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Division of Federal Employees' Compensation (DFEC)

Field Nurse Handbook

Part 3


Part 3 - Early Disability Management Field Nurse Assignments

Paragraph and Subject

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FNHB Trans. No.

Table of Contents

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1. Overview

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2. Early Disability Management FN Assignments

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3. Interventions

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4. Common/Frequent FN Contacts

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5. Other FN Contacts

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6. EA Nurses

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7. Timeframes

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8. Dual Tracking

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1. Overview. There are several types of assignment categories associated with Field Nurse (FN) services which may have varying timeframes and/or expenditure limits. However, the primary focus of the OWCP Nurse Intervention Program (NIP) is the Early Disability Management phase of case management, when nurse interventions are concentrated on expediting medical management (facilitating medical care to promote recovery from the work injury) and return to work (RTW) efforts.

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2. Early Disability Management FN Assignments. After the Claims Examiner (CE) accepts an injury claim and determines eligibility for medical and/or compensation benefits, s/he will refer the case to the District Office Staff Nurse (SN) for FN assignment if the injured worker (IW) is either off work or working in less than full duty capacity. The SN then reviews the referral and proceeds with the assignment of a FN.

a. FNs are expected to have face–to–face interactions with the case participants (the IW, employing agency (EA) and medical providers). However, the SN may determine in rare situations that the case assignment is better suited for only telephonic nurse intervention activities when, for example, the IW resides in a remote location. In these situations, the SN will specifically designate the assignment as a "telephonic assignment only" in the documentation provided to the FN at the time of assignment.

b. Assignment of a particular FN may be based on special needs/conditions of the case. For example, the need for a FN with specialized skills (ASL, foreign language, expertise in psychological, neurological, and/or catastrophic injuries, etc.). In addition, if a specific FN had been previously assigned to an IW's case (or a previous injury case), assignment of that same FN may be beneficial based on pre-existing knowledge of the injury and/or established nursing relationships with the IW and his/her medical provider(s).

c. The FN is advised of an assignment via issuance of an assignment packet which should contain, at a minimum:

(1) Case specific documents and contact information that will assist the FN in becoming familiar with relevant case issues, including a Statement of Accepted Facts, if available, and the referral form (OWCP-57 or equivalent);

(2) An indication of the goals and objectives specific for the nurse intervention activities (issues to address with the treating physician, documentation of a treatment plan, obtaining work tolerance limitations, etc.), and any pending adjudicatory issues (whether the CE is developing an additional medical condition not yet approved, has referred the case for a second opinion medical examination regarding a surgery request, etc.);

(3) Authorized timeframe for nurse case management intervention services (e.g. date of assignment and date of scheduled closure); and

(4) A letter of authorization for FN services.

d. Additional communication pertaining to the case assignment is at the discretion of the District Office (e.g. a pre-assignment contact from the SN).

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3. Interventions. A nurse intervention may be defined as a single action or a series of actions designed to achieve a desired outcome. OWCP expects the FN to organize and coordinate nurse intervention activities in the most efficient and cost effective manner. The interventions must address the goals and objectives of the individually assigned case and be performed within prescribed timeframes and expenditure limits.

a. FN interventions should be planned based upon the outcomes expected during the course of a case assignment.

b. The FN should assess and re-evaluate intervention actions on a continuing basis to ensure that the specific case issues are being addressed.

c. The FN should ascertain through the assessment and evaluation of his/her nurse intervention activities that the case is progressing towards resolution of the stated goals and objectives; and s/he should adjust nursing case management plans to coincide with any changes in the case status.

d. OWCP expects the FN to develop a cooperative, non–adversarial working relationship with all involved parties; encouraging all recognized stakeholders to actively participate in the nurse case management plan, medical treatment plan, and resolution of issues that may impact the medical recovery and RTW efforts. To that end, the FN is expected to:

(1) Keep the CE, EA and treating provider(s) apprised of any relevant changes in the status of the case as they occur,

(2) Follow CE and/or SN directives, and

(3) Make recommendations to the CE for ongoing case management progression.

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4. Common/Frequent FN Contacts. Timely, well-coordinated communications and contacts are essential for promoting purposeful decision making, proactive interventions, and achieving Disability Management goals. The FN should conduct the following kinds of intervention activities as part of his/her nurse case management plan for each case.

Reference Part 6 of this handbook for documentation and reporting guidelines for FN intervention activities and required communication and contacts with the CE and/or SN.

a. Contact with the IW. The FN should contact the IW a minimum of 2 times per month, or more frequently as case activities or medical status warrant. The FN should outline the outcome(s) of interventions performed to date and evaluate the IW's progress toward medical recovery and RTW.

Contacts with the IW are expected to be a combination of face-to-face and telephonic encounters. Face– to–face encounters may include, but are not limited to, attending key medical appointments with the IW and/or requesting that the IW be present during the FN meetings with the EA at the work site to discuss RTW opportunities and light duty work.

(1) All face-to-face encounters with the IW must occur in an accessible location. See FECA Bulletin 12-05 (Handling Requests for Communication Assistance, Accommodations, and Modifications Under Federal Disability Nondiscrimination Law by Claimants and Others in the Federal Employees' Compensation Act (FECA) Adjudicatory Process), which is available on DFEC's website.

(2) Whether a particular location or facility may be considered "accessible" is determined pursuant to the accessibility standards that are applicable to Federal facilities (as well as to facilities designed, built, altered, or leased with Federal financial assistance). See http://www.access-board.gov/aba/index.htm.

b. Contact with the EA. The FN should contact the EA a minimum of 1 time per month, or more frequently as case activities or RTW efforts warrant. It's imperative that the FN maintain open communication with the EA regarding the IW's readiness for RTW. This should include discussing the availability of light duty work accommodations, obtaining a written job offer, performing pre- and/or post-RTW job site evaluations and visits; and follow-up telephonic contacts to monitor the success of the RTW effort. Specifically, the FN should:

(1) Consider the primary point of contact for the EA as the Injury Compensation Specialist (ICS). The local duty station supervisor may be contacted when the ICS is unresponsive or unavailable; however, the ICS should be kept informed of the communication(s) and outcome(s);

(2) Obtain from the EA ICS a copy of the IW's date of injury position description and the physical requirements of the job and submit those to OWCP;

(3) Inquire about the EA's ability to provide light duty work and meet with key EA personnel to assist in identifying such potential light duty work. This meeting should include the EA ICS and/or the local duty station supervisor. This meeting may also be attended by the IW and the EA nurse, if there is one. Having all of these participants involved in the RTW discussion is an effective approach for identifying light duty positions to accommodate the IW's documented work tolerance limitations; and

(4) Provide the EA ICS with medical documentation to support the IW's current work status (via Forms CA–17, CA-20, OWCP–5, or any other medical documentation reporting specific work tolerance limitations) as soon as it is received.

c. Contact with Medical Providers. The FN should take a proactive approach in his/her collaboration with the treating provider(s); not only as a health care professional but also as a liaison for the OWCP NIP. The FN should consider the following when planning on-site and telephonic contacts with medical providers. The FN should:

(1) Attend all key medical appointments where it is anticipated that a significant change in medical/case status may occur (e.g. issuance of a work release, documentation of work tolerance limitations, changes in medical status or treatment plan, determination of maximum medical improvement (MMI), discharge from care, etc.);

(2) Discuss treatment options, to include a referral to a specialist or other health care service provider, as necessary;

(3) Assist the IW with scheduling medical appointments;

(4) Obtain relevant medical documentation and treatment notes for submission to OWCP;

(5) Obtain updated treatment plans from the treating physician along with the anticipated work release and/or MMI date;

(6) Provide the treating physician with a description of the physical requirements of the IW's date of injury job and request a work release to return to the full duties of the job, if applicable, or advise the IW and the treating physician of the availability of light duty work. If the IW is currently working in a light duty assignment, the physical requirements of the light duty assignment should also be provided to the treating physician;

(7) Provide the treating physician with relevant forms as needed (e.g. OWCP-5 or CA-20), which can be found on DFEC's website at: http://www.dol.gov/owcp/dfec/index.htm;

(8) Assist in the authorization process when medical services are requested by the medical provider(s). (See Part 8 of this handbook for a description of the medical services that a FN can authorize.);

(9) Assist the medical provider(s) in understanding issues related to the release of medical information and authorizations, for example, HIPPA vs. the Privacy Act. (See Part 10 of this handbook for additional information.); and

(10) Conduct telephonic follow–up to obtain routine medical progress updates.

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5. Other FN Contacts. During the course of any nurse case management assignment, the FN may be approached by other entities requesting case-related information and/or documentation. The FN does not have discretionary authority to independently release documents or enter into case discussions with persons not specifically identified as a contributing party to case activities by OWCP. Such decisions are the purview of the OWCP. Specific guidelines exist to assist the FN in responding to these entities. These guidelines apply during the course of any nurse case management assignment, regardless of type.

FN responsibilities related to communications outlined in this paragraph are also addressed in Part 10 of this handbook. If questions arise, the FN should follow the SN instructions to ensure compliance with, and implementation of, the above referenced protocols.

a. Contact with Legal Representatives. Although the FECA is an exclusive remedy for Federal IWs, they may have legal representation. As all case-related information and documentation is the property of the DOL/OWCP, there exist specific policies regarding communications and contacts with legal representatives and the handling of case information.

It is the OWCP policy that all requests for medical and/or other case file documentation from a legal representative be made in writing to the OWCP. The FN should not release case documentation to a legal representative, but direct him/her to contact the responsible CE. The FN may, however, discuss case-related issues with the IW while a legal representative is present.

b. Contact with Agency Investigative Units/Office of the Inspector General (OIG). DFEC may receive requests from the OIG as it performs audits, evaluations, inspections and investigations.

DFEC has established protocols to ensure all such requests are handled appropriately. The FN should not respond directly to a request from the OIG, and instead should advise the OIG representative to contact the CE.

Note - While a FN is a contractor for OWCP/DFEC, the Department of Labor's Office of the Solicitor cannot provide legal advice to a FN. See Part 1 of this Handbook, paragraph 2a(4).

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6. EA Nurses. Several EAs have developed their own nurse intervention programs. Whereas the concept of early intervention is in keeping with current case management techniques, the activities of these EA nurse programs should be coordinated with the OWCP adjudicatory and case management activities.

a. Specific guidelines established for EA Nurses and EA Nursing Programs include:

(1) The IW's participation in an EA nurse intervention program is voluntary;

(2) An EA nurse intervention program is limited in its scope and authority, and has no jurisdiction over issues under the purview of OWCP;

(3) OWCP FN intervention activities/actions supersede the EA actions and the EA nurse should suspend any independent actions during the course of OWCP nurse intervention; and

(4) OWCP officially recognizes only one EA point of contact responsible for coordinating compensation and RTW efforts (e.g. the EA ICS or EA duty station supervisor).

b. Communicating with EA Nurses. As noted above in 6a(4), the FN should only be communicating directly with the identified EA point of contact. The EA nurse is not recognized as a point of contact for case-related communications, however, the EA nurse can act as an EA resource during RTW conferences. The EA nurse may assist the EA and FN with issues related specifically to the RTW effort and identification of light duty work (as well as identification of any barriers the IW may encounter upon RTW). The FN may recommend to the EA point of contact that the EA nurse be made available to participate in RTW discussions and work site evaluations; however, such RTW discussions and work site evaluations should not be delayed in order to accommodate the EA nurse's schedule.

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7. Timeframes. The Disability Management process involves specific timeframes for interventions by not only the FNs, but also the CEs and Vocational Rehabilitation Counselors, if applicable. As a result, each FN case assignment is time sensitive.

a. Time management. The FN should consider the following when developing individual nurse case management plans:

(1) FECA is a workers' compensation program focused on RTW efforts and is not a medical insurance or retirement plan. All efforts should focus on recovery from the accepted work-related injury and establishing work tolerance limitations as soon as medically feasible with the anticipation of ultimately obtaining a release to the full duties of the IW's date of injury job.

(2) Nurse interventions and activities should be planned on a time sensitive basis that reflects forward progression of the IW's medical status and recovery. This requires proactive nurse case management activities.

(3) Nurse case assignments are finite. The medical goals and treatment plans, as well as the RTW efforts, should be advancing throughout the course of the established nurse case assignment timeframe so as to obtain successful resolution of the specified goals and objectives.

b. The initial assignment period is generally 120 days. This begins with the date of the assignment.

(1) The 120 day assignment period includes all nurse case management intervention activities focused on the IW's medical recovery and actual RTW.

(2) Unless otherwise specified during the course of the FN case assignment, the FN will be expected to close his/her nurse case management services at the end of the 120 day time period. See sections c and d below for more detailed information on extensions.

(3) In addition to the initial 120 day timeframe for FN case management, there are also expenditure limits associated with the authorized nurse service timeframes. These will be outlined to the FN at the time of assignment.

c. RTW Monitoring. The FN is afforded time to monitor the IW's transition back to work. This time may or may not be inclusive in the initial 120 day assignment authorization, depending on the date of the actual RTW.

(1) Light Duty monitoring. The FN should generally provide follow-up and oversight for a period of 60 days after the IW has returned to work in a light duty position. However, depending on the circumstances of the case, there may be additional nurse case management services requested by the CE after a light duty RTW (i.e. when a full duty release is imminent or permanent work restrictions are expected to be outlined in the near future). As a result, the FN should confer with the CE immediately upon the IW's RTW to determine specific follow-up details and post-RTW interventions. See Part 6 of this handbook for further details.

(2) Full Duty monitoring. The FN should generally provide follow-up and oversight for a period of 30 days after the IW has returned to work in a full duty capacity.

(3) If there is a specific reason for any additional monitoring period following a RTW, the FN should provide appropriate rationale and request authorization from the OWCP.

d. Extensions. The OWCP may extend nurse intervention services beyond the initial 120 day nurse case management assignment period. However, there must be a substantial reason (a significant change in case status is expected, a RTW is imminent, etc.) for an extension to be authorized. Extensions may be recommended and/or requested by the FN or they may also be initiated by the CE.

(1) Extensions may be authorized in 30 and 60 day increments.

(2) Extensions beyond the initial 120 days of nurse case management assignments are separate from authorized RTW monitoring periods. See section c above for RTW monitoring periods.

(3) The extension should be discussed and authorized prior to the end date of the established nurse case management timeframe.

(4) Extensions require OWCP written authorization, which documents the case file with the necessary rationale regarding the need for ongoing FN services. These extension authorizations must be communicated to the FN.

(5) Extensions beyond 120 days, up to 180 days, may be authorized by the CE.

(6) Extensions beyond 180 days (120 day initial authorization + 60 day extension authorization) require OWCP Supervisory authorization, including rationale regarding the need for ongoing FN services.

(7) All authorized extensions should include a written confirmation regarding the scheduled nurse case management closure date.

e. Change in Work Status. In the event that the IW is unable to continue in his/her work status during a RTW monitoring period and stops working or decreases the number of hours s/he is working, the CE needs to determine whether or not the work stoppage is related to a recurrence of the accepted work injury.

The actions required of the CE related to these types of changes in work status may impact the FN assignment and authorized timeframes. As a result, accurate and timely notification of such changes in work status is essential so that these actions may be appropriately coordinated.

(1) The FN should notify the CE and/or SN within 48 hours of any work
stoppage during the RTW monitoring period.

(2) The FN should notify the CE and/or SN within 48 hours of a downgrade in work hours occurring during the RTW monitoring period (e.g. the IW initially RTW 8 hours per day, however, s/he subsequently was downgraded by the treating physician to working no more than 4 hours per day).

(3) The FN should seek guidance from the CE and/or SN related to continuation of nurse case management services at the time such an event is reported.

f. OWCP may direct the FN to close his/her nurse services at any time during the nurse intervention process.

g. See Part 6 of this handbook for the type of documentation that is required when requesting an extension of services.

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8. Dual Tracking. Based upon the circumstances of a case (e.g. when it is apparent that the severity of an IW's work injury will result in permanent partial disability restricting him/her from returning to the full duties of his/her date of injury job), the FN may sometimes be assigned to work in conjunction with a DFEC Vocational Rehabilitation Counselor (RC) to facilitate a RTW with the IW's previous EA. This partnership may promote a quicker RTW. Through team-work, dual tracking can assist both the IW and EA with exploring reemployment options that may not have been originally considered.

a. Dual tracking may be appropriate when:

(1) The EA is having difficulty identifying a suitable position which accommodates the IW's work restrictions;

(2) Clarification of work tolerance limitations is needed;

(3) Assistance is needed to determine whether there are reasonable accommodations which could make a RTW possible; and/or

(4) Assistance is needed to determine whether there are other jobs within that agency that the IW could perform.

b. Complementary roles. During dual tracking, the FN and RC have different, but complementary, roles.

(1) The FN will focus on the medical aspects of the case in order to obtain stable and well-defined work restrictions, and to coordinate any necessary medical intervention.

(2) The RC will concentrate on the vocational aspects of the case. The RC may also assist with facilitating medical rehabilitation interventions (Functional Capacity Evaluation, work hardening, etc.), if needed, to clarify work tolerances and restrictions and provide additional assistance with the RTW efforts.

c. Lines of Communication. During dual tracking, the FN will be the designated point of contact with the treating physician and any other medical providers. Any questions that the RC may have regarding medical issues should go through the FN.

The RC and FN, along with the SN and OWCP Vocational Rehabilitation Specialist (RS), can decide on the best approach for working with the EA in order to facilitate streamlined communications and the best outcome.

Unless otherwise authorized, the FN's involvement in the case will usually end once stable and well-defined work restrictions are established. RC interventions will continue as needed and as authorized by the RS.

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