management streams. The centrally managed streams include a sensitive claims unit and a remote claims unit.5 The case management processes, supporting infrastructure, and practices in these units are similar to case management in local offices. We have not audited these services in detail, but our general findings about case management also apply to centrally managed streams.

1.21
When a claim has been assigned to a case manager, the case manager should consider all information about the claim. The case manager then creates an individual rehabilitation plan with the injured person's input. During the week ending 28 June 2014, 87.4% of ACC's active case-managed claims that were more than 13 weeks in duration had an individual rehabilitation plan.

1.22
We use the term "case manager" to include all case management staff. For example, in the SIS stream, "support co-ordinators" and "service co-ordinators" manage claims. For the purposes of this report, we refer to them as case managers.

Our expectations

1.23
We expected that ACC would:

  • use case management to rehabilitate injured people effectively and efficiently; and
  • deliver services to the highest practicable standard of service and fairness, in line with the requirements of the Code.

1.24
We expected ACC to:

  • have based its case management approach and the design of its case management system on sound evidence (we provide our assessment of this in Part 2);
  • have the right staff and systems to deliver rehabilitation services focused on claimants (we provide our assessment of this in Part 3);
  • effectively and efficiently deliver rehabilitation services that meet its claimants' needs (we provide our assessment of this in Part 4); and
  • use performance information to improve its service delivery (we provide our assessment of this in Part 5).

How we carried out our audit

1.25
To carry out our audit, we:

  • interviewed staff at ACC's head office in Wellington;
  • visited and interviewed staff at eight ACC local offices;6
  • reviewed and analysed more than 100 documents, including change management plans, engagement surveys, performance information, customer satisfaction information, and outcome information;
  • met representatives from ACC's Older Persons Advisory Group;
  • met the chairperson of the ACC Advocates and Representatives Group;
  • reviewed a small, random sample of 30 claimant files from the case management streams and the offices we visited;
  • got information about ACC's case management costs; and
  • got information about case managers' caseloads.

1.26
We asked Colmar Brunton to carry out 10 in-depth interviews with claimants to hear about their experiences of ACC. These people were randomly selected from the local offices we visited during our fieldwork. Colmar Brunton also interviewed 23 claimants who had previously contacted our Office about ACC.

1.27
Appendix 2 sets out interviewees' suggestions about how ACC can improve its case management services. It is important to recognise that these suggestions have been collected through in-depth qualitative interviews and are not necessarily representative of all claimants.

1.28
Where it was relevant to case management, we have also used information from Colmar Brunton's survey of, and interviews with, claimants who have complained to ACC.

What we audited

1.29
Our audit included cases that were managed in ACC's local offices (sometimes referred to as "front-end" case management), claims in the RIS stream, and claims in the SIS stream. We looked at those claims because they can involve the most expensive injuries and injuries that have a substantial permanent effect on people's lives.

What we did not audit

1.30
We did not look at ACC's short-term claims centres and accredited employers' management of claims.

1.31
We did not look at how ACC determined cover (whether ACC covers a person's injury) or at ACC's injury prevention activities. A separate review process is available to claimants who disagree with ACC's decisions about whether ACC will cover their injury. These claimants can apply for a review of ACC's decision, in which an independent party looks at whether ACC made the right decision.

1: Both reports are available on our website at www.oag.govt.nz.

2: Minister for ACC's 2013/14 letter of expectations.

3: ACC measures client satisfaction using the Common Measurements Tool. "The Common Measurements Tool is a set of survey questions and scales that allows State Services agencies to measure client satisfaction and identify service delivery improvements for service users. By using a common set of questions, agencies are able to compare their performance with other State Services agencies, with the Kiwis Count national survey and also measure how they are progressing over time." See the State Services Commission's website at www.ssc.govt.nz.

4: ACC considers that a person has a serious injury if they have a significant (usually permanent) impairment or loss of function. The person's injuries must meet a set of clinical criteria to be considered a serious injury, but in general consist of these types of injury: moderate to severe traumatic brain injury, spinal cord injury, or other catastrophic injury (such as multiple amputations or burns to more than 50% of the body).

5: A sensitive claim is a claim that arises from sexual abuse or sexual assault. The remote claims unit manages claims for people who ACC has determined are most appropriately managed at a distance rather than in person.

6: The eight local offices were Hamilton (for a preliminary visit), Christchurch, Greymouth, Porirua, Henderson, Counties Manukau, North Harbour, and Whangarei. We chose these to cover a range of rural and urban locations, big and small offices, and different economic conditions (because this affects the availability of work).

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