Tag: ethics matter

AMA Discharge and Case Management’s Responsibility: Ethical and Compliance Quandary

Case managers are frequently pulled into the ethical, legal, and compliance crosshairs. What is a case manager’s responsibility when the patient refuses a recommended discharge plan?

Consider this scenario:

A patient is admitted to the hospital and the physician and treatment team recommendation is clear: the patient would benefit from being discharge to a skilled nursing facility (SNF). However, the patient adamantly refuses and only wishes to go home. Does the physician have the right to request that the patient leave the hospital against medical advice, or AMA?

This question has become a hot topic in acute care case management circles, and the short answer to it is “No”. However, like most decisions in our practice world, there are several nuances to consider. Oh, there are logistical concerns about when, if, and what type of written notification to provide the patient and family about denial of care and coverage. This article is not about those moving parts of Utilization Management. Instead, this piece addresses proactive ways for case managers to stay out of ethical and compliance trouble! 

Patient Autonomy 

As Physician Advisor thought leader, Dr. Ronald Hirsch, recently noted in a post for the Case Managers Community, there is no requirement that the patient actually sign a form for the discharge to be considered AMA. If the patient is leaving against the advice of the physician, even if the patient is discharged with prescriptions and follow up plans, it can be considered against medical advice. If a patient insists on going home, but the physician knows the home environment is not safe and advises the patient not to do it, their discharge is against medical advice, and can be coded as such. 

Yet, when a patient declines a physician advised, skilled nursing facility discharge, it IS NOT always against medical advice. Patients can still receive care in their home, even if that care is suboptimal for their condition. Patients have autonomy, which must be respected. With autonomy comes the right for patients to also make bad decisions. 

Case managers should be mindful of not abandoning patients or quickly reacting to their request to leave before the treatment team and provider indicate the clinical readiness to do so. In fact, best practice should involve assessing a patient’s motivation to leave AMA vs. an in the moment reaction to it. This is where keen case management assessment, intervention, and documentation enter the scene. That focus, plus the reminders below provide case managers and their employers some level of medical and legal protection should an adverse event occur post-discharge.

What Case Managers Need to Know

  1. Every organization should have a clear AMA policy that is aligned with Federal requirements, including the Medicare Conditions of Participation (COPs) for Discharge Planning, Patient Bill of Rights, and any relevant state laws; several states also have “Right to fail” laws, such as Vermont. 
  2. Quality documentation should reflect how the case manager fulfilled that AMA policy. At the least, there should also be documentation of the patient’s “informed refusal” of care. This concept is a thread of “informed consent”, and relevant to this article’s theme. Remember, if it wasn’t documented, it didn’t happen!
  3. Patients with clinical and legal capacity (AKA competence) or their legal decision-makers have the right to refuse treatment, discharge plans, and other interventions. It is why those situations should not be viewed as AMA discharges. This will get sticky in that a discharge must be “safe” (Nod to Tiffany Ferguson’s recent article, Understanding the ‘Safe Discharge’ Plan). This is one of many reasons why some providers may opt to define a specific discharge plan, as an SNF or home with 24 hours of supervision. Unfortunately, these plans are recommendations only. Final decision-making is up to the patient and their legal decision-maker, and leads to the next point.
  4. Those Medicare COPs are clear in that professionals involved in discharge planning processes should document how all options and information about those processes were reviewed and provided to patients and their decision-makers as relevant. This action should be done in a language or mechanism reflective of a patient’s unique needs (e.g., language proficiency, visible and invisible disabilities, health literacy).
  5. Case managers should consider the 5 Core Considerations for Case Managers. These 5 Cs are aligned with those ethical, regulatory, and legal requirements:
    • Ensure patient Clinical Capacity, and
    • Legal Capacity (Competency)
    • Consider how the patient and family are Coping, then
    • Provide Choice
    • Complete the process via clear Communication

By using the 5Cs, case managers fulfill their ethical and legal obligation to inform the patient what can and can’t be provided safely and realistically. This dialogue doesn’t have to start as an antagonistic discussion, but rather an informative one. There are usually a number of emotions at play in these situations, especially as patients (and families) come to terms with lack of control around an unexpected illness, prognosis or outcome, such as decreased independence. These dynamics can easily make for tough maneuvering of these situations for all involved, and especially case managers. This is where attention to coping comes in. 

No case manager wants is to be accused of abandoning a patient. In situations where the patient defies treatment team (and provider) recommendations and discharges to home rather than a nursing home, the traditional industry recommendation is to provide discharge instructions, prescriptions, and follow-up appointments. You can also call Adult Protective Services if there are documented concerns of patient safety, or potential for abuse, neglect, or exploitation. 

6. All case managers, independent of case management credential (e.g., ACM, CCM, CMGT-BC) and discipline (e.g., counseling nursing, rehabilitation professional, social work) are mandated to heed case management’s codes of ethical and professional conduct, and standards of practice, particularly:

  • Ethical Principles: Autonomy, Beneficence, Fidelity, Justice, and Nonmaleficence
  • CMSA Standards of Practice– B. Professional Responsibilities C. Legal, D. Ethics, E. Advocacy G. Resource Management J. Client Assessment, K. Identification of Care Needs and Opportunity L. Planning M. Facilitation, Coordination, and Collaboration 
  • ACMA Standards– Accountability, Professionalism, Collaboration, Advocacy, Resource Management.

NOTE: ANCC’s Nursing Case Management credential (CMGT-BC) has a formal test reference list that incorporates items a and b above.

7. All professional case managers should receive onboarding to understand these nuances in and requirements for care. Case management bears a hefty responsibility to assess, facilitate, and coordinate care for patients, and through quality-driven collaboration with the interdisciplinary treatment team. Case managers also advocate on behalf of patients to ensure that their highest degree of self-sufficiency and autonomy are met when possible. Patient advocacy is among the profession’s most vital objectives.

These books published through the Case Management Institute validate and expand on this article, and should be part of every professional case manager’s library!

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: