NEW CLAIM APPROVAL
The optimal time a DCM would advise the Plan Member of the forecast date, their next steps and expectations moving forward.
What is the Approval Phone Call.
According to practice, this action is expected to occur on files before the forecast date and as part of the action plan, to ensure the RTW plan is on track.
What is a follow-up phone call.
When a Director of Mental Health review is conducted on a claim these should be actioned as soon as possible upon receipt of the review.
What are their recommendations.
These details should be embedded into the action plan to demonstrate that the case manager is acting with urgency. Optimally, they need to be logical and rationalized.
What are follow-up tasks, FTIs, PSD and other action items.
This Athena Page has information on topics such as Pharmacology, appropriate treatment, specific diagnosis and the Senior Consultants of Mental Health (among other things).
What is The Mental Health Landing Page.
The optimal review on an APPROVED STD Mental health claim is conducted by this Sun Life Staff.
Who is the Director of Mental Health *Bonus points for naming all 3 (Dr. Sam Mikail, Valarie Legendre and Carmen Bellows)
According to the Mental Health Landing page, these resources can be provided to plan members who are struggling with mental health symptoms. They are a great way to demonstrate we are acting with urgency while a Plan Member is awaiting optimal treatment.
What are the "On-Line Resources"
These two people are available for clinical and case management consultation. They can assist with finding community resources or other treatment options.
Who are the Senior Consultant of Mental Health and the Mental Health CMC. *Bonus points for providing their full names- Nicola Forde, SCMH and Kassandra Krauss (MH CMC)
When possible, DCMs should be engaging this group of people as part of the action plan and ensuring optimal treatment plans. Tasks should be set within the action plan at logical times to demonstrate this.
Who is the third party providers (counsellors, therapists, psychologist etc.)
According to practice, DCMs have the responsibility to impact both the non-medical and medical versions of these things. Specific suggestions on how to influence these things are listed on the same practice page.
What are Influencing Factors.
On mental health claims, this form of communication is encouraged- especially following a phone call where expectations have been set with the plan member.
What is an email follow-up. *Bonus points for identifying that all expectations should be clearly documented in the email for the Plan Member to see.
For mental health claims, creating a collaborative rapport with this group of people early on in the claim is vital for optimal case management.
What are Third Party Providers. Will also accept counsellors, therapists, psychologist, psychotherapist etc.
Ensuring this has been optimized as soon as possible, has a direct impact on the plan members overall recovery and ability to return to work within the STD period.
What is treatment.
Who are DCMs
What are community resources, online resources, and treatment recommendations.
Plan members should have this tool / documentation reviewed with them as a way to set expectations and involve the plan member in their own recovery.
What is the action plan.
Anticipating barriers by having a solid understanding of these things, is key in proactive case management as they are likely the reason a plan might derail. Plans to address these things should be incorporated into your action plan.
What are Influencing Factors.
Providing resources such as links to waitlists for attending physicians offices, local CMHA offices, Lumino Health, or other community resources to address various influencing factors is an example of this case management principle.
These types of discussions should be occurring regularly with the plan member, and as early as the initial claim approval phone call.
What are Return-to-Work & / or VOC discussions.
Funding treatment during SalCon claims can be challenging, national programs provided by this organization can be recommended to plan members. The programs are free of charge to the community and usually only require a self-referral.
Who is the Canadian Mental Health Association (CMHA).
On a mental health claim, setting a forecast date and advising the plan member to submit medical if they are unable to return to work- with no other follow ups or intervention would be considered this type of case management approach.
What is a "Wait-and-See" approach. (This approach is discouraged on mental health claims)
As part of optimal case management, this strategy should be used between the DCM and the plan member during an FTI to promote recovery and reactivation.
What are S.M.A.R.T goals
Establish trust, demonstrate empathy and compassion, Engage the member in their customized case management plan, Empower the member to be their own advocate with their employer and physician(s), Focus on the earliest opportunity for return to work...Are direct quotes from this case management principle.
What is Empower the plan member
Although determining this can be challenging in mental health claims, this should be established by considering treatment timelines, influencing factors, and logistical policy needs.
What is the Forecast Date.
Statistics have proven that this intervention / person is the leading driver to successful recoveries on a claim.
Who is the DCM and their ability to empower the plan member during FTIs.