Category: Ethics

ERCI’s 2025 Top 10 Patient Safety Issues and Heeding Case Management’s Professional Obligations

ERCI’s 2025 safety issues represent a clear and present danger for patients with opportunities for all healthcare professionals. Yet, these quality missteps also yield concern for how case managers understand their professional obligations to the practice principles that underlie our licensure, certification, and organizational accreditation. 

I am a quality warrior! This fact means that my brain goes into overdrive when certain reports cross my radar.  The latest intel to have this impact was ERCI’s 2025 list of Patient Safety Threats. My focus immediately focused on the #1 issue, “Dismissal of the Patient and Caregiver Voice”. As a social worker by education and licensure and board-certified professional case manager, I am responsible for mitigating this quality gap. I also happen to be a fierce industry disruptor courtesy of my Doctorate in Behavioral Health. My DBH colleagues and students will get this one,  but I digress. 

I am an enduring ethical, legal, and regulatory champion to my core. I have been digging deep into the research, writing about, and presenting on medical gaslighting and invalidation for the past year. The dismissal and devaluing of any patient and caregiver voice is clearly associated with this obstructor to care. Medical gaslighting’s connection to increased costs of care is significant with billions of dollars lost from delayed and missed diagnoses. Increased healthcare utilization has come from unnecessary hospitalizations, readmissions, treatment missteps, yielding poor health outcomes. Mortality rates are equally higher when a patient’s voice or that of their caregiver is ignored.

Yet, two other areas of concern stood out to me as I reviewed the list of other patient safety priorities on the ERCI list:

  • #5. Caring for Veterans in non-military health settings
  • #9. Inadequate coordination during patient discharge

These two issues speak loudly to all of my colleagues, but particularly those in my professional case management world.

Professional Obligations Matter

Colleagues frequently ask me, why I get so hot about our established resources of guidance (e.g., accreditation and credentialing requirements, standards of practice, codes of ethics) ”. Yes, the hashtag or #EthicsMatter has become my hallmark. However, the list of 2025 safety issues represent a clear and present danger for patients. Quality missteps and patient safety concerns mean case managers are not heeding their professional obligations to the practice principles that underlie our licensure, certification, and organizational accreditation. This action represents potential professional sanctions for breach of the very requirements that bolster our case management profession. 

Standards of Practice

Those professionals who walk in the world of case management are accountable to assorted standards of practice and codes of professional conduct. The Case Management Society of America (CMSA) set the tone for these seminal documents, crafting the initial version in 1995. Updating of each version of the standards occurs through a formal vetting process that was completed in 2002, 2010, 2016, and 2022. The addition of Standard Q: DEIB and Health Equity yielded a revised version of the document in 2024. 

The intent of the standards are simple: to “serve as a compass for all who practice case management. They stand as a blueprint for excellence in practice”. They are not meant to be prescriptive in intent. Instead, they serve as a guide for professional case managers and their organizations to define optimal practices for the industry that meet ethical, legal, and regulatory guidelines and requirements. The relevant standards of practice by CMSA that address these patient safety realities include: 

D. Ethics

E. Advocacy

G. Resource management

I. Client selection

J. Client assessment

K. Identification of care needs and opportunities

L. Planning

M. Facilitation, coordination, and collaboration

N. Monitoring

O. Outcomes

P. Closure of professional case management services

Q. DEIB and health equity

Each standard details clear guidance for the workforce in each of these critical areas of case management practice. 

Licensure and Certification Requirements

Case managers have a primary responsibility to the licensure and scope of practice that underlies their professional discipline, whether in counseling, medicine, nursing, occupational, physical, respiratory or vocational therapy, social work or other qualified disciplines to practice (CMSA Standard A. Qualifications).  Yet, we are then responsible to our case management credentialing, which is often dependent on this primary licensure. 

Our credentialing entities prioritize the importance of critical competencies for their certificants through dedicated resources. The Code of Professional Conduct for Case Managers authored by The Commission for Case Manager Certification (CCMC) details keenly defined ethical standards, rules, procedures, and penalties for the workforce. The document’s Preamble sets a critical tone by defining case management as “a professional, collaborative, and interdisciplinary practice guided by the Code of Professional Conduct (the Code)”. The resource goes on to further denote the main purpose of the code; “to protect the public”. While the guidelines provided are advisory in nature, they still set a professional standard to which all board-certified case managers are held accountable.

The American Case Management Association (ACMA)’s Scope of Services and Standards of Practice also define clear competencies for practice. This resource also aligns with the association’s Accredited Case Managers Credentialing Exams, which have oversight by the National Board for Case Management:

Relevant Scope of Services, including but not limited to::

  • Assessment
  • Care coordination
  • Facilitation
  • Transition management  competencies 
  • Longitudinal care management
  • Identification
  • Implementation

Relevant Standards of Practice, including but not limited to:

  • Accountability
  • Advocacy
  • Resource management

Organizational Case Management Accreditation

Attention is also paid to these critical domains of practice by each of the entities that are tasked with providing, regulating, and monitoring of organizational case management accreditation. These include NCQA, URAC, and ANCC’s Magnet Recognition Program. The agencies define strict compliance requirements and standards for case management practice, as well as for the entities by which they recognize certification through. 

The workforce should remain aware of the following: 

Note: As of January 1, 2024, Magnet Status Recognition only accepts certifications accredited by the Accreditation Board for Specialty Nursing Certification (ABSNC) or the National Commission Certifying Agencies (NCCA). Included are  ANCC’s Nursing Case Management board certification (CMGT-BC) and the Commission for Case Management Certification’s Board-Certified Case Management Credential (CCM).

The Bottom Line

Case managers have a critical role in ensuring compliance with the ethical, legal, and regulatory  standards and requirements that underlie our practice. Each one of the established resources of guidance for case management prioritize our professional obligations to advocate for, monitor, and ensure patient safety; public protection remain a priority. They also heed every case manager’s accountability to the industry’s Quality North Star of the Quintuple Aim: patient- and family-centric care rendered at the right time, for the right cost, by professionals who embrace the work, and delivered in a way that is equitable and accessible for all.

ERCI’s Top 10 Patient Safety List for 2025 should be a call to action by every healthcare organization with attention from every case management leader and their teams. How will you and your organization step up to mitigate these gaps in quality and care? 

The DEI Crackdown in Academia Will Further Harm Patients and the Quality of Their Care: No “Could” About it!

There is no “could” about it; the current DEI crackdown in academia will yield negative outcomes for the workforce, but also worsen the quality of care rendered to patients, their families, and the communities we serve. 

A recent article published by MedPage Today and KFF Health News sent my brain into orbit. Entitled, Amid Falling Diversity at Med Schools, a Warning of DEI Crackdown’s Chilling Effect, the sub-title noted, “Education and health experts say this could ultimately harm patient care”. Use of “Could” in light of overwhelming evidence infuriates me. There is no “could” about it; the current DEI crackdown in academia will yield negative outcomes for the workforce, but also worsen the quality of care rendered to patients, their families, and the communities we serve.

The Value of Concordant Care

Concordant care involves aligning treatment with patient values and preferences. It is demonstrated in many ways, from open communication to having providers of the same race, ethnicity, sexual orientation, as well as gender identity, or gender expression. As a result, patients and their families feel psychological safety within a practice setting. Empathy is a vital competency for every healthcare professional that should be demonstrated toward every patient. But the ability to do so does not always assure concordant care. This is especially true when practitioners are employed by larger healthcare systems and organizations.

A patient’s need for health and behavioral health treatment brings them to practitioners for care. Yet, it is a patient’s trust in these practitioners that fosters their engagement in the care process. In addition, a patient’s comfort with providers of the same ethnicity, gender, race, or life experiences promotes their ability to feel safe, seen, heard, valued, and respected in the treatment space. In tandem, the practitioner’s knowledge of a patient’s culture, values, and beliefs inform their awareness of patient health literacy opportunities. This might translate to addressing spiritual and cultural differences in care, such as the need for prescription medications or treatments for chronic illness or even behavioral health. 

Discordant care contributes to medical gaslighting and invalidation. Dismissal of the patient and caregiver voice is the top patient safety issue for 2025, and a frightening fact. Increased numbers of Black primary care physicians are associated with longer life expectancy and lower mortality rates among Blacks. Similarly, when providers can identify with their patients, there are higher degrees of patient engagement, patient satisfaction, and treatment adherence for women, members of the LGBTQIA+ community, and other traditionally marginalized groups.

Healthcare utilization is higher and care costlier for these populations due to a trail of ignored complaints and symptoms and missed diagnoses. Their mortality rates are upwards of double that of numbers for less marginalized groups. These figures will only worsen as the patient voice is reduced, and particularly for traditionally marginalized populations and communities. My prior articles have detailed these abysmal numbers, with an upcoming article on this topic to be published in the May/June issue of Professional Case Management.

Systemic Bias

Countless thought leaders have emphasized the need for attention to treatment bias in healthcare. The Institute of Medicine’s seminal 2003 report, Unequal Treatment noted how African Americans and those in other minority groups receive fewer procedures and poorer-quality medical care than Whites. Stereotypes and stigma have impacted care across every cultural nuance encompassing ethnicity, gender, disability, race, and sexual identity to name just a few. These faulty beliefs have impacted every aspect of care from inaccurate treatment algorithms that fail to account for gender, race, and ethnicity to effective pain and other symptom management. Proper prescription medication dosing and other treatment is also at issue with condition not properly addressed. Patients are unnecessarily blamed for their symptom presentation rather than being fully assessed for individualized care.

The Mandate for Workforce Diversity and DEI Programs

A series of professional reports have identified opportunities to advance diversification of the healthcare workforce. The Council on Social Work Education revealed while 90% of social workers graduating with their MSW were women, opportunities for enhancing diversity continue to present. Only 22% of these same students were Black and 14% were Hispanic or Latino. The National Council of State Boards of Nursing revealed similar numbers with nurses from minority backgrounds representing under 20% of the RN workforce. Composition with respect to racial backgrounds is: 

  • 80.6% Caucasian
  • 6.7% African American 
  • 7.2% Asian
  • 5.6% Hispanic
  • 0.5% American Indian/Alaskan Native
  • 0.4 Native Hawaiian/Pacific Islander 
  • 2.1% two or more races; and 
  • 2.5% other

The Physician workforce also fails to reflect the inclusive nature of patient populations:

  • White: 56.5%
  • Asian: 18.8%
  • Hispanic or Latino: 6.3%
  • Black or African American: 5.2%
  • Multiracial (non-Hispanic): 1.3%
  • Other: 1.1%
  • American Indian or Alaska Native: 0.3%
  • Native Hawaiian or Other Pacific Islander: 0.1%
  • Unknown: 10.4% 

Gender composition notes a greater percentage of those identifying as male vs. female: 60.5% compared to 39.5%. 

There is growing availability of health and behavioral health professionals who provide affirming, accepting, and inclusive care to all patients, yet access remains challenging. Outcare and FOLX health provide directories of LGBTQIA+ friendly providers. Data detailing workforce composition for this community remains limited, though one report notes barely 14% of all medical students identify within the community.

In direct response to the percentages above, professional schools advanced DEI programs. Academia has worked for the better part of the last decade to shift from a curriculum of racial bias and develop antiracist and anti-oppressive programming. New coursework was developed with expansion of learning experiences, practicums, residencies, and specialized learning forums. These approaches prepared clinicians to better understand the patients they treat. Deshazo et al. (2021) identify how “deeply rooted bias is within the infrastructure of American Medicine, based on skin color, religion, immigrant status, gender, and ethnicity are deeply rooted, and taught as scientific racism medical schools from their earliest points in history.” This new societal playbook is a return to those times where fear of segregation and rampant inequities in access to quality care are the norm, along with putting minorities and women “back in their place”.

The UC Davis School of Medicine initiated a “race-neutral, holistic admissions model”, which tripled enrollment of Black, Latino, and Native American students. Assorted other efforts increased funding and entry to healthcare career pathways for students unable to otherwise afford or access them. There are an endless list of merits for the communities served by these new clinicians, including growth of diverse workforce that matches the patients served. 

Communities Take Care of Their Own

I’ve long said that communities take care of their own and this reality can’t be overstated. Practitioners of color are more likely to build their careers in medically underserved areas, from rural communities to lower socioeconomic areas.  The 2024 report by AAMC is clear: a shortage of >40,00 primary care doctors is expected by 2036 unless dramatic changes occur.

One way to assure workforce intercultural effectiveness has been through CEU-requirements for licensure and renewal. Yet even these requirements are now at risk. The Texas Behavioral Health Executive Council voted for removal of language requiring cultural competence as a CEU-requirement for licensed mental health professions with other states working to advance similar actions. This move de-emphasizes cultural context as a critical element of providing and assuring ethical and responsible care and intervention to each person. These shifts will create gaps in the knowledge and skills needed for the workforce to effectively engage with and serve patients from diverse backgrounds, cultures, and genders. Respect for the unique experiences, beliefs, and values that distinguish populations and communities will surely be at risk.

Moving Forward

As my colleagues in this space know, strategic action remains a moving target. We stay informed, yet angry at the daily assault on inclusion. Yet, that anger drives my actions, which are absolute: 

  • I stay committed to the Quintuple Aim: providing patient- and family-inclusive care at the right time, right cost, rendered by those who embrace the work, and ensuring equity and accessibility for all. 
    • I continue to heed my professional ethical obligations to patients, their families, and colleagues. Every day, I define one tangible way to step up in this shifting space to advance diversity, equity, inclusion, accessibility, belonging, and social justice, and through my every action, whether by:
      • Use of my professional voice through teaching, training, or authorship.
      • Supporting the workforce through ethical challenges faced in their workspaces.
      • Mentoring newer practitioners on clear strategies for their own sustainability.
      • Advocacy through my assorted roles across the industry 

How will you step up and into this space today?

Caught in the DEI & Health Equity Crossfire?: The Current State of the Social Work Compact

The Social Work Licensure Compact is again on the move. However, will it stall amid the current DEI and Health Equity crossfire spanning the US? What will the impact be to other licensure compacts, such as those for nursing, medicine, psychology, and others?

As the current state legislative session is in full swing, I thought it was a good time to review the status of the Social Work Compact. We entered the 2025 session with 24 states previously passing the Compact: Alabama, Arizona, Colorado, Connecticut, Georgia, Iowa, Kansas, Kentucky, Louisiana, Maine, Minnesota, Mississippi, Missouri, Nebraska, New Hampshire, North Dakota, Ohio, Rhode Island, South Dakota, Tennessee, Utah, Vermont, Virginia, and Washington State. The Social Work Licensure Compact Commission is advancing the formal infrastructure with the current target date for implementation by Fall 2025.

As of the time of this writing, 18 more states have stepped up with new legislation to advance the compact further: Alaska, California, Florida, Illinois, Indiana, Maryland, Mississippi, Montana, Nevada, New Jersey, New Mexico, North Carolina, Oklahoma, Oregon, Pennsylvania, South Carolina, Texas, Wisconsin. 

The Compact Landscape

There is considerable workforce commitment to advance compacts across every discipline. Contributing factors include workforce mobility and for their patient populations, along with telehealth popularity. The current state tally for compact passage across other professions includes: 

A Clear and Present Danger

Let’s get one elephant out of the corner of this room. There has been pushback by several states against the Social Work Compact due to inclusion of a requirement for passage of a standardized licensure exam. That is a valued discussion, though not the focus of this blog article.

The immediate concern to compact passage involves those states with what may be considered as more liberal rather than conservative practices or vice versa depending on your viewpoint. To practice in any compact member state, social workers must abide by laws, regulations and scope of practice of the state in which the client is located. As a result, concern has been expressed over any potential liability of workforce members should their interventions be counter to emerging legal practices for the state. Precedents for these concerns have already been defined through legal actions against our interprofessional colleagues across medicine, nursing, and other behavioral health professionals in some states. There are equal concerns about practitioners contacting ICE to report patients who present for treatment that may be undocumented. These actions are counter to professional standards previously addressed in my blog article on this topic several months ago, To Report or Not Report: Mandatory Duty to Warn for Case Management (though applicable intel for all professions). Of primary concern are states that:

  • Do not allow abortion or limit emergent medical attention to the mother in emergency situations where the health of the individual is at gross risk (e.g., miscarriages)
  • Do not allow or limit provision of resources to minors of their families for the purpose of obtaining out of state abortions in the instance of child abuse or exploitation
  • Do not allow or limit provision of resources to adults or their families for the purpose of obtaining out of state abortions for any reason including for rape, incest, or other sexual assault or intimate partner violence; this might also include providing of the morning after pill or other medical treatment guidance. 
  • Have restrictive reproductive health limits for treatments (e.g., in vitro fertilization), or other medical treatments (e.g., stem cell transplants). 
  • Do not allow or limit gender-affirming care or the provision of information on such care to minors 
  • Do not acknowledge transgender rights and access to necessary care
  • Do not acknowledge the value of concordant care across vulnerable and traditionally marginalized populations
  • Enforce cuts to Medicaid and Medicare Advantage plans that limit access to or deny services that promote patient, family, or care-giver self-sufficiency and wellness (e.g., durable medical equipment, home health care, skilled nursing facility)
  • Limit access to substance use disorder and medically-assisted treatments 
  • Do not allow use of language specific to diversity, equity, inclusion, belonging, accessibility, health equity, social justice and any aligned terminology 

There are endless examples of other concerns, along with emerging legal cases against the workforce. Some states are engaged in lawsuits against practitioners for denying emergent medical care to patients hemorrhaging from miscarriages, with mortality rates unnecessarily rising from this level of negligence. Maternal deaths in Texas have risen by close to 60% following the abortion ban. An Ohio women who suffered a miscarriage at 22 weeks of gestation in her home and sought treatment at a local hospital, initially faced criminal charges. As if the trauma of her health experience was insufficient, she was then charged with a felony; a judge ultimately dismissed the case. There are countless other similar situations. 

Moving Forward

As noted in my prior blog article, there have always been caveats to a professional’s legal and ethical obligations when religious, cultural, or other values and mores have the potential to obstruct effective care of a patient. In those situations, a safe handoff to another professional is indicated. These caveats carefully balance patient right to autonomy, self-determination, and do not harm with practitioner values. Yet, despite these protections, compact expansion has still gotten caught up in the latest values- and cultural-backlash. 

Mental health demand in the U.S. has never been higher. Given the pent-up demand for behavioral health and other services, social workers and other professionals must be able to practice across state lines. Compact expansion and social work ethics must not be allowed to suffer due to these current realities. 

The Ongoing Saga of Healthcare’s Ethical, Legal, and Regulatory Dilemmas Due to those Executive Orders

Recent Executive Orders and related actions have brought new ethical, legal, and regulatory challenges for healthcare professionals.

I traditionally avoid posting on social media about anything that might be viewed as “political”. However, my view has changed amid the latest string of Executive Orders and related actions. Each of these EOs seeks to deny the presence of certain populations, restrict equitable care access for historically marginalized and minoritized communities, as well as obstruct educational and professional pathways to career opportunities for all persons.

Colleagues have authored countless articles and blogs on the intent and reach of Executive Orders, impact on DEI efforts, and related themes. The resources are worth a deeper dive for those with interest. My focus for this article is on how the issue puts healthcare professionals directly in ethical, legal, and regulatory crosshairs, and especially my colleagues in case management.

The “Flagged Words” and Existing Regulations and Requirements

The lengthy and growing list of “flagged words” to avoid in grant requests, professional references, education, and continuing education is concerning. Most of the included terms appear in rigorous CEU-requirements for the healthcare workforce, and across more than half of the U.S: accessibility, anti-oppressive practices (implicit) bias, cultural competency and/or humility, discrimination, diversity, equity, immigration, inclusion, and social justice, to name a few. For CEU-approval, these words are required to appear in presentation and training abstracts or their learning objectives. Among other cautionary words are advocate, female, gender, political, socioeconomic, status, trauma, women, and victim.

Much of the terminology is embedded within our established resources of guidance: regulatory language for licensure practice acts, federal mandates, academic and organizational accreditation, case management and other individual exam-based certifications, ethical codes of conduct, and professional standards of practice. Examples of these include:

Licensure Renewal or Not?

Many of the terms at issue appear across professional practice acts and regulations. I’d cue my colleagues to check their current CEU-requirements for any state(s) of licensure or certification; the language is crystal clear. There are large consequences for persons unable to fulfill their renewal requirements, including fiscal costs by loss of employment. There are also potential sanctions or reprimands should one choose to abandon, refuse, or rescind care (without an alternative provided) to patients in need of emergent treatment and intervention. 

Ethical and Legal Exclusions

It is understood that not every professional shares the same belief system and mores. Yet, caveats have long been written into the established resources of guidance for religious or moral exclusions and other acknowledged beliefs that could bias or obstruct a person from rendering the acceptable standards of care delivery. All professionals are accountable to complete a safe and appropriate transfer of care to minimize the potential for patients to be put at risk of physical or emotional harm. This language, or some similar verbiage, appears across professional standards of practice and ethical codes for all disciplines and advanced specialty practices, including those for my case management colleagues.

It is also understood that some professionals reside in states where certain language has been excluded under federal law. However, our professional and ethical obligations to patients, their families, and other support systems remain paramount.

In a concerning move, the Texas Behavioral Health Executive Council voted to give preliminary approval for removal of language that requires cultural competence as a CEU-requirement for several licensed mental health professions, including counseling, marriage and family therapists, psychologists, and social workers. Prior requirements for renewal were for 24 total hours of CEUs, of which 6 were dedicated to ethics and 3 for cultural diversity or competence. The proposed revision is to “ensure competency when providing services to a distinct population, defined as a group of people who share a common attribute, trait, or defining characteristic of the licensee’s choice.” The term cultural competence has long been challenged due to its implication that every professional should be competent in every culture, which is not possible. However, other terminology has been recommended from intercultural effectiveness to cultural humility. The latter term is focused on practitioner awareness of distinct cultural nuances across populations and communities with a dedicated commitment to ongoing learning that advances their practice.

The action by Texas has prompted considerable pushback with concerns by other states on how the new rule could allow practitioners to bypass cultural diversity training about marginalized communities. This action de-emphasizes the topic’s importance to the workforce, as a critical component of providing and assuring ethical and responsible care and intervention to each person. Further actions of this type will lead to gaps in the knowledge and skills needed by the workforce to effectively engage and serve clients from diverse backgrounds, cultures, and genders. Respect for the unique experiences, beliefs, and values that distinguish populations and communities will surely be at risk.

Our Quality North Star is Under Attack

Excluding words or erasing populations does not dismiss the inequities and injustices faced by those communities. Quality-driven patient-inclusive care is an industry mandate for anyone in healthcare and its associated sectors.Colleagues have even shared how content referencing the Quintuple Aim has come under fire. This construct is the long-respected Quality North Star of our industry: population and patient-inclusive care rendered at the right time, for the right cost, by those who embrace the work, and is accessible by all persons. With National Health Expenditures slated to be at over $5.3 Trillion dollars for 2025 and hit over $7 Trillion by 2031, too much is at stake for any lesser of a quality vision.

Our Enduring Professional Obligations

Advocacy is another “forbidden word”. Yet, that word remains an enduring ethical mandate and legal obligation for all licensed and/or certified healthcare professional and disciplines. All persons deserve to feel safe, seen, heard, valued, and respected. Equally included in this mix is each practitioner, our families, as well as any friends who are patients receiving care. I have no intention of waiving these obligations or shifting my professional focus of the past 42 years.

What about you?

Tackling Workplace Bullying and Promoting Psychological Safety

October is National Workplace Bullying Awareness Month. The incidence of bullying within healthcare continues to rise, and with dangerous consequences for patients, as well as the workforce itself. Identify workplace bullying’s newest dimensions and learn how to promote your psychological safety.

October is National Bullying Awareness Month. Every year I hope for improvement in the landscape of this fierce disruptor, and especially for my colleagues within healthcare. Yet, the incidence of incivility keeps rising. The post-pandemic disruption continues with workforce shortages, attrition and retention challenges, staff burnout, and a slew of occupational hazards. What began decades ago with a few posturing practitioners and nurses who ate their young remains an interprofessional sport that every discipline plays, and nobody gets to sit out.

Psychological Safety and Workplace Bullying

Bullies take chronic hits at your psychological safety. Their goal is to make you feel inefficient, ineffective, and incapable of performing your role. They mess with your perception of whether it is safe to take interpersonal risks within your appointed role at work, such as in taking initiative to advocated for patient care and treatment. They sabotage your sense of self and thus confidence so that you may fail to follow through on critical communications with team members. Ultimately, the quality of your workplace performance is questioned along with your mental health.

Bullies are ever-present across sectors and can invade your volunteer experiences, such as roles for a professional association or other efforts. An activity you engaged in for sheer enjoyment, becomes as arduous to engage in as any professional role. Ultimately your occupational health, mental health, and safety are all compromised. Every member of healthcare’s valued interprofessional workforce is impacted:

Bullying and incivility incidence have ramped up from DEIB’s lens, and impacting:

Negative outcomes are plaguing quality improvement and risk management specialists across practice settings. Incivility by practitioners leads to medical errors >75% of the time, and resulting in death >30% of the time. The workforce is also at elevated risk of trauma, and especially suicide from repeated psychological assaults:

  • Suicidal ideation: >30% of victims (of bullying) 
  • Suicide: Victims 2X as likely to take their own life compared to those not exposed

Bullying’s Advancing Dimensions

Bullying is a consistent pattern of repeated, health-harming mistreatment of one or more members of the workforce, marked by abusive conduct that is threatening, humiliating, or intimidating. Work is delayed, sabotaged, and obstructed. These are impediments that NO professional can afford in the fast-paced industry. We’re not talking about random episodes when someone feels crispy around the edges or has a bad day, but rather a chronic and recurrent pattern of behaviors that somehow devalues others.

Gaslighting, Mobbing, and Remote Bullying, OH MY!

Bullying has morphed into assorted dimensions. Gaslighting occurs when a colleague ignites the gas by tossing out an inflammatory implication that forces you or others to question your actions or ability to do the job. The bully fans the fire by ongoing attacks; they may challenge your memory of events, such as implying that you ‘forgot’ to follow up on dialogues with a patient’s family or member of the care team. There may be comments to other colleagues about your bouts of ‘memory loss’. Imagine, being approached by staff or patient families to verify if you completed documentation that you clearly recall doing. Even you start to question the quality of your work performance, especially as your reputation and job performance are at issue. Six types of gaslighting are:

  • Countering: Challenging someone’s memory 
  • Denial: Refusal to take responsibility for actions
  • Diverting: Changing a discussion focus by questioning someone else’s credibility 
  • Stereotyping: Generalizing through negative or discriminatory views of a person’s race, ethnicity, sexuality, nationality, or other cultural nuance. 
  • Trivializing: Disregarding when someone feels minimized by what is said and devaluing the impact
  • Withholding: A bully pretends to not understand a conversation and refuses to listen to another person’s view. That person ends up doubting themself. 

Mobbing is bullying on steroids and occurs when multiple staff target one or more personnel. Almost 50% all bullying incidents involve mobbing with 54% of primary care professionals exposed to this type of incivility on at least one occasion. Perhaps, a new director of Case Management at an MCO changes the job description to require all new hires to possess case management certification; current employees must be certified by the end of that calendar year. Staff view this requirement as an undue hardship and become frustrated. The rumor mill ensues: ‘The quality of the work isn’t important, only if we can pass a test.’; ‘she doesn’t care about us.’ The mob works to discredit the boss and push her out the door. Staff may view a new colleague as not fitting in, whether because of being in a different age group, professional discipline, as well as race, ethnicity, gender, sexual orientation or other cultural nuance. As a result the staff member does not feel safe, seen, heard, or valued.

Remote bullying has risen amid the increase of virtual roles. Some 43% of employees were exposed to remote bullying experiences:

  • 50% of incidents during virtual meetings
  • 10% via email interactions, and 
  • 6% during group emails and chats. 

What YOU Can Do to Promote Psychological Safety!
Bullies are insidious and invasive in their efforts. BUT, here’s their dirty secret and biggest misstep! BULLIES target the most ethical, hard-working, and high-performing individuals in an organization. If you’ve been bullied, it means you’re more powerful than you’ve ever imagined, as you’re a threat to the bully and their ineptitude.

Tackling bullying involves strategy:

  • Intervene early: Don’t let a precedent be set and address the behavior directly
  • Don’t react to the bully: ‘Take 10’ to breathe, consider, and define an approach
  • Document each incident: Date, time, witnesses, and who you discussed it with.
  • Don’t let the bully isolate you: Keep engaged with peers and those who trust your savvy.
  • Set limits on negative behaviors you will allow: We may let small things go, but stay vigilant.
  • Don’t share lots of personal details at work: This info will be used against you
  • Take time to recharge from incidents: Mental health days or vaca help restore your resilience
  • Seek Support: Peer support and mental health support are MUSTS; one may potentially need independent legal support!
  • Put your best professional self forward: Bullies thrive on the weakness of others, so keep showing that best version of yourself  
  • Approach bullying as a work project: Being methodical keeps you in control. Assess  financial costs of staff departures related to bullying, and the ROI of psychological safety and other workforce retention strategies

Those steps and other ways to advance each above strategy live in Chapters 3 and 6 of The Ethical Case Manager: Tools and Tactics. The book’s content:

  1. Defines terms associated with workplace bullying
  2. Discusses how workplace bullying impacts physical and mental health 
  3. Aligns workplace bullying, quality of care, and patient safety 
  4. Recognizes the “Bullying Recipe” within organizations
  5. Examines how the practice culture of professional education impacts incidence
  6. Explores the incidence across the DEIB landscape 
  7. Identifies types of organizational culture that contradict workplace bullying
  8. Discusses leadership styles to impact workplace bullying in organizations
  9. Identifies legislation and professional initiatives to combat workplace bullying
  10. Explores how bullying impedes the ethical performance of case managers 
  11. Offers quality monitoring tools to address unprofessional behaviors
  12. Informs you how to calculate costs of workplace bullying for your organization 

REMEMBER

Keep Ellen’s Ethical Mantras close by:

  • We deserve respect.
  • We deserve to feel safe. 
  • We deserve not to feel trapped in a toxic workplace.
  • We deserve to have our knowledge and expertise valued.
  • We deserve to have confidence that all are accountable for their actions.
  • We deserve to be able to confront workplace bullying without fear of retribution.

October is National Bullying Awareness Month. Every year I hope for improvement in the landscape of this fierce disruptor, and especially for my colleagues within healthcare. Yet, the incidence of incivility keeps rising. The post-pandemic disruption continues with workforce shortages, attrition and retention challenges, staff burnout, and a slew of occupational hazards. What began decades ago with a few posturing practitioners and nurses who ate their young remains an interprofessional sport that every discipline plays, and nobody gets to sit out.

Psychological Safety and Workplace Bullying

Bullies take chronic hits at your psychological safety. Their goal is to make you feel inefficient, ineffective, and incapable of performing your role. They mess with your perception of whether it is safe to take interpersonal risks within your appointed role at work, such as in taking initiative to advocated for patient care and treatment. They sabotage your sense of self and thus confidence so that you may fail to follow through on critical communications with team members. Ultimately, the quality of your workplace performance is questioned along with your mental health.

Bullies are ever-present across sectors and can invade your volunteer experiences, such as roles for a professional association or other efforts. An activity you engaged in for sheer enjoyment, becomes as arduous to engage in as any professional role. Ultimately your occupational health, mental health, and safety are all compromised. Every member of healthcare’s valued interprofessional workforce is impacted:

Bullying and incivility incidence have ramped up from DEIB’s lens, and impacting:

Negative outcomes are plaguing quality improvement and risk management specialists across practice settings. Incivility by practitioners leads to medical errors >75% of the time, and resulting in death >30% of the time. The workforce is also at elevated risk of trauma, and especially suicide from repeated psychological assaults:

  • Suicidal ideation: >30% of victims (of bullying) 
  • Suicide: Victims 2X as likely to take their own life compared to those not exposed

Bullying’s Advancing Dimensions

Bullying is a consistent pattern of repeated, health-harming mistreatment of one or more members of the workforce, marked by abusive conduct that is threatening, humiliating, or intimidating. Work is delayed, sabotaged, and obstructed. These are impediments that NO professional can afford in the fast-paced industry. We’re not talking about random episodes when someone feels crispy around the edges or has a bad day, but rather a chronic and recurrent pattern of behaviors that somehow devalues others.

Gaslighting, Mobbing, and Remote Bullying, OH MY!

Bullying has morphed into assorted dimensions. Gaslighting occurs when a colleague ignites the gas by tossing out an inflammatory implication that forces you or others to question your actions or ability to do the job. The bully fans the fire by ongoing attacks; they may challenge your memory of events, such as implying that you ‘forgot’ to follow up on dialogues with a patient’s family or member of the care team. There may be comments to other colleagues about your bouts of ‘memory loss’. Imagine, being approached by staff or patient families to verify if you completed documentation that you clearly recall doing. Even you start to question the quality of your work performance, especially as your reputation and job performance are at issue. Six types of gaslighting are:

  • Countering: Challenging someone’s memory 
  • Denial: Refusal to take responsibility for actions
  • Diverting: Changing a discussion focus by questioning someone else’s credibility 
  • Stereotyping: Generalizing through negative or discriminatory views of a person’s race, ethnicity, sexuality, nationality, or other cultural nuance. 
  • Trivializing: Disregarding when someone feels minimized by what is said and devaluing the impact
  • Withholding: A bully pretends to not understand a conversation and refuses to listen to another person’s view. That person ends up doubting themself. 

Mobbing is bullying on steroids and occurs when multiple staff target one or more personnel. Almost 50% all bullying incidents involve mobbing with 54% of primary care professionals exposed to this type of incivility on at least one occasion. Perhaps, a new director of Case Management at an MCO changes the job description to require all new hires to possess case management certification; current employees must be certified by the end of that calendar year. Staff view this requirement as an undue hardship and become frustrated. The rumor mill ensues: ‘The quality of the work isn’t important, only if we can pass a test.’; ‘she doesn’t care about us.’ The mob works to discredit the boss and push her out the door. Staff may view a new colleague as not fitting in, whether because of being in a different age group, professional discipline, as well as race, ethnicity, gender, sexual orientation or other cultural nuance. As a result the staff member does not feel safe, seen, heard, or valued.

Remote bullying has risen amid the increase of virtual roles. Some 43% of employees were exposed to remote bullying experiences:

  • 50% of incidents during virtual meetings
  • 10% via email interactions, and 
  • 6% during group emails and chats. 

What YOU Can Do to Promote Psychological Safety!
Bullies are insidious and invasive in their efforts. BUT, here’s their dirty secret and biggest misstep! BULLIES target the most ethical, hard-working, and high-performing individuals in an organization. If you’ve been bullied, it means you’re more powerful than you’ve ever imagined, as you’re a threat to the bully and their ineptitude.

Tackling bullying involves strategy:

  • Intervene early: Don’t let a precedent be set and address the behavior directly
  • Don’t react to the bully: ‘Take 10’ to breathe, consider, and define an approach
  • Document each incident: Date, time, witnesses, and who you discussed it with.
  • Don’t let the bully isolate you: Keep engaged with peers and those who trust your savvy.
  • Set limits on negative behaviors you will allow: We may let small things go, but stay vigilant.
  • Don’t share lots of personal details at work: This info will be used against you
  • Take time to recharge from incidents: Mental health days or vaca help restore your resilience
  • Seek Support: Peer support and mental health support are MUSTS; one may potentially need independent legal support!
  • Put your best professional self forward: Bullies thrive on the weakness of others, so keep showing that best version of yourself  
  • Approach bullying as a work project: Being methodical keeps you in control. Assess  financial costs of staff departures related to bullying, and the ROI of psychological safety and other workforce retention strategies

Those steps and other ways to advance each above strategy live in Chapters 3 and 6 of The Ethical Case Manager: Tools and Tactics. The book’s content:

  1. Defines terms associated with workplace bullying
  2. Discusses how workplace bullying impacts physical and mental health 
  3. Aligns workplace bullying, quality of care, and patient safety 
  4. Recognizes the “Bullying Recipe” within organizations
  5. Examines how the practice culture of professional education impacts incidence
  6. Explores the incidence across the DEIB landscape 
  7. Identifies types of organizational culture that contradict workplace bullying
  8. Discusses leadership styles to impact workplace bullying in organizations
  9. Identifies legislation and professional initiatives to combat workplace bullying
  10. Explores how bullying impedes the ethical performance of case managers 
  11. Offers quality monitoring tools to address unprofessional behaviors
  12. Informs you how to calculate costs of workplace bullying for your organization 

REMEMBER

Keep Ellen’s Ethical Mantras close by:

  • We deserve respect.
  • We deserve to feel safe. 
  • We deserve not to feel trapped in a toxic workplace.
  • We deserve to have our knowledge and expertise valued.
  • We deserve to have confidence that all are accountable for their actions.
  • We deserve to be able to confront workplace bullying without fear of retribution.

Medical Gaslighting and Employing Ethical Equity Advocacy

Medical Gaslighting intersects directly with health equity and is among the industry’s top priorities. What started with Lyme disease, chronic illness and chronic fatigue syndrome, now spans every disease state. There are massive fiscal, clinical, and human consequences from delayed and incorrect treatment.

Stop and consider if you, a family member, or someone you care about has experienced any of the following:

  • Had pain, or the severity of that pain, devalued by a provider?
  • Had a healthcare symptom, or severity of a symptom, dismissed by a provider?
  • Had a healthcare symptom, or severity of a symptom, attributed to “too much stress or balancing too many priorities”?
  • Had the presence, or severity of a behavioral health symptom (depression, anxiety, agitation, worry, insomnia), minimized by a provider?
  • Been told that you’re overthinking symptoms because of being “in the biz”?
  • Been interrupted by a provider while presenting symptoms
  • Had a diagnosis and/or treatment delayed or deferred?
  • Been told to stop self-diagnosing on the internet, OR
  • Left a provider feeling that you weren’t safe, seen, heard, or valued?

If you’ve acknowledged any experience on this list, then Medical Gaslighting (MG) has gained unwelcome entry into your world. What started with Lyme disease, chronic illness and chronic fatigue syndrome, now spans every disease state. However, it is also evident that MG intersects directly with health equity, and is among the industry’s top priorities.

Definitions and Distinctions

Gaslighting involves psychological manipulation through inappropriate use of power and has long been associated with bullying. Consider the boss who invalidates an employee’s thoughts, feelings, or emotions by making that person question what was said, thought, or if any of the events that were experienced really happened. Logical rationale is questioned, as well as the individual’s mental sanity. MG is an extension of this behavior and counter to patient-inclusive and proactive care.

MG is not simply a difference of opinion or negative interaction with a practitioner. It involves physician (or practitioner) ignorance and a blatant misuse of power to disregard, dismissal, degrade, and devalue the patient, their family, or other decision-makers. These actions may occur verbally or non-verbally, as in the curt reply to a question posed, eye-rolling or grimacing. Patients may face chronic interruptions by the provider and not be permitted to present their symptoms fully. Worries about increased shortness of breath, chest pain, decreased endurance, or brain fog become trivialized and chalked up to stress. Concerns about decreased mobility or functionality are automatically associated with menopause or “normal” aging.

There may be documentation entered in a person’s electronic health record noting biased perspectives of a patient’s “chronic” or “repeated” visits to the provider, or even “drug-seeking” behaviors. Perhaps a patient’s unanswered questions about their health status prompt frustration and, thus, a more assertive presentation. The provider views this behavior as aggressive and documents it as such. Patients are made to feel powerless and guilty for their self-advocacy, and blamed for being engaged and motivated participants in their healthcare process. These dynamics can easily trigger a patient’s trauma experiences, and from any point in their lives.

Ethics, Evidence, and Equity Impact

MG involves the privilege of biomedical expertise over lived experience. The physician is often viewed as a revered spokesperson for the institution of medicine; this perspective provides them with an endowed power to pronounce which symptoms are real and which are not. The result is a refusal to listen to patients and appropriately diagnose their illness, with increased morbidity and mortality rates. There are massive fiscal, clinical, and human consequences from grossly delayed, poor, and incorrect treatment.

MG is counter to the ethical principles shared by all health professionals: autonomy, beneficence, fidelity, justice, and nonmaleficence. The evidence demonstrates the concerning escalation of MG’s ethical equity impact across populations, and specific to patient physical and psychological harm:

  • 94% of patients note at least one experience of MG in their interactions with providers, with roughly 10% on multiple occasions
  • Women and Persons of Color have the highest rates of maternal mortality with dismissal of symptoms or voiced concerns, and delay in treatment; this is often associated with systemic racism and bias by providers.
    • Black women die at a rate of 41.7%, American Indian and Alaska Native women at a rate of 28.3%, and White women at a rate of 13.4%.
  • 66% of women are told (by providers) that their physical symptoms (e.g., headaches, shortness of breath, severe pain, excessive bleeding) were stress-related, or due to obesity
  • Women are 4X more likely than men to have their physical symptoms attributed anxiety, depression, or stress.
  • Diagnoses of cancer, heart disease, and other chronic illnesses in Women are often delayed by a minimum of 4 years compared to men.

Marginalized and minoritized populations experience a far higher incidence and prevalence of MG compared to other populations. Recent research validates how >50% of healthcare workers identified providers as more accepting of White patients who advocate for themselves than Persons of Color. Even when communicating the same messaging and in the same way (e.g., in-person), Whites are viewed as assertive while Persons of Color are more often assessed to be aggressive, and an immediate safety threat.

Data across these populations would fill several articles, but chew on these outcomes for now:

The LGBTQIA+ Community:

  • 50% are more likely to have experienced MG vs. cisgender, heterosexual people.
  • 40% had at least one negative experience or form of mistreatment from a health care provider in the past year

Individuals seeking Reproductive Health:

  • 72% experienced MG by providers
  • 57% were told their infertility was due to stress or anxiety
  • 54% were told that gaining or losing weight would improve their fertility outcomes
  • 37% of Women of Color were denied care for symptoms associated with cancers, blood clots, and other acute health issues.

Older Adults

  • 45% felt their symptoms were dismissed or devalued by providers
  • 54% were Women of Color

Ableism

There is a large data gap involving Ableism and MG. Ableism is the marginalization of disabled people according to their disability status. Individuals with visible and invisible disabilities are among the largest marginalized groups in the US. They face gross health inequities with poor outcomes and were officially designated by the National Institute on Minority Health and Health Disparities (NIMHD) as a health disparity population. Considerable literature speaks to the mandate for practitioner training, as well as ongoing care gaps, stigma, and discrimination faced by individuals. Yet, despite these realities and almost 25 years since passage of the 1990 Americans with Disabilities Act, systemic barriers to healthcare access are the norm versus the exception. While volumes of anecdotal data demonstrate the severity of these issues, frequent invalidation by practitioners remains a mandated area of focus for the research.

Long COVID

  • 79% report negative interactions with providers
  • 34% had symptoms dismissed
  • 39% identified delays in treatment
    • 75% identified as Female
    • 22% identified as Male
    • 3% as other

Employing Ethical Equity Advocacy

Four critical steps will enhance effective management of MG by case managers and other health professionals.

First, Heed Established the Resources of Guidance: These evidence-based and industry-vetted resources guide how professionals step into their work. These resources span professional regulations and practice acts across all disciplines, organizational accreditations (e.g., CMS, NCQA, URAC, NQF, Joint Commission) and codes of ethics and professional conduct for individual certifications and credentials, as well as standards of practice for professional associations. My colleagues in case management should be particularly familiar with their professional codes of conduct (2023) through CCMC, CDMS, and CRCC and CMSA‘s Standards of Practice for Case Management (2022). All:

  • Prioritize cultural humility and awareness
  • Mandate a whole person assessment
  • Promote health equity through every effort
  • Heed integrity, worth of the person, and objectivity in all relationships
  • Leverage ethical principles of autonomy, fidelity, beneficence, justice, and nonmalfeasance through every professional intervention and interaction.

Second, Promote Psychological Safety Using Trauma-Informed Care and Other Anti-Oppressive Practices: Implement use of Trauma-informed Care to set a space where patients, their families, and staff feel respected by, comfortable with, and confident of the care they receive, and by every member of the workforce. Every professional interaction should assure:

  • Physical, psychological, and emotional safety
  • Trust
  • Choice
  • Collaboration
  • Empowerment

This action involves more than simply offering annual and mandatory employee continuing education on the topic, or other related content on microaggressions or implicit biases. Instead, professionals should always ask:

  • Does the person fully understand your role?
  • What are their provider preferences or choices?
  • What name or pronouns they wish you to use?
  • What types of accommodations might they need with respect to physical, cognitive, intellectual, or other disabilities?
  • How will health literacy be assessed and addressed?
  • Will information be provided in the patient’s primary language, whether written or electronic?
  • Who does the patient want with them during the interview, assessment, examination, or test (if anyone)?
  • Do they know how to use, update, or troubleshoot their digital device, specific EHR platforms, or apps?
  • How do they understand their diagnosis?

Third, Employ Advocacy at the Macro, Meso, Micro Levels Practice: This domain spans policy, community/organizational, and population-based practices, such as:

  • Advance professional state-specific CEU requirements for licensure renewal encompassing Anti-oppressive practices, trauma-informed care, intercultural effectiveness, bias management, microaggressions and other related themes.
  • Advance and enforce Federal requirements by HHS, the Office for Civil Rights (OCR) and EEOC including the 2024 HHS Rights of Conscience Bill , EEOC Workplace Guidance to Prevent Harassment, and the HHS Health Equity Action Plan.
  • Case managers can also refer to the work of CMSA’s DEIB Committee for guidance inclusive of the association’s Position Statement (2024) and upcoming resources to guide case management practice. These items will encompass a dedicated standard of practice, position paper, member library, and other deliverables.

Within organizations:

  • Provide easy ways for patients and staff to anonymously report situations involving racism or discrimination 
  • Examine policies to make sure they result in equitable outcomes
  • Require coursework on bias and discrimination at professional schools, and 
  • Ongoing performance metrics that address continuing education
  • Ensure policies and procedures through Human Resources that enforce anti-discrimination practices, and are addressed through employee performance appraisals. Incentives and disincentives for heeding (or not heeding) these policies should also be consistently enforced.
  • Have patient voices reflected through involvement on boards and organizational committees and with the ability to vote on decisions.

Fourth and most importantly, Model and Mentor: Maneuvering MG is not a “one and done” activity, especially amid the changing face of patient and workforce demographics. Nobody is an expert in this space. Any ethical, caring, quality-driven professional should be committed to eliminating MG. We must recognize the uniqueness of each patient experience, and:

  • Be a steward of inclusive, empathic care and lead by example
  • Be humble and accept the need for lifelong learning
  • Strive to engage and establish rapport that fosters partnership with patients and their families
  • Talk to, and with patients and their families, rather than at them
  • Use shared-decision making for every dialogue with patients and their families
  • Inform patients of your process the start of each interaction; this will promote your valuing of their voice
  • Hire diverse staff to ensure patient populations are reflected

I know there are other strategies to stop MG and welcome those through your comments. Experience my CMSA Annual Conference presentation on MG through the digital content. Register for CMSA of Houston’s Annual Conference on 9/14 where I’ll be presenting on Medical Gaslighting’s Universal Truth and moderating a panel discussion on this topic of critical workforce importance.

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!