American Adopts Interdisciplinary Approach
Several years ago, a data analysis by healthcare information specialist Ingenix pointed out to American Airline’s management that “mental nervous conditions” were a factor driving up their healthcare costs. In fact, at any one time, 4% of American Airlines' active, long-term disability claims have a primary diagnosis of mental/nervous disorder and/or substance abuse. In response, American created a proactive, integrated approach to address the disabilities associated with these conditions.
French credits American’s corporate lead nurse and disability plan manager, Christine Mankins, for this visionary approach to keeping people healthy and equipped for work while better managing costs. Here are some of the innovations of American’s proactive integrated approach:
Monthly Reviews: The interdisciplinary team—comprised of EAP personnel, case managers, a consulting psychiatrist from American’s external disability administrator, and clinicians across the country—reviews cases each month by conference call to ensure that claimants are progressing through the healthcare system in a timely fashion. Mankins facilitates these interdisciplinary team conference calls and says that the monthly reviews have been instrumental in increasing communication among the disability team management members, the employees on disability leave, and their clinicians.
Specifically, the team looks at these key factors:
Has a good, solid ICD-9 code been identified?
Is treatment inpatient or outpatient?
Has an estimated return-to-work (RTW) date been provided? (RTW dates are critical in helping employees anticipate and prepare for their return.)
Is restricted duty an option?
Revised Outcomes Assessment Form: American’s EAP program played a vital role in developing a brief form for the assessment of measurable outcomes and a description of treatment progress, in lieu of typical clinical notes, that disability clinicians use in reporting patients’ treatment. American found that if the form was user-friendly (1 page instead of the previous 5-6 pages), it was more likely to be returned by clinicians. This form profiles status improvement in several areas, including activities of daily living (ADLs).
American’s EAP also helped create a list of critical psychosocial indicators for disability case managers to use in assessing RTW barriers. If an assessment and progress form is not returned, a team member calls the physician and they discuss treatment plans and RTW barriers.
In cases where physician behavior itself could be a RTW barrier, a consulting psychiatrist on the team contacts the physician to discuss treatment strategies.
Role of Internal EAP: EAP providers are available to assess and refer, if needed, at no cost to the employee. If additional care is indicated, the employees are referred to their medical insurance plans. Employees pay co-pays based on the plan they selected; these fees typically are comparable to co-pays for medical care.
The EAP also provides in-house services to employees for stress management as well as critical incident debriefing for managers and seminars on strategies for talking with employees who are off work or returning from a mental/nervous leave of absence.
Warm Referrals: The interdisciplinary approach to disability management helps each team member see the patient from a different viewpoint and use that perspective for improved service with the provider and employee. In addition, a “warm referral” system was created to help manage employees with more than one illness. For example, if a patient with a primary diagnosis of diabetes also has indicators that treatment is needed for a mental/nervous disorder, a “warm referral” to EAP is elicited. The case manager may ask permission to call EAP for the patient, something that individuals with depression may not have the energy or motivation to do on their own.
Blind transfers/blind referrals: the referring clinician transfers the call and hangs up, leaving the caller to fend for himself or herself, or the clinician simply provides a number to call.
Red Flags: Certain circumstances are “red flags” that prompt a team contact, such as depression treated by a family physician or no reported RTW date. Other conditions that are increasing in prevalence and are frequently treated by primary care physicians include fibromyalgia, low back pain, carpal tunnel syndrome, and bipolar disorder—all conditions that may benefit from consultation with a psychiatrist.
Interdisciplinary Program Empowers Team: The interdisciplinary approach has given a sense of empowerment to team members—the assessment/progress notes provide specificity in discussion with clinicians and encourage goal setting and a timely return to work. Therapists and physicians working with EAP team members learn the business realities of keeping people working, and the process facilitates discussion of how work can be therapeutic to recovery. In addition, unlicensed, unethical, or other inappropriate clinicians may be discovered through the data mining process if a number of employees are using the same clinician and there is no documentation of treatment progress.
Disability Program Outcomes: Initial outcomes are positive. The duration of disability claims has gone down, and American’s percentage of mental/nervous claims is below the average for its disability administrator’s average book of business.
As a result of the process change, Mankins reports, “The disability management team now functions as a more integrated and proactive group.” She notes, “We initiate team management of disability cases and reach out to employees much sooner, even for conditions like simple depression that would not have been targeted in the past.”
The team is also establishing closer relationships with physicians to encourage better coordination of care and an earlier return to work, as appropriate.
Psychiatrists are increasingly releasing patients for restricted duty (e.g., resuming work duties for a few hours a day) as a way to accommodate the employee’s disability and medical needs while keeping workers involved in vital occupational roles. This encourages maintenance of the employee’s daily work routine, continued social contacts with co-workers, and regular communication with supervisors—all of which ease the return to successful full-time work when appropriate.
Clearance for full duty in safety-sensitive positions, as for many industries serving the public, is given great consideration by the disability management team.
Commitment to Program Is Crucial: One factor enhancing the team’s efforts is their disability administrator’s consistent assignment of one or two people to manage American’s cases exclusively. Both Mankins and French believe this commitment has allowed the team to develop important and close working relationships.
The disability management team members have come to appreciate the different perspective each brings as a result of diversity in training and professional experience, and they feel more comfortable sharing opinions and challenging each other’s thinking in their regular team conference calls.
In summation, French said, “I truly love my job. I sense a strong commitment on all sides to getting employees the care they need in a timely manner to help them be as productive and successful at work and in their personal lives as they possibly can.”
Therapists at WorkReturns can assess cognitive and behavioral components that are important to work, such as concentration, social skills, and attention to task, and they can point out to clients how they are improving, thus building a sense of self-efficacy. In some cases, patients have trouble seeing how they have improved and how they can be more effective when they do return to work. WorkReturns addresses that need.
For more information about American Airlines’ integrated disability program, contact Christine Mankins, Disability Plan Manager, at 1- 817-963-1687 (e-mail Christine.Mankins@aa.com) or Lela French, CEAP, Manager, AA EAP, at 1-800-555-8810 #9 (e-mail Lela.French@aa.com).