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Home » Health Professionals » General Information » Managing Complex Cases

Managing Complex Cases



The first two things to do when managing “complex cases” is understanding:

  1. What  is meant by complex
  2. Why they are complex

Approximately eighty five precent of work injuries resolves within a couple of weeks.  They are simple in that it is likely that:


  • The injury is relatively minor, i.e. a simple sprain, or cut -  A psychological injury such as a trauma  from  an incident like an armed hold up is processed and dealt with through debriefing and some short term counselling and no residual problems remain
  • There is one injury only -  not multiple injuries
  • The diagnosis is straight forward
  • The treatment is straight forward - it may require a brief period of rest or reduced activity such as selected duties
  • The injury is clearly directly related to work


As well the injury being relatively minor and treatment straight forward it is likely that:


  • Environmental factors that could have had an effect on the injury occurring  are insignificant  -  such as family difficulties / pressure were not relevant to the injury occurring , treatment progress, or the workers motivation to go back to work
  •  The claim was processed efficiently
  • The NTD assessed, treated and certified fit for pre-injury duties quickly
  • The worker was motivated to get back to work
  • The employer was supportive and offered appropriate duties.


Although complex injuries / claims constitute only 15% of total injures they contribute to more than 50% of workers compensation claims costs.  As the injury  /  claim becomes more complex ( it is worth noting that complexity does not have to be a consequence of the injury, it can be due to liability assessment and management issues)  more resources -  people and money is required for diagnostic assessments, follow up treatment and progress reviews.

Below is a summary of the types of situation that cause injuries and claims to become complex.  In following sections the specific things an employer needs to consider and do will be explored  in resolving claims and helping the injured worker get back to work.







Flags are warning signs of potential barriers to recovery from injury or illness. The two most commonly utilised to identify workers at risk are “Red and Yellow flags”

RED FLAGS—Risk factors for serious pathology or disease AND may indicate serious but relatively uncommon conditions or diseases requiring urgent evaluation.  In a discussion paper presented by NSW Workcover Authority: ”Work Related Activity Programs for the Prevention of Long Term Disability in Workers with Musculo-Skeletal Injuries (Non-Red Flag Conditions) Health Provider Guidelines”, red flags were described as conditions that included tumours, infections, fractures and neurological damage. Recommendations are made that immediate notice be taken if an important red flag is present and consideration given to medical intervention. The nominated treating doctor (NTD) should consider or request referral to an appropriate specialist or investigations.  “The Red Flags equal physical risk factors.


YELLOW FLAGS are non-medical barriers to recovery. They may be psychological, or social.  The greatest risk for long-term disability relates to yellow flag condition and include:

  • Family Barriers includes weak family support for RTW, over protective partner, partner overly involved in workers injury or management of claim, and no support person to talk about problems, over protective significant other.
  • Attitude and Belief Barriers include the belief that even mild pain or discomfort is harmful or indicative of ongoing or further tissue damage. Associated beliefs may include behaviours of avoiding any activity that could lead to an increase in pain, underlying fears being that any pain is an indicator of further damage.  There may also be a strongly held belief that the injured part must be diagnosed and treated first, and that work or other activity will increase pain and should be avoided.



Compensation Issues include the fact an injured worker may have had negative experiences when notifying his/her injury to their employer – such as being discouraged from making claim, the employer requesting the  insurer deny the claim, lack of early assessment of RTW barriers by insurers, or perception of an uncaring or inefficient claims/case management officer. This can result in the injured workers engaginga  representative (i.e. a union representative) to negotiate with employer or in circumstances where this would not normally be necessary.



Treatment and Diagnosis There are situations where a health professional may sanction a  disability e.g. a GP may continue to certify the IW as unfit, or a health care provider continues to encourages passivity and discourage activity


Other situations include:

  1. Conflicting diagnosis over injury
  2. Health care provider will not communicate with insurer or providers
  3. Advice to withdraw from job or work from home
  4. Other Occurrences of Injury or previous Injury
  5. Previous compensable injury
  6. With extended time off work
  7. Older worker.



Return to Work issues can include:

  • A negative attitude to RTW of injured worker, employer or treatment provider
  • When an IW hasn’t RTW at 52 weeks this predicts a very poor RTW rate
  • There is a history of manual work in occupations such as construction, farming, forestry and fishing, nursing, truck drivers labourers
  • Work history includes job dissatisfaction, frequent job changes, and poor vocational goals
  • Unsupportive or unhappy work environment
  • Low educational background and economic status
  • Lack of availability to do suitable duties at a work site
  • Employer has no RTW program
  • Job involves shift work and unfriendly family hours
  • Depression
  • Fear of increased pain from activity
  • Anxiety
  • The  presence of social anxiety
  • Feelings of uselessness and not being needed
  • Use of extended rest to cope, reduced Activities of Daily living 
  •  History of poor compliance in exercise programs 
  • Has not RTW within usual time frames for that injury 
  • Reports of high to extreme intensity pain - >8/10
  • Poor sleep quality 
  • High intake of alcohol or other substances since pain
  • Belief about injury  -  “It will get better if I rest”, it won’t get better, fear, conflicting information and thoughts, unrealistic expectations
  • Personality type and personality disorders – Workaholic, Avoider, catastrophiser, martyr, passive aggressive 
  • Emotional health – anxiety, depression difficulty coming to terms with injury
  • Poor Industrial relations and Organisational culture  in relation to management generally, and in particular of managing and supporting workers with injuries
  • Job mismatch -  poor motivation, poor work satisfaction, poor job suitability before and after injury
  • Lack of support – from peers and various, and various levels of management
  • Wages delayed
  • Slow Response to Treatment Request
  • Slow Response To Specialist or Procedural request
  • Phone calls not returned
  • Multiple case managers -  having to tell story over and over, different approaches
  • Personality conflict with case manager
  • Heavy handed threatening manner, verbally or letter


Poor RTW rates are most likely when:

  • Emotions are not being managed
  • There are problems related to the work place
  • There are problems with the agent
  • There are social family issues such as the role in family change, if there is secondary gain, if there are false beliefs about doctors of culture or professionals



Treating Doctors issues can include:

  • Doctor or treating professional reinforcing illness or fear about the injury, it’s seriousness that is encouraging inactivity
  • Multiple referral to specialists or diagnostic tests with extended delays for appointments or reports to be finalised
  • Doctor not providing clear information about injury diagnosis, prognosis and what treatments and self management should be used
  • Conflicting information, particularly within patients treating teams
  • Unreliable information being received



Legal issues can include:

  1. Lawyer not providing correct information about entitlement or compensation leading to unrealistic expectations
  2. Lawyer encouraging avoidance of activity as strategy to increase lump sum payment due to wage and functional loss
  3. Common law - employer being sued for alleged negligence in causing the accident to occur


What a Company Needs to Know and Do:

  1. Understand how workers compensation and WHS  works-  the information provided on this site overviews most areas
  2. Follow the guidelines in setting up preventative measures for injury
  3. Understand and identify the types of environments and injuries most likely to occur in your industry and workplace
  4. Put strategies in place  to minimise risk
  5. Have a injury management policy in place
  6. Provide education to your staffing:
    • injury prevention and WH&S
    • Policy, procedures for managing injuries
    • Expected attitudes and behaviours of all staff, managers and injured workers in relation to injury management.
    • Review the practices



For more detail and specific strategeis for managing specific types of injuries and difficulties refer to our packages, Managing Physical Injuries in the Workplace - and - Managing Psychological Injuries in the Workplace.  Each of these packages provides an overview of common injuries and treatments, support needed, complications that can arise, where to get more information, Non injury realted barriers and suggested strategies are included in each package.








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