Choosing the right path

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Accurately reserving money for claims is something insurers will always strive to perfect. But when it comes to using rehabilitation for personal injury claims there is no set formula. Dr Ed Bonikowski looks at whether care pathways hold the answer

Insurance, by its very nature, is based around the premise of predictability. Just as the insurance industry has developed highly sophisticated models around which to base drivers' car insurance premiums, so it aspires, in the context of personal injuries, to have a set formula that will allow it to reserve sums of money to accommodate these claims.

So far, the rehabilitation sector has been slow to produce 'off-the-shelf' formulas to provide insurers with what they are looking for.

The reasons for this are valid because, unlike the NHS, where care pathways are intrinsically seen as a way of defining services, the cases that rehabilitation providers have to manage are far more complex and have the added variable of being part and parcel of a litigation action. However, the environment is changing and rehabilitation providers and insurers are slowly moving towards a consensus - or at least the start of one.

Integrated care pathways are useful because they help reduce unnecessary variations in patient care and outcomes. They provide explicit standards, which specify the interventions required for the patient to progress along the pathway, placing them against a timeframe measured in terms of days, weeks, milestones - and also cost.

A classic example of where a care pathway can come into its own is for patients requiring a total hip replacement. In fact, care pathways work brilliantly for elective surgery, where the operation is pre-booked, planned and where there are few, if any, variables on top of the condition being treated.

Within the context of PI claims, integrated care pathways will facilitate multi-agency communication and collaboration and empower claimants, employers and treating teams to meet the requirements of clinical governance.

So, what would be the end point of an integrated care pathway within the PI sector?

In most cases, this should be a sustainable return to work or, in the case of exceptional catastrophic injuries, it could be a care regime based on the claimant achieving maximum independence.

At the lower end of the scale, the rehabilitation sector has achieved significant improvements in managing whiplash injuries - many of which can be reasonably predicted in terms of claims management.

However, care pathways for more severe bodily injuries remain elusive. This is because, unlike the NHS, rehabilitation providers are working within a broader bio/psycho/social model, which more often than not will require considerable investment in addressing future vocational options.

The very context of the intervention can be a key influence, namely the injured party is placing a claim against the perceived cause of the accident. Research indicates that psychological adjustment after an accident is impaired by repeatedly reporting the accident and the events surrounding it. The claimant's motivation to engage in the rehabilitation programme and the perceived impact that returning to work may have on their 'payout' are key psychological factors that would impact on any integrated care pathway.

What also has to be accepted is that, for example, no two people who break a leg are the same. One might be a manual worker with few other vocational skills, while the second person may be a sedentary worker already with underlying medical conditions. Their care pathways would need to follow different routes and the challenge for the rehabilitation provider is to address their individual circumstances.

So is this mission impossible? Are care pathways an elusive Holy Grail and should rehabilitation providers simply throw their hands in the air and give up? The NHS is increasingly moving towards specialisation and more clearly delineated lines of care - and rehabilitation providers should not buck this trend.

It is only right that the services provided should be monitored, along with the work of case managers and the wide range of clinical and vocational therapists who work on programmes.

Insurers and lawyers need to know that the rehabilitation provider they are working with will deliver the quality of service their client deserves. They also need reassurance that the rehabilitation service itself is not being dragged out unnecessarily.

It is only by setting benchmarks that insurers will be able to compare processes and outcomes across rehabilitation providers. Kynixa, for one, is looking to produce clinically verified and statistically based care pathways, which will account for the variable demographics that rehabilitation providers have to work within such as age, gender, type of fracture, similar job type, good pre-accident work record and similar social support as well as comparative length of time from accident to NHS treatment through to referral to the rehabilitation provider.

These variables will be factored into any care pathway - with the pathway itself verified by independent clinicians. Integrated care pathways can be developed for personal injuries - and it is time rehabilitation providers accepted the inevitable and saw them as a genuine opportunity to raise standards in rehabilitation.

Rehabilitation is moving forward at a rapid pace within the UK and the speed of change means it is essential there is a system in place that sorts the wheat from the chaff and provides a frame of reference within which insurers and lawyers can make decisions with confidence. Developing care pathways certainly provide part of the answer.

- Dr Ed Bonikowski is a consultant in rehabilitation medicine and founder of rehabilitation services provider Kynixa.

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