Part 2: An evidence-based approach to case management

Accident Compensation Corporation: Using a case management approach to rehabilitation.

In this Part, we set out our assessment of the extent to which ACC has a clear, evidence-based approach to how it manages cases.

Using evidence to help design and operate its case management system should ensure that ACC uses treatment, and rehabilitation pathways that are known to be effective in certain circumstances.7

Summary of our findings

ACC manages cases in a clear, evidence-based way. However, it could use the evidence much better to steer work flow and to help staff manage cases.

ACC has clear and comprehensive policy, process, and procedural information about how it approaches case management.

ACC has researched ways to treat and rehabilitate people. It has sought the views of its claimants and providers to find out what works well, but could better integrate this evidence – especially evidence from New Zealand – into its systems.

ACC recognises the need to more strongly focus on claimants when managing cases. It has made some progress with this through its Client Service Optimisation projects, but has yet to fully integrate that approach into how it manages cases.

ACC is improving its approach to understanding rehabilitation outcomes for its clients and is working with providers of rehabilitation and treatment services to strengthen this approach.

Streaming of case management

ACC has a relatively intensive case management approach, which is based on directing people to the case management stream most appropriate to their needs.

What do case managers do?

ACC told us that "case management describes a claimant relationship that is collaborative in nature" and that case management helps to assess "individual need and circumstance in which those needs arise", so that ACC and claimants can plan, put into practice, co-ordinate, and monitor the services required to meet claimants' injury-related needs and "support the clients' restoration of their independence or optimal resumption of their roles within family/whanau, community, work and wider society".

Case management is the approach that ACC uses to help assess a person's treatment and rehabilitation needs, and to help plan and provide treatment and rehabilitation to meet those needs.

There is a continuum of possible case management approaches. At one end of the continuum are heavy caseloads that require a case manager to exercise little judgement (with a focus on transactions). Cases at this end of the continuum usually have a relatively low average cost. At the other end of the continuum are light caseloads that require a case manager to exercise a lot of judgement (with a focus on relationships with claimants). Cases at the latter end of the continuum usually have a relatively high average cost. In the case management streams that we looked at, ACC's approach is more closely in line with the latter situation.

Case managers, together with the injured person and with advice from internal and external specialist advisors, work out the treatment, rehabilitation, and support steps that are required to return the injured person to employment or independence.

Case managers identify and enter the tasks needed to complete these steps in ACC's case management system, which is known as Eos. This is a manual process and defines the work for that case manager for that injured person.

Case managers record actual work performed as a "contact". This could be a record of a phone call or a copy of a sent letter. We looked at several files that had more than 700 "contacts" recorded in them. Although ACC refers to work performed as "contacts", not all of the work actually involves contact with a claimant.

If a task involves seeking specialist advice or committing ACC resources (providing an "entitlement"), case managers are generally required to complete the relevant ACC form or letter. ACC relies heavily on standard forms and letters to manage access to entitlements.

Entitlements provided for under section 69 of the Accident Compensation Corporation Act 2001 are:

  1. rehabilitation, comprising treatment, social rehabilitation, and vocational rehabilitation;
  2. first week compensation;
  3. weekly compensation;
  4. lump sum compensation for permanent impairment; and
  5. funeral grants, survivors' grants, weekly compensation for the spouse or partner, children and other dependants of a deceased claimant, and child care payments.

ACC has about 1700 case managers supporting about 41,500 claimants at any one time. Figure 1 sets out the number of case managers and active claims by case management stream. Figure 1 also shows the average number of minutes a week a case manager works on an active claim. This ranges from about 20 minutes a week for RIS cases to about 90 minutes a week for front-end cases.

Figure 1
Number of case managers and active claims, by case management stream

Case management streamNumber of full-time equivalent staffNumber of active claims*Minutes each week**
Front-end 1435.5 25,428 95
Recover Independence Service 152.6 11,817 22
Serious Injury Service 136.0 4,251 54
Total 1724.1 41,496

* Number of active claims is as at 7 June 2014.

** Average number of minutes for each active claim each week for each case manager. This assumes that a case manager has 70% of a work week available for case management (leave, training, and so on make up the remaining 30%).

Source: Staff numbers, claims, and caseload information from ACC. Minutes each week is our analysis.

The average number of minutes spent on each claim in the RIS stream is relatively low when compared to the front-end and SIS streams. This suggests that some RIS claimants do not have contact with ACC for long periods of time.

Averaged throughout all ACC local offices, the ratio of full-time equivalent staff to managers is about six to one. The team manager focuses on team management, leadership, coaching, and managing team members' development needs. Figure 2 shows the structure of a typical ACC local office.

Figure 2 Typical structure of a local office

Figure 2 Typical structure of a local office .

ACC's recent approach

ACC aims to treat all claimants, employers, and providers as customers. ACC needs to balance the rights of all customers while focusing on the needs of claimants.

An external review, customer feedback, and government expectations have led to ACC trying to deliver better customer service and improve outcomes for claimants as part of its case management approach.

The focus on quality customer service is intended to improve trust and confidence in ACC and to get better outcomes for the claimant, while keeping the scheme affordable.

In 2013, ACC launched Client Service Optimisation. This is a set of projects that aims to improve people's experiences with ACC, rehabilitation outcomes, and the efficiency of the claims process. This set of projects is the basis of the case management streams that ACC uses (see paragraphs 1.12-1.22).

ACC has a significant change programme under way called Shaping Our Future, which is meant to result in ACC working in a more customer-led way. ACC intends the programme to result in ACC delivering better services to claimants and, in doing so, to reduce administrative costs through avoiding extra work required to manage poor quality. ACC told us that external feedback helped it prepare Shaping Our Future.

Using forms and letters to manage access to entitlements

ACC comprehensively and clearly records its case management process, procedural information, and delegations. However, ACC relies heavily on standard letters and forms to manage access to entitlements.

Recording the technical aspects of the approach

ACC has an internal online resource called CHIPS that frontline staff can refer to. CHIPS lists all guidance, policies, and procedures relating to case management and ACC's claims. For example, there is guidance on what claimant-focused case management looks like and the steps a case manager should take to assess a person's rehabilitation needs to help them return to work. In our view, the information recorded in CHIPS is generally of good quality and abundant.

We looked at the guidance material in three of the eight collections of information in CHIPS. This was material about treatment and rehabilitation, claimant management, and claims management. There were 88 separate policy documents and 68 separate process documents in these three collections, as well as 135 other documents.

We looked at ACC's records of the delegations that case managers hold – the limits on the services that they can refer claimants to and the money that they can commit ACC to. We found that the delegations were comprehensive and clearly recorded. This included information on who (expressed in terms of roles within ACC) a case manager is required to consult when exercising specific delegations.

Case managers supporting front-end and RIS streams have the same delegations. The staff who provide case management support to claimants in the SIS stream largely have the same delegations, although some SIS stream case managers can also:

  • approve residential rehabilitation up to 270 days for each admission for people with a traumatic brain injury;
  • approve non-acute in-patient rehabilitation up to three weeks; and
  • work out eligibility for weekly compensation (based on incapacity).

Team managers for front-end, RIS, and SIS streams generally have similar delegations to staff in their teams, but with higher thresholds in terms of quantity and/or cost.

Where discretion can be exercised, the delegations manual clearly defines the scope for decision-making. CHIPS includes guidance on how and when to apply discretion.

In our view, the delegations appeared appropriate to support a streamed case management approach.

Recording the approach's softer aspects

ACC has clearly recorded the "softer" aspects of its case management approach. These include the customer service that case managers are expected to show when managing a case. Guidance outlining this customer service, put in place in 2003, is intended to be in line with the Code.

Customer focus is a core competency and skill required of all staff. ACC requires all its staff to:

  • put people first, injuries second;
  • tell the truth and keep promises;
  • help people to receive their entitlements;
  • behave professionally in every respect;
  • set up working relationships with claimants and colleagues that enhance claimants' self-esteem;
  • be sensitive to culture, values, and beliefs;
  • make decisions based on facts, not assumption, bias, or prejudice; and
  • communicate in a clear, simple, and helpful way to minimise the potential for misunderstanding.

ACC's set of service standards highlight the minimum service that frontline staff should provide when working with claimants. The service standards focus on communicating effectively, professionally, and in a timely way.

Knowledge supporting the approach

ACC knows a lot about the treatment and rehabilitation approaches that work well, from a clinical and claimant perspective. However, ACC could better integrate the available evidence into tools and procedures it uses to manage claims.

ACC has comprehensively researched rehabilitation practices to inform its policies, procedures, and interventions. It keeps up to date with international research on rehabilitation. ACC evaluates the effectiveness of health interventions and produces summaries of clinical best practice for providers.

International research has shown that work is good for most people's health and well-being.8 Returning to work provides a person with a sense of fulfilment. Social interactions at work benefit a person's psychological well-being. A person's loss of earnings is minimised when they return to work sooner. This research underlies ACC's approach.

ACC is working to improve guidance for frontline staff on suitable rehabilitation time frames. Predictive modelling can identify which people are more likely to require rehabilitation and active case management. ACC uses data to calculate a range of claim durations. ACC staff told us that, as part of Shaping Our Future, ACC envisages that it will prepare treatment and clinical pathways based on New Zealand evidence.

In Part 5, we discuss ACC's case management performance information, including the claimant experience. In short, ACC knows what works well for its claimants and what does not.

7: A pathway describes what treatment and rehabilitation services a claimant needs and what order those services should be provided in.

8: For example, the Royal Australasian College of Physicians, Australasian Faculty of Occupational and Environmental Medicine (2010), Position Statement on Realising the Health Benefits of Work, Sydney and Black D-C. (2008), Working for a healthier tomorrow: Dame Carol Black's review of the health of Britain's working age population, The Stationery Office, Norwich.

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