Before You Label an Injured Worker “Non-Compliant,” Ask Why

The Case Manager

Many times, healthcare professionals label patients non-compliant. In this article, I wanted to talk about non-compliance, what it means and what the nurse case manager can do in a workers compensation case when the patient is labeled non-compliant. 

Non-compliance in healthcare traditionally means a person does not follow a doctor's medical advice or treatment plan. A more progressive term used is non-adherence. Non-adherence describes when a person misses treatments by accident or due to outside barriers—such as high medication costs, confusion over instructions, or lack of transportation—rather than active defiance. 

Before we label an injured worker “non-compliant or non-adherent” we need to ask why. “What is preventing this person from following the plan of care?”

Here are some of the most common barriers seen in the area of the workers’ compensation arena and what a nurse case manager can do to decrease the barriers causing non-compliance.  

1. The injured worker does not understand the plan

Medical instructions can be complicated, especially when someone is dealing with pain, medications, multiple providers, or unfamiliar medical terminology. They may leave the appointment thinking they understand what they are supposed to do, only to discover later that they don't.

What the case manager can do:

• Ask the injured worker to explain the treatment plan in their own words. This is called teach back and can be a good strategy to use to ensure the patient understands the plan of care and their role in the plan. 
• Clarify confusing instructions with the healthcare provider before you leave the appointment. 
• Reinforce the purpose of the treatment, therapy, medication, or diagnostic testing and why each is necessary. 
• Make sure everyone on the team gives consistent information. This is why case managers need to talk to the providers and review documentation to make sure everyone is on the same page. 
• Follow up after the appointment to see how the injured worker is doing and if they have questions on the plan of care.

2. Transportation problems

Another area that can cause compliance or adherence to the plan of care is that the injured worker may miss physical therapy, physician appointments, or diagnostic testing because they don't have reliable transportation. Their injury may also prevent them from driving. Many people are too proud to admit their care is broken down or unreliable or that they don’t have money for an uber or public transportation. 

What the case manager can do:

• Identify transportation barriers early. Asking how will you get to your appointments. 
• Determine whether transportation benefits or services are available under the applicable workers' compensation system. 
• Coordinate appointments, when possible, to reduce unnecessary trips. Also setting up the appointments allows you to know when they are so you can attend if you do onsite case management or follow up if you do not. 
• Explore whether appointments can be scheduled closer to home or at a time when the injured worker can go. Many injured workers need to work about their families schedule so be mindful of the caregiver’s time as well as the patient. 

3. Financial and social pressures

Although workers' compensation may cover authorized medical care, an injured worker can still experience significant financial stress. Household bills, reduced income, childcare, housing concerns, and other pressures can compete with treatment. Again, an injured worker my not bring this in ‘normal conversation’ but if you ask, you may learn of the challenges they are facing. Also talking to the caregivers can unveil this type of issue so building a relationship with the family members is important. 

What the case manager can do:

• Ask about concerns outside the medical treatment plan. 
• Identify available community or employer resources when appropriate. 
• Communicate concerns to the claims professional. 
• Recognize that financial stress can affect concentration, motivation, and the ability to manage care. 

4. Fear of treatment or fear of reinjury

An injured worker may avoid therapy because it hurts or because they are afraid that participating will make their injury worse. They may also be afraid of surgery, injections, medications, or returning to work. Finding this out early is important so that the doctor is aware and might offer an alternative approach to a situation. 

What the case manager can do:

• Ask what specifically concerns the worker. 
• Encourage the injured worker to discuss those concerns with the treating provider or their therapists. Many workers trust their therapists as they have seen similar conditions, and they may support the treating physician recommendation or an alternative treatment based in their experience. 
• Help distinguish expected discomfort from warning signs that require medical attention. Education the injured worker what to look for so they don’t put off calling the doctor if/when a complication comes up. Many people don’t want to ‘bother’ a doctor. They need to know that the doctor does not know what the patient does not tell them. Repercussions could be serious so helping them communication is important. 
• Reinforce the purpose and goals of treatment without minimizing the person's concerns. 

5. Pain and other symptoms

Someone experiencing significant pain, fatigue, sleep problems, or medication side effects may have difficulty following a complicated treatment plan.

What the case manager can do:

• Determine whether symptoms are interfering with participation. 
• Communicate concerns to the treating provider. 
• Look for opportunities to simplify scheduling and coordination. Maybe the patient is better in the AM vs. the PM. Make appointments when it is better for the patient. 
• Avoid assuming that missed care automatically represents unwillingness to participate. Case managers who establish good communication with their patients decrease this issue. 

6. Mental and emotional barriers

An injury can affect much more than the physical body. Anxiety, depression, fear, frustration, anger, isolation, and uncertainty about the future can all affect a person's ability to participate in care.

What the case manager can do.  

The case manager does not need to diagnose a mental health condition. However, the case manager does need to recognize when emotional issues may be affecting recovery and communicate those concerns to the appropriate members of the healthcare team.

7. Cultural, language, or health-literacy differences

The worker may understand the words being used but not understand what they mean in the context of their care or language or culture. Language differences, cultural beliefs, health literacy, and previous experiences with healthcare can all influence how someone responds to treatment.

What the case manager can do:

• Use qualified interpreters when needed. 
• Avoid medical jargon. 
• Ask open-ended questions. 
• Use the teach-back method rather than simply asking, "Do you understand?" 

8. Conflicting information from the healthcare team

This is particularly important in workers' compensation. The injured worker may hear something different from the physician, therapist, employer, the claims professionals, and case manager.

When everyone is giving different messages, the worker may appear "non-compliant" when they are actually confused.

What the case manager can do:

• Bring the team together. 
• Clarify the treatment plan and restrictions. 
• Make sure the injured worker understands who is responsible for each part of the plan. 
• Address conflicting information quickly. 

9. Work and family responsibilities

An injured worker may have children to care for, an aging parent, another family member who depends on them, or other responsibilities. Appointment times may conflict with these obligations.

What the case manager can do:

• Ask about scheduling challenges rather than assuming missed appointments reflect a lack of interest. 
• Help coordinate appointments when possible. 
• Look for patterns in missed appointments. 
• Discuss whether scheduling changes could improve participation. 

10. Lack of trust

Perhaps one of the most overlooked barriers is trust.

If the injured worker believes the healthcare system, employer, insurer, or case manager does not believe them, they may become defensive or disengaged. Once trust is lost, even a reasonable treatment plan can become difficult to implement.

What the case manager can do:

• Listen without immediately judging. 
• Explain their role clearly. 
• Follow through on commitments. 
• Acknowledge concerns even when they cannot change the outcome. 
• Focus on the injured worker's goals as well as the goals of the system. 

So, the bottom line is before You Label an Injured Worker "Non-Compliant," Ask Why! 

Have a good week! 

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