Author: Ellen's Interprofessional Insights

Dr. Ellen Fink-Samnick is an award-winning industry entrepreneur whose focus is on interprofessional ethics, wholistic health equity quality, trauma-informed leadership, and competency-based case management. She is content-developer professional speaker, author, and educator with academic appointments at Cummings Graduate Institute of Behavioral Health Studies, George Mason University, and the University of Buffalo School of Social Work; her latest book is The Ethical Case Manager, and available on Amazon. Dr. Fink-Samnick serves in national leadership and consultant roles across the industry. Further information is available on her LinkedIn Bio or her website

To Report or Not to Report? Mandatory Reporting and Duty to Warn for Case Management

Case managers and other professionals have a front row seat to the psychosocial realities faced by their patients and families. The workforce also faces increasing pressures to report undocumented patients and other situations to legal authorities. Yet, what are case managers mandated to report? This article lays out the facts.

The topic of mandatory reporting has been a major conundrum for the health care industry, and especially for those in case management. After all, our workforce has a front row seat to the life circumstances of patients and families, which can mean anything and everything across the psychosocial landscape. I’ve had a number of case managers express major confusion about the reporting requirements, especially whether they should report patients or their family members who are “undocumented illegal immigrants” to the authorities. Let’s clear up this conundrum!

Mandatory Reporting

Mandatory reporting refers to case managers and other practitioners informing formal state authorities about their suspicions for potential child or adult abuse, neglect, and exploitation. That word “potential” is an important one as it is up to those formal state authorities and agencies to define the actions and not the case manager. I’ve had countless colleagues in leadership roles for these agencies remind me of that fact! 

Mandatory reporting is codified as law across the states most, if not all, health care disciplines, as well as other licensed professions (view your state requirements here). The Child Abuse Prevention and Treatment Act (CAPTA) was enacted in in 1974 and led to the subsequent Federal Laws in for this arena. The federal government, states, commonwealths, territories and the District of Columbia also have laws in place to protect older adults from abuse, neglect, and exploitation; they also guide the practice of adult protective services agencies, law enforcement agencies, and others. These laws vary across jurisdictions with more information available from the U.S. Department of Justice website.

Keep in mind any suspicions by you or the treatment team should be based on objective and documented facts deemed from a preliminary assessment versus subjective judgments or biases. It is easy to make assumptions about other person’s actions, but that is not the role of any case manager or other licensed professional. Besides, we all know that mantra about assumptions, or at least should. 

In these situations, case managers should use critical thinking which involves 4 distinct steps: 

  • Enjoy objectivity by removing biases 
  • Assess the situation and obtain the facts
  • Reflect on the assessment facts and obtain quick consultation as needed, then 
  • Document the information and move into action, whether mandatory reporting or not. 

Keep in mind that there are potential consequences for failing to report potential acts of child, elder, or other abuse that could have been prevented. These actions vary based on the professional discipline sanctions by a state licensing board, to criminal culpability. Case managers are reminded that each case management credential prioritizes the importance of their workforce to heed any Federal, state, and local laws that guide their practice (Yup, those scope of practice laws for the state(s) of your primary licensure). In addition, CMSA’s Legal Standard of Practice (C) is equally clear on this professional requirement for case managers. 

Mandatory Duty to Warn

A professional’s mandated duty to warn or duty to protect is different from mandatory reporting. Duty to warn involves when there is foreseeable and immediate concern about a patient’s potential to harm themselves or specific others, such as in suicidal or homicidal intent or action. 

Duty to warn legislation was first imposed by the California courts in 1976 as part of the ruling in Tarasoff v. The Regents of the University of California. The ruling in this landmark case made it the legal duty of psychotherapists to warn third parties of patients’ threats to their safety. Yet, while the Tarasoff case triggered passage of duty to warn or duty to protect laws in most states, great variation exists among these laws, including which professionals they cover, and whether reporting is mandatory, permissive, or viewed in some other light. At the time of this writing 29 states have mandatory reporting laws, 14 states have permissive laws, and 4 states have no legislation. Georgia has unique nuances in their legal statutes that bear attention. Detailed information on these laws is available on one of my favorite websites for the National Conference of State Legislatures. You can access a state-to-state table with each law, its scope and status, as well as a color-coded interactive map. 

As far as case managers go, in the absence of a state law to guide their actions, most professionals will err on the side of caution. They will proceed with assessment of the person, obtain requisite information about the potential threat, and then contact local authorities as there are concerns about a patient’s potential for self- or public-harm. This may include law enforcement, state or country agencies for mobile psychiatric emergencies and mental health crisis, or other entities and resources in place to manage said events.

Reporting Undocumented Individuals

It is a HIPAA violation for case managers to report persons who are undocumented to legal authorities for it breaches patient privacy and confidentiality.  Hospitals and healthcare organizations have no duty to report individuals that they suspect or find out are undocumented immigrants. Legal and ethical guidance across case management’s established resources of guidance (e.g., state practice acts, codes of ethics and professional conduct, standards of practice) and the disciplines which comprise our workforce are unified in this stance (e.g., counseling, medicine, nursing, occupational therapy, physical therapy, social work, and others). 

Hospital employees should only ask questions about a patient’s immigration status to define if the that person or their family is eligible for services or needed resources, and not to report them. Reporting patients and family members puts them at immediate risk of stigma, and potential discrimination by workforce members who may not be immigrant-friendly. Patients and family members may easily delay or refuse treatment because of their fears around being reported by a clinic, hospital, or other care provider and ultimately, deported. 

Disclosure of information is limited to:

  • When there is a court order or court-ordered warrant, subpoena, or summons issued by a judicial officer or grand jury officer
  • There is an administrative or other legal request, or
  • The covered entity in good faith believes the PHI to be evidence of a crime that occurred on the covered entity’s premises

More information on all the moving parts of HIPAA, including Mandatory Duty to Warn and Report is in The Ethical Case Manager: Tools and Tactics, specifically in Chapter 7: Ethics is What you do While Everyone Watches!

Women’s Health and Health Equity Continue Under Attack

March may be Women’s History month, but the recent events in Alabama were not any cause for celebration. They represented an attack on women’s and reproductive health and a major setback for inclusive and quality-driven patient-centered care. The need for ongoing advocacy is a must.

March is a month for celebration for it prompts attention to priorities for health equity warriors everywhere, from Developmental Disabilities Awareness Month and Social Work Month, to Women’s History Month.

This blog’s health equity happenings focus on actions that signify, yet, another dichotomy in our space this week. The events are as profound as when the Federal Health Equity Plan advanced the same week as glaring data on patient discrimination by the workforce hit the media.

In the same week that First Lady Jill Biden and the White House announced $100 M in federal funding for women’s health research and development, the Alabama Supreme Court overstepped, and (falsely) ruled that embryos are children, freezing all access to fertility treatment for women in that state. This action is an attack on women’s and reproductive health for all persons. It equally represents a major setback to attainment of inclusive and quality patient-centered care.

To Catch Everyone Up

For those who need a quick review, The Hill’s Martha Nolan wrote a stellar piece providing the realities and moving parts of In Vitro Fertilization; I’m all about attributions so give that piece a read here. However, this quote really got me thinking:

“Whatever your political or religious beliefs, limiting access to safe, effective and essential medical care is bad for women…….Alabama has made a hard situation — infertility and the struggle to have children — more complicated, stressful and difficult.”

Pregnancy is emotionally and physically stressful and traumatic for individuals. Some persons face even greater risks in walking down this road than others. Nolan frames high maternal mortality rates, which have been areas of major focus. I’m a fan of other notable data cited by the OECD and WHO, and in a wonderful article by Njoku et al. (2023). The data points speak to the profound risks faced by persons who become pregnant, whether that pregnancy is planned or not:

  • The mortality rate in the US was 32.9 maternal deaths per 100,000 live births, and >10X the estimated rates of comparable developed high income countries
  • Black and Hispanic women experience 2 to 3X higher mortality rates compared to White women.
  • Every day in 2020, almost 800 women died from preventable causes related to pregnancy and childbirth, with a maternal death occurring every 2 minutes.
  • Almost 95% of all maternal deaths occurred in low and lower middle-income countries in 2020.

These dire outcomes are exacerbated by the pervasive incidence of racial trauma, discrimination, and marginalization. The recent attacks on rights associated with the health and well-being of all persons makes this latest assault even more worrisome. Alabama and other states have made challenging situations for patients far more complicated and traumatic, from managing unwanted pregnancies (such and those during child abuse, domestic and sexual abuse/assault) and access to receiving necessary emergent medical care that saves the life of the mother. Receipt of gender-affirming care has put countless youth at risk. The latest game of political football involves management of infertility and an individual’s challenge to become pregnant. Political scrutiny dictates who defines care plan versus the rightful purview of these decisions: between patients and their chosen practitioners and specialists. The ethical principals of practice are put to test: autonomy, beneficence, fidelity, justice, and nonmaleficence.

Advocacy for Action

Yes, there is much work to do. I couldn’t agree with Ms. Nolan more in that the Biden-Harris Administration should invest in research to advance health for ALL persons. It’s tough to write a piece on women’s and reproductive health without providing attention to all marginalized groups who struggle with accessing care reflective of their needs, such as members of the Trans community. You don’t want to miss the Fierce article on how Trans men struggle for inclusive gynecological care. The topic is a relevant thread of this post given my mantra on ensuring that all patients and their families feel safe, seen, heard, and valued.

I’ll quote the White House Proclamation for Women’s History Month 2024…., though also add a respectful mandate. I understand the imperative to speak to all “women” but feel compelled to remind everyone that the rights of all identities are at stake. To that end I’ve added language in parentheses.

“All of us stand on the shoulders of these sung and unsung trailblazers — from the women (and all persons) who took a stand as suffragists, abolitionists, and labor leaders to pioneering scientists and engineers, groundbreaking artists, proud public servants, and brave members of our Armed Forces.

  Despite the progress that these visionaries have achieved, there is more work ahead to knock down the barriers that stand in the way of women and girls (and all individuals) realizing their full potential — in a country founded on freedom and equality, nothing is more fundamental.”

Far more work is needed to right the wrongs and shift the latest tide of attacks on personal civil rights. The acknowledgment of monthly designated celebrations is nice, but insufficient for the level of advocacy needed. Advocacy for action is vital. Time to get the word out to vote, plus engage in public policy actions with professional organizations, and other advocacy groups. Feel free to add to the list below.

  1. The American Civil Liberties Union (ACLU) has links to a range of reproductive freedom sites.
  2. The American Medical Women’s Association provides a further robust list of groups focused on women’s and reproductive health advocacy
  3. The American College of Obstetrics and Gynecology provides a position statement on healthcare for Transgender and Gender Diverse Individuals.
  4. The Transgender Law Center is the largest Trans-led organization focused on empowerment for the Trans community.

Ethics Book for Case Management Frames a Vivid Ethics Spectrum

Ethics book aligns ethical, legal, and regulatory practice for Case Management

Ethics has long been viewed as not simple black and white, but varied shades of gray. Oh, how the times have changed! Ethics now comprise a spectrum of vivid colors that reflect its fierce disruptions to practice. This reality spans every health and behavioral health professional across every setting. Yet, those in case management face unique struggles. My latest book, The Ethical Case Manager: Tools and Tactics, offers clear guidance.

Unique Workforce Challenges

Case management’s workforce faces challenges not experienced by other professions. First, case management is an umbrella profession comprised of varied professions (e.g., counseling, nursing, occupational therapy, and social work). Each discipline has a distinct code of ethics or professional conduct, as well as dedicated standards of practice. Let’s add another layer of complexity that includes over 25 case management-related credentials for individuals (e.g., ACM, CCM, CDMS, CMGT-BCTM, CRC), organizations (e.g., NCQA, URAC) and their unique requirements. There are assorted professional associations across the industry, which each possess their own standards of practice. The landscape gets more confusing when we include the industry’s hierarchy of case management roles: community health workers, case management assistants, community-based case managers, board-certified case managers, and those in leadership positions. 

The question beckons: Where should your ethical compass point? The range of established resources of guidance defined by each of the above entities makes the answer to this question challenging to answer. It also yields two more confusing conundrums for the workforce:

  1. Defining the ethical and legal parameters for case management practice, and 
  2. Reconciling these parameters with employer policies and procedures across the industry.

The Ethical Case Manager to the Rescue

Here’s where, The Ethical Case Manager: Tools and Tactics comes to the rescue. The book’s content is written for an interprofessional audience that spans the spectrum of degrees held by case managers. This approach provides a context for accountability, while addressing the most complex ethical dilemmas to date.

Focus is on case management job descriptions, outcomes measurement, discharge planning, and care coordination. There’s content on digital healthcare innovation and patient assessment, addressing implicit biases, microaggressions, and health disparities. Promoting the latest domain of health equity, inclusion and belonging is covered, as is workplace bullying, licensure compacts and interstate practice.

Practical facts are blended with Federal and state regulations, tables, templates, and dedicated resources. Each chapter includes case scenarios and critical-thinking review questions for learners to apply the content. 20 Ethical Tactics provide touchpoints for learning. Every reader will reap their own reward, from students, to new and more seasoned case managers, consultants, as well as those in leadership roles.

The Ethical Case Manager’s 318 pages encompass the most vital areas for case managers:

  • Forward by Dr. Colleen Morley
  • Section 1: Essentials of Ethics
  • Chapter 1: Terms and Definitions
  • Chapter 2: Established Resources of Guidance
  • Chapter 3: The Value Proposition
  • Section 2: Realities of Practice
  • Chapter 4: Population-based Practice
  • Chapter 5: Diversity, Equity, Inclusion, and Justice (co-authored with Michael Garrett)
  • Chapter 6: Workplace Bullying
  • Chapter 7: Health Information Technology
  • Chapter 8: Interstate Practice
  • Section 3: Activation of Ethical Decision-Making
  • Chapter 9: Ethical Decision-Making Models
  • Chapter 10: Case Scenarios
  • Epilogue

The Ethical Case Manager: Tools & Tactics will be your primary resource, whether you wish to:

  • Educate students
  • Onboard new staff
  • Benchmark ethical practices
  • Resolve ethical dilemmas
  • Possess timely compliance knowledge
  • Ensure successful fiscal, clinical, and operational outcomes 
  • Use ethical decision-making models
  • Leverage interprofessional teams
  • Inform individual practices

No wonder the book is now on ANCC’s formal list of study references for their Nursing Case Management Exam (CMGT-BCTM)

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The Ethical Case Manager: Tools and Tactics is only available on Amazon

Attending these conferences? Special access for attendees to book signing events and giveaways: 

Federal HHS Equity Action Plan Advances Amid New Data on Discrimination by the Health Care Workforce

There’s much to follow on the current health equity radar, from advancement of the HHS’s Equity Action Plan to concerning data validating the high incidence of discrimination by the health workforce toward patients. The onset of stress and vicarious trauma for staff witnessing these events was also identified. Each of these actions will provide pause to even the most seasoned health equity warrior.

The title of this blog article reflects one jam-packed week in our health equity space! There’s much to follow on the health equity radar, from advancement of the Federal Equity Action Plan to concerning data validating the high incidence of discrimination by the health workforce toward patients. The onset of stress and vicarious trauma for staff witnessing these events was also identified. Each of these actions will provide pause to even the most seasoned health equity warrior.

An Equity Action Plan Amplified

The U.S. Department of Health and Human Services (HHS) released a 2023 update to its Federal Equity Action Plan! The plan amplified the commitment of the Biden-Harris Administration to employ its whole-of-government equity agenda that empowers inclusive access to care for all. Many of this blog’s readership are aware of my affinity for wholistic health approaches that encompass physical, behavioral and psychosocial health. Research affirms the validity of these models to ensure successful outcomes for those populations living amid the wholistic health determinants encompassing social determinants of health and mental health, political determinants health, and the systemic racism that perpetuates them.

The HHS Plan outlines five key areas to advance health equity at the macro, meso, and micro practice levels:

  1. Prevent neglect and improve care to help children thrive in their families and communities. 
  2. Promote accessible and welcoming health care for all. 
  3. Improve maternal health outcomes for rural, racial, and ethnic minority communities. 
  4. Prioritize the behavioral health of underserved populations. 
  5. Increase clinical research and trial diversity to support innovation. 

Each of these actions has been the focus of legislation and funding targeting minoritized and marginalized communities. At the Federal level Aligning for Health is a membership association that uses a team of federal and state administration experts to address the mandate for efficient, integrated and coordinated programs that enhance health outcomes for Americans. Their website has an in-time and interactive tracking tool for legislation on health equity and the SDoH. The current 118th Congress is reviewing the following legislation in this space. The current bill count tally is:

  • SDoH Bills; 118
  • Health Equity/Disparity Bills: 36 
  • Maternal and Infant Bills: 0

Since the Equity Action Plan was released in 2022, some progress to address health equity and racial justice has advanced:

  • Proposed rules on language access in all health programs and activities funded by HHS and guidance to states on how to comply with language access and effective communication obligations during and after public health emergencies. 
  • Approved 42 states, DC, and the Virgin Islands to provide 12 months of continuous postpartum coverage through the Centers for Medicare and Medicaid Services (CMS) so that women with low-incomes have stability in coverage.
  • Proposed rules that prohibit discrimination on the basis of disability by updating critical provisions that help persons with disabilities access health and human services under section 504 of the Rehabilitation Act of 1973.
  • Provided practical guidance to HHS offices on identifying actions to ensure opportunity for all.

In addition, The Kaiser Family Foundation (KFF) Medicaid Waiver Tracker shows 63 approved and 37 pending 1115 Waivers in process across the states. For those who haven’t accessed this informative tool, it is a must read. You can also access a current view of the 1115 Waiver landscape by state through the KFF Tracker.

Discrimination by the Workforce: More Norm Than Exception

This action by HHS is especially timely in light of this week’s compelling and concerning research by the Commonwealth Fund on Health Care Workers Observations of Discrimination Against Patients. The report details the perspectives of >3000 members of the interprofessional care team. Discrimination against patients due to race, ethnicity, language and other cultural areas remains widespread, as does the traumatic impact for the workforce itself. Among the most concerning findings include:

Recommendations

Much more work is required to attain the pinnacle of health equity excellence that society deserves. The Commonwealth report lists a series of recommendations to advance actions to mitigate discrimination and ensure psychological and physical safety for patients and the workforce itself:

  • Provide an easy way for patients and health care staff to anonymously report situations involving racism or discrimination. 
  • Examine policies to make sure they result in equitable outcomes
  • Require classes on discrimination at professional schools
  • Create opportunities to listen to patients of color and health care professionals of color
  • Examine treatment of non-English-speaking patients
  • Train health care staff to spot discrimination

I would also add the importance of an ongoing and consistent organizational total quality management approach. This action ensures continuous improvement efforts that are ongoing and sustainable. Addressing health equity, systemic racism, and trauma are NOT one and done.

Professional associations also need to continue their important work to develop advance, and activate strategic health equity deliverables such as implementing revised standards of practice, ethical codes, formal position papers, dedicated tool kits to name a few. 

As I’ve quoted through my health equity and DEIB work on many occasions, “Every patient, their family member, and member of the healthcare workforce should feel safe, seen, heard, and valued.”. The healthcare industry cannot possibly begin to address the health equity equation’s abysmal outcomes without first addressing these levels of oppression, racism, and manifesting trauma faced by for all involved. 

The Interstate Licensure Compact Imperative

Despite interstate practice being more norm than exception, significant obstacles exist for those persons rendering and accessing care. Learn about the current Interstate Compacts and how you can advance them.

What times we are in! Providing clinical intervention and treatment can happen anywhere courtesy of telephonic platforms, plus virtual, remote, and digital products galore. Rural populations rely on these technologies to engage with their practitioners and even health plan case managers, whether for assessment or monitoring of the care process and resource linkage. Patient with disabilities can now access care with greater ease. Yet, there’s a BIG CATCH! Despite interstate practice being more norm than exception, significant obstacles exist for those persons rendering and accessing care.

The health and behavioral health workforce continues to be held hostage by lack of an inappropriate licensure portability structure. Care for consumers is obstructed amid a regulatory system that fails to account for the reality of our professional practice landscape.

Regulatory Realities Reduce Access to Care and Employment

Technology is only one driver of the need for professionals to practice across state lines. Society is more mobile than ever, both for clients and clinicians alike. Traveling practitioners (e.g., case managers, nurses, social workers) are commonly hired to fill employment gaps for staff on medical or family leave, and to mitigate workforce shortages. Yet, this sector of the workforce and their employers face chronic challenges with licensure delays, which only perpetuate barriers and limits to care for the public.

Throngs of licensed mental health providers are at the ready to provide sorely needed telehealth intervention across the states. However, care is often delayed and waiting lists for treatment grow from an antiquated licensure structure that limits one’s inability to practice across state lines. Military families move their state residence every few years and in doing so deal with financial difficulties imposed by licensure delays, and thus, employment. First responders may find their interventions are limited when disasters occur across state lines.

There are an endless list of challenges for the workforce and the public they serve. With minimal exceptions (e.g., licensed professionals who are military members, employed for military contractors), licensed professionals may only practice in the state(s) where they are licensed in good standing. How can licensed practitioners engage with their ethical and legal due diligence when their practice regulations interfere with their ability to do so?

Licensure Compacts on the Move

Licensure compacts are a viable solution for professionals seeking to be licensed in multiple jurisdictions and the that hire them. Through the compact structure, members of the workforce, such as behavioral health providers, case managers, and others who are licensed in one state can actively practice at that same level in other states which are part of the compact. The presence of a compact also reduces the economic burden faced by licensed individuals in dealing with multiple state licensure applications.

The practice of all licensed professionals is controlled by the law in the state(s) where each individual is licensed, typically by the practice act of each state. Scope of practice even supersedes academic degrees. For example, one might presume that as a Doctor of Behavioral Health, I am licensed to prescribe psychopharmacological agents to patients. However, prescribing medications is not included under the scope of practice for my licensure as an LCSW in the Commonwealth of Virginia. The scope of practice for any practitioner extends only to those activities that a person who is licensed to practice as a health professional is permitted to perform.

A change in the traditional licensure structure is mandated: one that allows health and behavioral health professionals to intervene across state and jurisdictional lines. Several professions have engaged in rigorous efforts to advocate for licensure portability through formal regulation.

Nursing

Nurses are required to be licensed in any state where they practice and where the recipient of nursing practice is located at the time service is provided. This fact is a common point of confusion for most licensed professionals—and especially tricky for those my case management colleagues. In contrast, many employers believe licensure must be held in the professional’s state of residence only, instead of where a patient may reside or is receiving care. The Nurse Licensure Compact is actively on the move, and now covers 41 states. More information is accessible on the NCSBN website.

Social Work

The lack of licensure portability has been identified as a public
safety, workforce, and technology issue. The mandate is clear that the workforce responsible for providing the bulk of mental health services to society must be able to practice across geographic state borders. The formal language for the Social Work Licensure Compact was released in February 2023, with legislation actively being introduced across state legislatures; 24 states have done so at the time of blog post with a current map viewable on the official compact website. 4 states have fully approved the legislation: Missouri, S. Dakota, Utah, and Washington State. The Model Compact Bill must be approved by 7 states to be enacted in its entirety before its necessary infrastructure can be implemented, which is expected to happen in the coming months. After verifying eligibility, individual social workers will then be granted a multistate license, which authorizes their ability to practice in all other compact member states, and removes those longstanding barriers to interstate practice.

Counseling

The American Counseling Association Counseling Compact calls for counselors licensed in one state who have no disciplinary record, to be eligible for licensure in any state or U.S. jurisdiction where they seek residence. Like other disciplines, laws that impact counselors (e.g., mandated reporting statutes) vary from state to state, so the compact recognizes how jurisdictions may require a state jurisprudence exam. At the time of this writing, over 32 states have approved the Counseling Compact with the interactive map viewable on the compact site.

Compacts on the Move

In addition to the compacts listed, further information is available for those covering:

Individual practitioners must engage in advocacy efforts through their respective professional associations. Many of these entities have fierce public policy committees that work diligently to support interstate practice. In addition, contact local legislators to provide individual support for those licensure compacts of interest to you. Access your elected legislators through USA.gov. Remember, support for one interstate compact, leverages them all!

What to find out more on Interstate Compacts, and the Do’s and Don’ts of practice across state lines?? Read Chapter 8 in The Ethical Case Manager: Tools and Tactics, available on Amazon.

The Innovation in Behavioral Health Model: Will the Outcomes Reflect the Hype?

The Innovation in Behavioral Health Model is the latest greatest model from CMS and CMMI to ensure whole-person care for patients with complex, integrated physical and behavioral health conditions, who also experience health related social needs. Will the program outcomes reflect the preliminary hype?

The Innovation in Behavioral Health Model (IBH) is big news, and certainly worthy of a blog post. This newly unveiled state-run model from CMS’s Centers for Medicare and Medicaid Innovation (CMMI) employs that value-based mindset we’ve come to know and love from other CMS models. Among these latest offerings include Making Care Primary (MCP), ACO Reach, All-Payer Health Equity Approaches and Development (AHEAD), and Transforming Maternal Health (TmaH).

Each of these models strives to ease the clinical and fiscal burdens of care for all stakeholders by enhancing access for all beneficiaries, while reducing disparities experienced by minoritized and marginalized populations. Each model focuses on wholistic health approaches that leverage interdisciplinary team-based care to ensure timely screening, assessment and treatment of physical, behavioral, and psychosocial health needs. Each model is poised to ensure proactive attention to closed-loop care referrals that will hopefully yield decreased costs of healthcare utilization, reduce workforce burden and burnout, and ensure quality-driven care that heeds the Triple, Quadruple, and Quintuple or Quintile Aims (whichever you subscribe to). Clearly there’s lot of pent-up anticipation, but will the preliminary hype and the outcomes align?

The IBH Lowdown

  Primary care has long sheltered the full responsibility for mental health attention, though behavioral health practices will now receive extra funding to shoulder the burden. Here’s the IBH lowdown:

  • Notice of Funding Opportunity will be released late Spring 2024. 
    • Up to 8 states will be picked for an 8-year run that will launch in Fall 2024.
      • Years 1-3: Pre-implementation periods for states to conduct outreach and recruit behavioral health practice participants into the model. Funding will go to upgrading health IT, advancing EHRs, aligning practices with the model, and adding staff.
    • Year 4-8: The chosen states will implement a Medicaid payment model to support practice participants in implementing the care delivery framework. Practice participants in selected states who participate in the additional Medicare payment model will receive a per-beneficiary-per-month payment to support implementation of the care delivery framework and performance-based payments.

  Community-based health practices will be front and center in IBH. These sites already have interprofessional models equipt to manage whole person care. The model will maximize its power through a single point of entry that uses 4 pillars; each one will bolster the model’s framework and critical infrastructure:

  1. Care Integration: Behavioral health practice participants will screen, assess, refer, and treat patients, as needed, for the services they require across the wholistic health triad of behavioral, physical, and psychosocial health.
  2. Care Management: An interprofessional care team led by the behavioral health practice participant will identify, and as appropriate address care of patients and provide ongoing care management.
  3. Health Equity: Behavioral health practice participants will conduct screenings for HRSNs and refer patients to appropriate community-based services. Participating practices will be required to develop a health equity plan (HEP) that stipulates how the practice participant will address disparities that impact their service populations.
  4. Health Information Technology: Capacity building will the priority with expansion of health IT through investments in interoperability and necessary tools (e.g., EHRs). These actions will also ensure greater emphasis on quality reporting and data sharing.

A Sustainable Fix

  To say this model is a must is an understatement:

  • Medicaid is the large single payer in the US for mental health
  • 25% of Medicare beneficiaries experience a mental illness, 
  • 40% of Medicaid beneficiaries who are non-elderly adults experienced a mental illness or substance use disorder in 2020
    • The percentage of hospitalizations for patients with a mental health and substance use disorder condition (M/SUD) that involved a co-occurring physical health condition increases with age and has variation across subgroups:
      • These stays were more common among adults aged 45-64 years (92.3 %) and 65 years and older (97.9 %) than for adults aged 18-44 years (75.8 %). 
        • Co-occurring physical health conditions were more common among patients with Medicare (92.9 %) compared to patients in other payer categories (< 83 %) and among Whites (85.5 %) vs. Asian/Pacific Islanders (75.9 %)

  Patients and providers deal with a lengthy list of barriers to access and treatment, starting with how behavioral health services are not a specifically defined category under Medicaid benefits. Feel free to add further problems with service fragmention, poor reimbursement, limited treatment availability, and lack of true payment parity with physical health, but I digress. Many of behavioral health services are wiggled to fall under mandatory Medicaid benefit categories, such as when psychiatrist services are coded as physician evaluations or visits. Several states have defined mechanisms to cover behavioral health through optional benefit categories, such as case management services, prescription drugs, and rehabilitative services. Children diagnosed with behavioral health conditions can receive any service available under federal Medicaid law that is needed to correct or ameliorate the condition. However, the same requirements are not in place for adults. This lack of consistency is far from optimal and further perpetuates a dysfunctional system.

One Big Takeaway

  Under the IBH model, participating states will be responsible for ensuring delivery of integrated care to fully support the patient’s individual care needs. Comprehensive care coordination and care management will be key elements for inclusion. There are plenty of successful outcomes across the targeted populations that validate the power of those professional practices.

I know that my colleagues across case management and integrated care have developed successful models across Community Health Centers, Federally Qualified Health Centers, Rural Health Centers, Look Alikes, and other ambulatory care sites to meet the IBH requirements. I’ll be watching closely over the next 8 years to see where #IBH implementation goes and what the outcomes yield! 

And to All a Space Where They Feel Safe, Seen, Heard, and Valued…

2023 saw grand movement in the health equity space, especially in terms of accreditation, regulations, reimbursement, and programming. However, despite the best intent, there are miles to go before we sleep.

A flurry of recent headlines came to mind as I sat down to craft this last blog for 2023. Each of them were noteworthy for commentary:

At a time when society, and especially the health care industry have fixated their attention on policies and programs to advance diversity, equity, inclusion, and belonging, it appears that there is still much work to do. Despite the wins that we have seen in 2023, my fellow health equity warriors and I have miles to go before we sleep.

2023 Was Not For Naught

Now, we’ve seen some big wins in the health equity space this past year, including but not limited to:

There is a robust list of legislation and funding action that has occurred across the macro- , meso-, and micro-level arenas of care. However, I’m one of those who is impatient with the progress heretofore, despite the well-intended actions. It often feels that there so many gaps and chasms in care to address, that we’ve barely scratched the surface.


Moving Forward and My Commitment to You

Every step I walk in the health equity arena ignites my passion, purpose, and the promise of all that is possible for our industry and every stakeholder. I am appreciative of those who have followed and read my blog, attended presentations, and read the content that I’ve authored, whether books, chapters, scholarly articles and other continuing education content. Your enthusiasm for my innovative work in this space has meant so much.

My Top 5 blog articles for 2023 have been:

1. Health Equity and the SDoH Are NOT Synonyms

2. The U.S. Playbook to Address the SDoH: Launchpad vs. Final Comprehensive Strategy

3. Patient Compliance vs. Adherence: Advancing the Health Equity Mandate

4. Workplace Bullying’s Wrath Continues

5. Job Search Lessons for Health, Behavioral Health, and Public Health Students

I’m taking a rest to restore my resilience over these next few weeks. But as we embark on 2024, know how much your support fuels me to keep advancing our healthcare industry.

Every effort is meaningful, no matter how big or small. Only through our collective energies will we achieve that coveted wholistic health quality compass of the Quintuple/Quintile Aim. Only in this way will we forge a safe and ethical space for practice where every patient, population, provider, practitioner be able to feel safe, seen, heard, and valued.

The U.S. Playbook to Address the SDoH: Launchpad vs. Final Comprehensive Strategy

The White House released the inaugural U.S. Playbook to Address the Social Determinants of Health. The document serves as an important cross-sector guidepost for application, implementation, and action by all involved stakeholders to best serve their patients and communities. But, does the Playbook go far enough to fully address the SDoH? What other opportunities loom?

It’s been another exciting week for those of us taking our daily walk down Social Determinants of Health Lane. The White House released their U.S. Playbook to Address the Social Determinants of Health. The document has captured the industry’s attention, though also yielded some scrutiny.

The Lowdown

The Playbook is a bold undertaking. The document level-sets the massive work engaged in so far to address the health disparities and barriers to care engaged in across the industry. It quotes research and seminal reports citing the clinical and fiscal impact of health inequities faced by society’s minoritized and marginalized populations and providers. This vital foundation also highlights the importance of patient- and family- centric care that heeds the Quintuple and Quintile Aims at micro, meso, and macro levels, and across involved sectors.

For those who want the Cliff Notes version, here you go. Pages 1-18 provide critical information for persons and organizations who seek foundational information on SDoH (e.g., research, definitions, models) and context for them. This is especially valuable knowledge for students, as well as those who might not be as informed on this topic.

For my colleagues who have been in these trenches, pages 18-35 detail the three Playbook pillars with numbered strategic actions to advance each pillar. There is a candid and comprehensive review of the context for each pillar and potential challenges for implementation. Opportunities for Congressional Action are also detailed.

1. Expand data gathering and sharing: Advance data collection and interoperability among health care, public health, social care services, and other data systems to better address SDOH with federal, state, local, tribal, and territorial support.

2. Support flexible funding for social needs: Identify how flexible use of funds could align investments across sectors to finance community infrastructure, offer grants to empower communities to address HRSNs, and encourage coordinated use of resources to improve health outcomes.

3. Support backbone organizations: Support the development of community backbone organizations and other infrastructure to link health care systems to community-based organizations

The Appendics (pages 36-46) discuss how aspects of the Playbook are currently being operationalized using the Whole of Government approach. This section is a ‘must read’ for it provides specific examples to operationalize each action, with further guidance and information for readers on funding opportunities, toolkits with existing screening and assessment resources, and other critical community activities.

To Be Clear

Like most Federal reports and position papers, the Playbook was not developed as a ‘be all to end all’ document. This valuable resource highlights the mandate for all stakeholders and sectors of health and behavioral health services to ensure the most robust and sustainable approach to inclusive care for all populations possible.

How each organization accomplishes this critical priority is on them. Some might have preferred a greater Playbook focus on expanded funding and reimbursement, and that’s one clear opportunity. My take for ensuring organizational success in addressing the SDoH involves ten elements:

1. Take an honest and critical look at their current SDoH priorities.

2. Identify their target populations most impacted and develop means to ensure equitable and accessible care for all persons. This also includes incorporation of quality metrics and relevant outcomes that go beyond length of stay and readmissions to population-specific health priorities (e.g Patient-reported Outcomes Measures).

3. Align all existing inter- and intra-organizational resources and community partners.

4. Utilize and partner on funding access and opportunities; this includes ongoing investment in their communities served, advocacy for appropriate reimbursement (yup, those ICD-10-CM Z codes), and other fiscal imperatives.

5. Ensure appropriate mechanisms for data-gathering, interoperability, and use.

6. Heed industry compliance requirements (e.g., CMS, the Joint Commission, NCQA, NQF) to implement formal patient assessment (or Health-related Social Needs (HRSNs)) intervention, and direct referral linkage.

7. Ensure diverse and sufficient interprofessional staffing who can provide concordant and respectful whole-person care to all populations, which leverages integrated care frameworks and integrated behavioral health models of treatment.

8. Prioritize workforce training on trauma-informed approaches to care, eliminating implicit and explicit biases and microaggressions, and maximizing ethical engagement to enhance patient engagement and treatment adherence versus compliance and resistance.

9. Ensure the alignment and application of Diversity, Equity, Inclusion, and Belonging (DEIB) policies, whereby all patients and the industry workforce feel safe, seen, heard, and valued.

10. Commit to long-term strategic solutioning of the SDoH rather than short-term reactive response.

In Closing

“The Playbook is a launchpad, and not a final comprehensive strategy for addressing the SDoH”. It may not go as far as all stakeholders would like. Yet, the Playbook serves as an important guidepost for necessary cross-sector application, implementation, and action by all entities and individuals to best serve their patients and communities. I trust readers of this post will weigh in with other suggestions, and that input is encouraged. Just remember, final accountability for advancing these efforts is on us all.

Housing Insecurity=Increased Illness Morbidity and Mortality: Solutions Mandated

Despite abundant research on the intersection of chronic illness morbidity, mortality, & homelessness, poor health outcomes related to housing insufficiency continue. The data is meaningless without using it to activate solid solutions.

“Homelessness remains a key social determinant of health, with researchers from the University of California, San Francisco, revealing that individuals who are homeless are 16X more likely to experience sudden cardiac death than those who are not.” This quote appeared in my social media feed last week, and several thoughts immediately popped in my head. First, it had been over a month since I wrote a blog and that needed to be remedied pronto. Next, this topic gave me a mandate to chew on. However, I wondered, if I had missed something in translation. Surely, this topic was not new news. Despite the significance of this new research on the intersection of sudden cardiac death and homelessness, poor outcomes related to housing insufficiency have been long-standing.

Where it Started IS STILL How it’s Going

Housing insufficiency has been among the most frequently researched SDoH, particularly in how it contributes to excessive clinical and fiscal healthcare utilization for patients. I’ve always valued this quote: “While differences in health between housed socioeconomic groups can be described as a ‘slope’, differences in health between housed and homeless people are better understood as a ‘cliff’.”

Persons who are housing insecure face considerable wholistic health challenges across the domains of physical, mental, and psychosocial health. Barriers to care are only exacerbated by the provision of care that can be suboptimal, and is often fueled by implicit bias on the part of providers. This connection leads to lack of trust by the population of practitioners and the healthcare system overall. 

Global mortality rates for those who are housing insecure are far higher than other populations, and impacts every demographic. Research-driven me wanted to share a few items to ponder:

There’s plenty data more where that came from and across every cultural nuance spanning minoritized and marginalized populations (e.g., age, ethnicity, gender, persons with physical, developmental and intellectual disabilities, race, sexual orientation, socioeconomic status, and other groups) . However, amid my profound respect for the research is a valid concern; data is meaningless without using it to activate solid solutions. 

Strategic Solutioning

I posted related thoughts about this topic on LinkedIn earlier in the week. Countless colleagues and thought leaders in this space chimed in to echo similar and strong sentiments. Among the wisdom shared included:

  1. Active implementation and use of ICD-10-CM-Z codes: Homelessness and healthcare have been misaligned for well over my 40-year tenure in the industry. Fortunately the ICD-10-CM-Z code of Z59 for homelessness has morphed into more realistic and reimbursable codes for industry use, with many effective as of October 1, 2023. A big nod to Evelyn Gallego, the Gravity Project, Dr. Ronald Hirsch, Tiffany Ferguson, and other Z-Code warriors for their tireless energies in this space. Despite this progress, I still hear coders, utilization management specialists, and case managers push back on their use. Many are discouraged from using the codes in their organizations in deference to those that reap higher revenue capture. This is short-sighted, if not potentially fraudulent action; can we say “upcoding”? For those who need a refresher, the codes are listed below with a deeper dive available here:
    • Z59.1: Inadequate housing
      • Z59.10: unspecified
      • Z59.11: environmental temperature
      • Z59.12: utilities
      • Z59.19: other inadequate housing
    • Z59.81: Housing instability, housed
      • Z59.811: with risk of homelessness
      • Z59.812: homelessness in the past 12 months
      • Z59.819: unspecified
  2. Greater acknowledgement of and attention to all social drivers of health: For those who not privy to this information, the CMS 2023 IPPS Final Rule mandated that hospitals reporting to the Inpatient Quality Reporting program submit two measures, SDOH-1 and SDOH-2: voluntary for 2023 but required by 2024. We’re all waiting anxiously to see what the penalties for not reporting this data will be, but we can expect they’ll be significant. Joint Commission has also stepped in with standards NPSG.16.01.01 and EP 2 (Notes 1 and 2). You snooze, you lose!
  3. Attention to How Environmental Factors Exacerbate Social Drivers: Evelyn Gallego is the ultimate data mavin for our industry. Emphasis of environmental exposure due to homelessness and sudden death is a population health priority and public health imperative. As a fellow data-geek, I know how use of the data drives making the case to define policy and funding imperatives, so here are my favorites:
  4. Cities Taking Action to Address Health, Equity and Climate Risks: Through the RWJF’s grant-funded project, Cities Taking Action to Address Health, Equity and Climate Change, 6 U.S. cities have been supported to respond to the interconnected challenges of health, equity and the climate crisis with innovative, community-led projects. The cities and their areas include: 
  5. Enhanced Acknowledgement of the Different Types of Homelessness: There is a cultural shift as the industry is being forced to distinguish between types of housing insufficiency, such as acute and chronic homelessness across populations. Innovators working on the front lines of this challenge include Peter Badgley, Jake Rothstein, and John Gorman from Upside I Housing for Health. The National Alliance to End Homelessness continues their tireless crusade to prevent and end homelessness in the US. The National Community Action Partnership’s over 1000 state agencies take an active role in coordinating on housing advocacy and resource provision. FindHelp.org has a dedicated portal on their site for localized housing information.
  6. Expansion of Affordable Housing, Tax Credits, and other Housing Programs: The Center for Budget Priorities continues to advocate in this arena with a litany of recommendations for capital investments at the Federal, state, and local levels:
    • Reducing the shortage of deeply affordable rental housing 
    • Expanding vouchers for housing
    • Implementing a housing developer-focused renters’ tax credit
    • Reversing restrictive local zoning practices
    • Preventing the loss of existing affordable housing
    • Improving the Low-Income Housing Tax Credit program
    • Investing in tribal communities’ housing needs
    • Removing barriers to homeownership
    • Reforming project-based housing programs to encourage higher-quality housing.

Where We Need to Go

I’m just getting warmed up here, though always strive for comprehensive articles. I encourage others to add solid strategies and resources in the comments section of this blog post. Remember, we are made stronger by using the data to advocate for practical and sustainable solutions! Keep fighting the fight #SDoHWarriors.

The Ethical Conundrum of Healthcare Ethics Committees

Ethics committees have been a condition of Joint Commission accreditation since 1992, yet there is massive variation in their implementation and use. They should not replace the dialogues of interprofessional team members with patients, families, or each other.

There’s been a recent uptick by case managers of their patient referrals to hospital ethics committees. This topic is near and dear to me, especially having served as the chair or co-chair of several acute care-based ethics committees over the years. The industry demand for decreased hospital utilization and length of stay has meant a shift in how ethics committees are viewed and often utilized. We’ve gone from traditional referrals, as in defining a treatment plan when practitioners define care as futile or a patient lacks advance directives, to when an individual refuses to accept a discharge plan. I’ve heard of situations where ethics committee consults are tapped should a patient be “non-compliant” with their treatment; this is language that I challenge at every opportunity and my recent blog on this topic reveals just how much. But I digress….

Ethics committees have been a condition of Joint Commission accreditation since 1992, yet there is massive variation in their implementation and use. The Joint Commission standard is clear: “healthcare organizations must have a mechanism in place to develop and implement a process that allows staff, [patients], and families to address ethical issues or issues prone to conflict.” Yet, the details of that mechanism are left to the discretion of each organization and therein lies the conundrum and challenge!

The Power of Ethics Committee 

The requirements for ethics committees were driven by increasing patient situations that involved a lack of clarity between patient and family wishes, expectations for treatment, the provider’s prognosis, and/or the patient’s treatment plan. The case of Karen Ann Quinlan is often viewed as that legal landmark to set the precedent for formalization of bio-ethics and ethics committees in hospitals. In April 1975 at the age of 21, Ms. Quinlan became unconscious after consuming Valium with alcohol while on a crash diet. She lapsed into a coma, followed by a persistent vegetative state. After a lengthy legal battle, the New Jersey Supreme Court allowed Ms. Quinlan’s parents to disconnect the respirator, affirming the choice she would have made; Karen lived until 1985. Other patient situations would follow and continue to appear, Terry Schiavo to Brittany Maynard and David Adox. The real-life experiences of these individuals have bolstered the vital role of ethics committees as one firm pillar of today’s healthcare process, leveraging the industry’s ethical principles of autonomy, beneficence, fidelity, justice, and nonmalfeasance.

Misconceptions Run Amuck

Despite clear guidelines for ethics committees, organizations can have a varied understanding of their moving parts. Among these points of confusion can be what members of the interprofessional team should be involved, how many persons should serve and for how long, the amount of onboarding required, and scope of each member’s role. Even the amount of work expected can prompt a moment of pause. Ethics committees are too often developed haphazardly and without a formal plan. The consequences of these actions yield an Ethics Committee in name only, which devalues the role of this critical resource for patients, their families, and the interprofessional teams that care for them. 

One of the largest misperceptions of ethics committees lies in their true function. Despite recent popular belief, ethics committees are not used to tell patients, their families, and members of the interprofessional team what to do. Ethics committees review the clinical nuances of individual patient situations and documentation from interprofessional team members to make sure the wishes of the patient and/or their legal representatives are acknowledged. This may be specific to end-of-life decision-making, reviewing futility of care determinations by practitioners, or recognizing the rights of patients to refuse care or treatment.

Ethics committees play a vital role is reviewing that the care rendered is done in accordance with all Federal and State laws and regulations. One of my physician co-chairs used to say, “Ethics Committees step in when the treatment team has employed their due diligence to engage, assess, and communicate with the patient and family, whether through informed consent, shared decision-making, or other collaborative efforts (e.g., team and/or family meetings, care coordination rounds). Anything less reflects incomplete work by the team.”

Functions of Ethics Committees in a Changing Practice Climate

It might seem optimal to involve the ethics committee’s objective lens for review of discharge planning processes, such as when a patient refuses to go to a particular nursing home in deference to another facility or plan. However, that can also be a misuse or critical resources. Ethics committees should not replace the dialogues of interprofessional team members with patients, families or each other.

Ethics Committees have three basic functions:

  • Consultation:
    • Ensure training and support for committee members and consultants.

    • Provide consistent subject matter expertise for cases requiring formal ethics evaluation and recommendations.
    • Develop and implement evaluation metrics to ensure quality improvement, and,
    • Develop appropriate reports, publications, presentations for both internal personnel and external strategic partners.
    • Promote ethical leadership behaviors, such as explaining the values that underlie decisions, stressing the importance of ethics, and promoting transparency in decision making.
  • Education
    • Assure knowledgeable ethics committee members.
    • Provide appropriate education to the organization (e.g., trainings, journal articles, reports, available literature on professional resource trainings and conferences).
  • Policy review and development

In recent years, ethics committees affiliated with academic institutions and large healthcare systems have advanced into comprehensive ethics programs. A growing number of healthcare organizations integrate ethics from the bedside to the boardroom (University of Washington, 2023).Others provide consultations in response to non-clinical ethics questions, such as identifying and remedying systems-level factors that have the potential to induce or exacerbate ethical problems and/or impede their resolution, as in staffing issues from workforce shortages. A valuable article recommends key foundational principles to:

  • Strengthen the position of ethics committees in hospitals, 
  • Ensure continuous supervision over committee formation and meetings, operations and decision-making processes, and
  • Define how committees’ decisions are shared with involved hospital stakeholders and staff.

Case managers can find out more on ethics committees, the seminal cases that drove them, and innovative ways to engage with them in Chapters 2 and 4 of The Ethical Case Manager: Tools and Tactics available on Amazon.