Transitional duty, case management slash costs
November 1, 2002 7 minutes read
Nurse practitioner produces big results
You don’t have to start big to end up with a highly successful occupational health program. Just ask Trudy J. Rumann, MS, RN, FNP, COHN-S, Marriott International Inc. occupational health nurse practitioner in Scottsdale, AZ. From a modest 300-square-foot office in a senior living services facility, in 10 years she has grown her department to the point where it now has its own 1,100-square-foot facility, with staff that include a full-time administrative assistant, a full-time OSHA compliance manager, a part-time nurse practitioner, and a part-time physical therapist.
The department has also produced results: In its first six months of operation, there was a 60% drop in workers’ compensation indemnity costs.
Rumann credits her success with three key strategies: Expert clinical care, transitional duty, and case management. "Transitional duty is paramount to returning injured workers to their jobs," she explains. Injured workers are accommodated with a job suited for their physical restrictions. As their recovery progresses, the job moves toward resuming full duties.
"We approach every new injury with the attitude that the associate will return to work as soon as possible," she continues. "Part of their initial treatment is explaining that they are a valued worker and we need them in the workplace. It takes diligent communication between the nurse practitioner and the manager to keep the transitional job moving forward."
Rumann says this approach is successful because the associate understands that his or her well-being is her top priority. By asking the right questions, she determines if there are factors outside the workplace hampering his or her recovery. "Sometimes people need help navigating the health care system or to be aware of community resources," she explains. "These are all important pieces of caring for the whole person, not just the employee."
Corporate buy-in a key
She notes that the program got its impetus from corporate buy-in. In spring, 1992, businesses in the area were all experiencing extremely high workers’ comp costs. The hotel general managers got together and set up a problem-solving subcommittee. "They decided they didn’t need a doctor, but a nurse practitioner."
The individual at Marriott who was selected to guide the process was also a nurse practitioner, who knew that the Arizona state laws governing nurse practitioners were among the best in the nation. "We have a broad practice act," Rumann explains. "We can diagnose, prescribe, dispense, treat, order tests, and case manage, which is a piece doctors often miss. Yet it’s so important in occupational health and provides for a really good relationship with the patient."
She was hired as Marriott’s first nurse practitioner in April 1992.
Help from the top
In spring 1993, Bill Marriott visited the office, which at the time used a curtain to separate the lobby from the treatment area and had an answering machine instead of an assistant. "He came into to my little office, and we sat down and talked knee to knee," Rumann recalls. "He was so impressed that he asked, Is there anything I could do for you?’" She replied that she could really use a more professional setting, so that highly confidential discussions could be held more comfortably. "He said, Make it happen.’"
Were all the subsequent expansions similar rewards for a job well done, or did Rumann need to make a case and demonstrate a need? "First, I would go to my occupational health director in corporate," she explains. "A key to this is that my position is a corporate position — I’m not a hotel nurse. The other persons to whom I report are the general managers of the strategic business units that I serve."
So, for example, when she wanted to replace her answering machine "assistant," she said she could keep a human being busy three hours a week — a modest request. "The corporate director looked over our numbers and said OK, but said we should strictly adhere to those hours," says Rumann. "Pretty soon, however, I requested and got six hours a week, and then nine. When we moved into our current offices it became a 40-hour week. They realized the number of people needing appointments required that assistance, and that professional impression."
As time went on, it became increasingly difficult for her to get away for meetings and continuing education seminars. "We were able to contract with a nurse practitioner for half a day or a whole day a week," she says. "It kind of grew, and everything supported that — we were able to show the number of accidents, the number of claims that were open, the number of case management contacts, and so on. I was working some 50- to 60-hour weeks, and our number of associates (3,500) was three times what a hotel nurse would have — and they don’t do the medical treatment. A good case was made, I continued to ask for more help, and I’ve never been refused."
A comprehensive service
Today, Rumann’s department offers virtually every form of occupational health service imaginable. They include:
• Workers’ comp injury treatment and management.
• Nonoccupational health services: Managers are given permission to call the department within the first 90 days of employment (when associates are not yet covered) if the patient has a minor problem such as a rash, stomachache, or the flu. "We can often slip them into our schedule, which really makes Marriott look good," Rumann notes. "Then they take out their pocketbook and we tell them they don’t have to pay anything — It’s courtesy of your property and Mr. Marriott!"
• Physical therapy: PT services are provided through a sister office next door. "We invited a PT we really liked into that space, so associates can be treated immediately," Rumann explains.
• Disability and return-to-work coordination programs.
• Immunization programs: These include Flu, hepatitis B and tetanus.
• Mental health referrals for chemical dependency or psychiatric services: "Our associates appreciate the professional confidences they receive," says Rumann.
• "Ask the nurse practitioner": If someone has a health question, they can call the office and speak with one of the staff.
• Case management.
• Prescription drugs through an on-site dispensary.
• Nurse practitioner preceptor site: Students from the Arizona State University College of Nursing and the University of Phoenix College of Nursing have preceptorships at the facility.
• OSHA services: Rumann says that Barbara Goldstein, the area OSHA programs manager, (who has both a theater and a safety background) "mesmerizes people. [The employees taking her seminar] think safety is the coolest thing around."
• Stretching programs.
• Multilingual services.
Rumann says that sometimes little things can make a big difference. "When we see somebody for the first time, we often give them reusable frozen polar packs, which we keep on hand for sprains and strains," she says. "As a result, people end up taking them home, using them, and maybe taking one to work with them and eventually they end up at a picnic."
Another strategy Rumann employs, which she describes as "absolutely necessary" in a corporate practice, is three-way calling. "This is how you avoid triangulation," she explains. "What we do at the clinic visits, so that no one is confused, is that we call up the manager for the department while the associate is here. The nurse practitioner gets on the speakerphone; they discuss the condition of the associate and reassure the manager, for example, that the associate is OK. The manager might say something like, We’re glad you’re alright and we have some filing to do, and we could really use your help.’ The associate is beaming because they feel needed. We further explain to them that instead of using a sick day or a vacation day for a minor injury, they can sit at work for a day or two doing something to help their department and then use the sick days and vacation days for what they were really intended to cover."
As a result, the clinic — like other hotel-based nurse programs within Marriott — has demonstrated a frequency reduction of 30% to 50%, a drop in absenteeism by 30% with case management, and a cost reduction of 20%-30%. Annualized savings return on investment is 4-to-1, or 5-to-1, depending on the nursing model utilized. "Litigated cases have decreased 30%-50% on average, and I have the lowest number of litigated cases in all of Marriott," says Rumann.
Rumann offers this advice for someone just launching an occupational health clinic: "One thing I’d encourage them to do is be persistent, keep track of their information, document their cases, how many visits and so on, and absolutely provide a monthly report to their manager. That way, by keeping everyone informed, they will begin to see trends when those dollar savings grow."
[For more information, contact: Trudy J. Rumann, MS, RN, FNP, COHN-S, Occupational Health Nurse Practitioner, Marriott Occupational Health & OSHA Services, 7125 E. Lincoln Drive, Suite A-201, Scottsdale, AZ 85253. Telephone: (480) 443-4658.]
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