Case Management

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Ethics

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governs relationships with others.

is a value-based, integrity-based strategy of adherence to moral principles and character.

based on personal beliefs and values which guide the decision-making process.

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Advocacy

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focuses on advancing the welfare of patients, but these patients are served by a complex array of health care delivery systems with varying degrees of economic constraints.

can often be in direct conflict with legal responsibility, particularly when case managers are making initial determinations regarding authorization for services or payment.

is a fundamental ethical responsibility of case management.

is demanded in guidelines for professional conduct upheld national case management certifications.
is governed by case managers' professional licensing boards, and it is written into case management job descriptions.

appears in standards of practice authored by national membership organizations such as the Code of Ethics and the Standards of Clinical Nursing Practice, and the Case Management Society of America (CMSA) Standards of Practice for Case Management cites advocacy as a key role of the case manager, regardless of discipline.

focuses on the establishment and maintenance of vital and moral human relationships between patients and those in the health care profession.

The subject of encompasses the issue of treatment in the broadest sense.

deals not only with how we treat the patients in a medical and return-to-work sense, but how we relate to, or deal with, our fellow human beings in matters of injury, illness, death, and quality of life.

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paternalism and ethical dilemma

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occurs when an outside person makes decisions that are perceived to be in the best interest of another person, without getting the person's approval.
When an outside person takes on a parental role toward the patient/family,

often extended to the adjuster, case manager, the risk manager, the physician, and providers of care involved in what should be a team approach.

is often taken by the claims professional who believes that he or she possesses a superior knowledge of the case, and is solely privileged to make decisions in the best interest of the patient/enrollee.

can obviously produce tension and mistrust between the health care professional and the ill or injured patient, leading to miscommunication and a general breakdown in the relationship.

health care case managers can easily confuse advocacy with paternalism, resulting in an
ethical dilemma.

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Radical Individualism and ethical dilemma

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is the position that patients have absolute rights over their own bodies and lives, and therefore, may reject all recommendations from health care personnel, as well as many approvals for care/services given by claims professionals.

Often this position is coupled with an extreme distrust of the claims adjuster by the patient, whether or not the feelings are warranted. This can easily lead to an ethical dilemma.

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Reciprocity and ethical dilemma

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is the collegial or reciprocal approach that epitomizes a true team concept.

In the reciprocal approach, the claims adjuster views the case manager, the physician, the providers, the risk manager, and other professionals as key members of the team, as well as the patient and the patient's family.

Communication is encouraged and enhanced through a group approach to the ongoing care and services necessary for the patient's successful return-to-work.

When this process does not work, or key members are left out, this can lead to an ethical dilemma.

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Confidentiality and ethical dilemma

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is a key issue in the discussion of ethics.

arise when case managers struggle with the knowledge about a patient which may be in direct conflict with knowledge of the case on a professional level.

other times, case managers may struggle with the knowledge that a patient continues to abuse his or her own health, such as refusing to complete a personal physical therapy regimen crucial to recovery, or

refusing to take certain medications that are necessary for survival (eg, AIDS or cancer treatment).

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Allocation or Denial of Medical Resources and ethical dilemma

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Case managers are being put in the position of making decisions based on the quality of treatment versus the cost of treatment.

Without extensive clinical knowledge or the benefit of interacting on a personal level with the patient, the case manager must authorize or deny medical care and must deal in sensitive and often adversarial roles with the patient and/or family.

Decisions must often be based on a combination of experience, professional advice, and gut-level reaction. This invariably raises ethical issues.

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Autonomy

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A person's right to make his or her own decisions, a moral principle. In health care, the patient should be encouraged to make decisions about his/her health care treatment, even if the decisions are difficult for health care providers to accept.

It is respect for others and for their uniqueness.

promotes independence and gives the patient an inherent right to determine what happens according to his/her own preferences and value system.

defined by the Ethics Statement of the CMSA as a "form of personal liberty of action when the individual determines his or her own cause of action in accordance with a plan chosen by himself or herself."

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Beneficence

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The moral principle governing a person's obligation to promote good, to further a person's legitimate interests, and to actively prevent or remove harm is known as beneficence.

This principle is an attempt to balance paternalism and promote self-determination.

requires the case manager to promote the well-being of the patient/family within the constraints of the health care system. This includes using good resource management skills to promote a safe discharge for a patient.

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Nonmaleficence

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To refrain from doing harm to others.
By understanding and incorporating quality outcomes measurements into their daily practice, case managers can determine nonmaleficence. Outcomes can provide a picture about the quality, cost, and appropriateness of care delivered to a patient.

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Justice

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Maintaining what is right and fair
It is the moral principle that governs the responsibility of the case manager to coordinate appropriate allocation of resources to meet the patient's health needs.
It is a moral principle that, when practiced consistently, can establish and promote trust between the patient and the case manager.

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Veracity

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Truthfulness. It is truth-telling, and it also is an important component of developing a trusting relationship with the patient, the family, providers, and payers.
is essential in the practice of case management.
can promote trust and enhance trusting relationships.

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Quality improvement

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is the new direction taken in health care which emphasizes looking at the big picture and efficiently coordinating the entire system.

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Quality improvement and risk management differ in the following ways:

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Risk Management
• Risk management is concerned with acceptable care from a legal and financial perspective.
• Risk management attempts to minimize the cost of liability insurance and liability claims.
• Risk management looks at all hospital exposure.
• Risk management focuses on loss outcomes.
• Risk management works to decrease the risk of adverse outcomes.
Quality Improvement
• Quality improvement has its emphasis with patient-care issues rather than financial concerns.
• Quality improvement has its emphasis with patient-focused issues, which include all services involved in patient care; optimal quality care; adherence to professional standards; and reasonable and prudent delivery of care.
• Quality improvement focuses on preventing adverse patient issues.
• Quality improvement works to increase the prospect of positive patient outcomes.

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Risk management and quality improvement overlap in the following concern areas:

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• Both relate to anything that may cause risk of injury to the patient.
• Both try to identify and avoid adverse patient outcomes.
• Both stress monitoring of trends in patient care to identify risk patterns or problems.
• Both emphasize and require the need for complete and clear documentation.
• In order to assess trends and resolve problematic issues, both require cooperation and information from the medical staff, nursing staff, and hospital administration.
• To effectively achieve their goals and purposes, both may use many of the same tools.
• Both attempt to correct identified problems by educational methods, changes in policies and procedures, or disciplinary action.

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What are the laws governing patient rights and entitlements as well as the criteria determining fair treatment under the law (Criteria to Practice CM in HealthCare Setting):

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• Patient's Bill of Rights: Each hospital has a patient's bill of rights that outlines the individual's prerogatives regarding care, including the right to emergency aid, the right to diagnosis and prognosis information, the right to unbiased treatment, and the right to voice grievances.
• The case manager must have a core competency to perform the function of case management. This competency will be measured against accepted standards of care in the industry.
• In 1988 the Joint Commission (formerly known as the Joint Commission on Accreditation of Healthcare Organizations) identified privacy and confidentiality as two patient rights. Consents should be obtained from patients prior to release of information.
• Knowledge of case management Standards of Practice. Some of the existing formal standards of care pertinent to case managers are those developed by the following nonprofit trade organizations, each representing case managers nationwide:
o Case Management Society of America (CMSA)
o The Association of Rehabilitation Nurses (ARN)
o The National Association for Social Work (NASW)
o The National Association of Rehabilitation Professionals in the Private Sector (NARPPS)
o The National Association of Geriatric Care Managers (NAGCM)
• Knowledge of the Code of Professional Conduct for Certified Case Managers (CCM). While the CMSA and other organizations have developed individual ethical statements, all national certifications validated through written examination also include a Code of Conduct for their certification holders.
• Beyond these protocols and certifications are the basic educational curricula and degrees for the various health care professionals, continuing educational credits and the more informal standards of care set by peers in case management practice and by other health care professionals. Taken together, such standards will be used as criteria to ascertain whether a case manager has the background and experience to practice case management.

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Malpractice

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on the part of health care professionals has, unfortunately, increased over past years.
is professional negligence and it refers to any misconduct or lack of skills in carrying out professional responsibilities.
includes any professional person's wrongful conduct, improper discharge of professional duties, or failure to meet standards of care that would have protected the client from harm or undue costs.
case managers can also be held legally liable in a lawsuit. For this reason, all case managers should investigate obtaining professional liability insurance. Organizations like
the ANA and the CMSA offer group rates for liability insurance that are affordable by most professionals. Professional liability insurance will protect case managers in their own actions or inactions while performing the role of case management.

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Professional negligence

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must be proven for malpractice to exist.

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There are four elements of negligence that must be present, which include:

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duty (owed), breach (of that duty), causation, and harm or injury.

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Duty owed

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means that the provider has a responsibility to make reasonable decisions.
In terms of a case manager, the reasonable decisions may center on whether an appropriate referral for services or products was made, or that reasonable decisions were supposed to be made.

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Breach of duty

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means that the duty, or standard of care, was breached by an action or inaction.

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Causation

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means that there is a definitive connection between the breach by action, or inaction, and the damage that resulted.

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Injury

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means that damages to the patient resulted from the occurrence of the first three elements (duty, breach and causation).

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Professional negligence/malpractice are unintentional torts, meaning

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that harm was not intended at the time of the occurrence.

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Intentional torts are those wrongful acts carried out with intent to harm, such as

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assault, battery, invasion of privacy, and slander.

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A tort law is a law that addresses

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a wrongful act, whether intentional or unintentional, against a person or property.

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The most common law affecting health care practice

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is that of torts.

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Regarding Patient Appeals

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Case managers must ensure that the patient is provided with appeal process information in cases of denial for products or medical services.
While it is not appropriate to engage in completing or beginning the appeal process on behalf of the patient, the case manager does have an ethical responsibility and a duty to inform the patient or family of the appeal process.
The patient has a right to appeal a decision of the payer and to be given accurate and timely information on the appeal process.

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Any health care professional has the potential to be held liable for damages or harm to a patient when:

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1. Services being provided in the utilization management environment are not in accordance with standards of care;
2. The attending physician disagrees with the utilization management function, or;
3. Appeals on a medical decision are not pursued or are arbitrarily ignored or denied.

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Though not a medical practitioner, like a physician, the case manager should

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act on complete information.
If contradictory information exists, it is the case manager's responsibility to determine what is true.
The case management plan should be based on information that is accurate and adequate.
NOTE: First and foremost, case managers are patient advocates, and the law often demands that a patient's interests come first.

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The case manager should complete a comprehensive review of the case file, in order to protect himself/herself from liability claims resulting from differences in an existing treatment plan. The following format should be utilized:

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• Valid medical criteria
• A thorough review of medical records
• Discussion with the treatment team
• If a discharge is imminent, incorporation of an assessment of the discharge risk

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If a case manager knows about his or her own negligence or the negligence of others but does not report it, he/she is legally liable. The case manager has the following responsibilities when referring a patient to a facility or provider:

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• Act in the best interest and in good faith of the patient
• Investigate the competency and qualifications of the facility or provider, and utilize the grievance process when competency/qualifications are questionable
• Reasonable care should be taken in completing the referral
• Whenever possible, provide the patient with several provider choices
• Document all referral activity
• Provide patient follow up to review the status and response from the referral

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Documentation

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is the thread that connects all of the complex processes of patient care coordination in all health care settings.

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Document

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a patient's care; response to care; mutually planned goals for optimal recovery/wellness; issues/concerns that arise during care delivery or coordination to meet those goals; and evaluation of goals and outcomes.
If involvement in a patient's care includes required compliance with state or federal laws,
when work is conducted within the guidelines of the federal or state law.
when critical to provide a fluid picture of the patient's journey through the continuum of care.
when working with providers.
if a patient, family member, employer, physician or other integral member of the health care team raises concerns or issues with the case management plan along with the steps taken to resolve these issues or concerns.
all steps taken whenever there are nonadherence issues in a medical treatment plan.
When objectively reporting the facts — just the facts; should be free of suspicions, conjectures, and allegations, since entries are discoverable and can be subpoenaed.
without accusation and without giving legal weight to either side in court.