When a serious accident occurs, the outcome could be life-threatening or result in permanent disability. Pinnacol recognizes the immediate need for multiple services and care coordination to manage the medical conditions that involve multiple bodily functions and often, permanent impairment. However, it is often difficult to identify a “gatekeeper” physician willing and able to provide complex medical management in a catastrophic injury situation.
Through Pinnacol’s catastrophic case management program, physicians and medical case managers take responsibility for coordinating care from the very beginning of the injury. These professionals will work with the injured workers, their families, employers and caregivers to coordinate care, determine treatment plans, facilitate shared decision making and obtain records for catastrophic cases.
Injured workers or their legal representatives initially have the right to select their authorized treating providers from a list provided by their employer or the insurance carrier. Physicians selected to participate in this program will manage catastrophic claims based on their relevant professional experience, expertise and necessary proficiencies. Gatekeeper physicians review, analyze and make recommendations on the appropriateness of care and employ best practices in providing high quality, compassionate medical care.
Physicians are expected to rely upon their independent medical judgment in determining the appropriate type and duration of medical care provided to the injured workers. Pinnacol may ask a physician to provide opinions or address questions, but Pinnacol does not dictate medical care. It is the physician who will determine causality, manage specialty referrals, determine work restrictions, educate the injured worker, communicate with all parties, determine maximum medical improvement, permanent impairment, and participate in discharge planning during all levels of care.
Pinnacol is committed to providing whatever care is reasonable and necessary to cure and relieve the effects of all industrial injuries consistent with the nature of the problem(s) and the patient and family needs.
Care management may include:
- Developing and maintaining a comprehensive care plan
- Facilitating access to care and services needed by the patient and/or family
- Assessing and supporting patient involvement with the treatment plan and
- Educating the patient, family and/or caregiver to enable and support self-management, independent living and activities of daily living
- Communicating with home health agencies and other community services available
and used by the patient
- Communicating aspects of care to patient, family and/or caregiver
- Collecting health outcomes data and registry documentation
For questions, please contact the Catastrophic Medical Case Managers Susan Grigsby, RN, 303.361.4175, or Michelle Hall, RN, 303.361.4434.