Look to peers when ethics questions arise

Ensure your employers understand your role

When you're troubled by an ethical dilemma, don't go it alone. Reach out to your peers and your professional organizations for help, the experts say.

Case managers should consult with colleagues they trust when ethical issues arise, says John Banja, PhD, professor, Department of Rehabilitation Medicine, and a medical ethicist at the Center for Ethics at Emory University in Atlanta.

For example, you might be in a situation in which you're being pressured to move a patient with a long length of stay in the intensive care unit to a lower level of care, either at the hospital or in another setting. "This is a slam dunk ethical situation. If the case manager thinks the patient needs this intensity of service, he or she should speak up and resist the pressure," he says.

On the other hand, if you ask five other case managers to evaluate the same patient, two might say the patient would do well at a lower level of care. "This illustrates the fallibility of prognostic judgment. This is one of those gray zones that healthcare professionals face all the time," Banja says.

Patrice Sminkey, chief staff executive for the Commission for Case Management Certification (CCMC) adds, "If there is a conflict, the case manager should go back to the other stakeholders within the team and help them understand the impact of the decision, whether it's moving a patient from one setting to another or eliminating part of the treatment."

In today's fast-paced healthcare environment, the people who are pushing for a patient to be members of the treatment team might not be aware of the patient's psycho-social issues or other challenges that could prevent him from being discharged or moved to a lower level of care, Sminkey points out. Reach out to your colleagues and fellow case managers for advice and direction, she says. "One of the challenges case managers face is to help team members understand how a decision will impact a patient," Sminkey says.

Case manager must take patient safety and patient health into account when they look at transitioning patients to another level of care, and this consideration might mean keeping them in one level of care a little longer than average to prevent problems down the road, says B.K. Kizziar, RN-BC, CCM, CLP, owner of B.K. & Associates, a Southlake, TX, case management consulting firm. "One of the good things that came out of healthcare reform is the issue of readmissions," Kizziar says. "The focus has shifted from getting patients out in a certain number of days to making sure we are providing a good outcome for patients. Case managers at the payer level as well as the provider level need to look for the same things in terms of readmissions and outcomes."

Make sure your employer is familiar with case management standards of practice and the CCMC professional code of conduct, Sminkey suggests. "Our code of conduct goes into great detail about how to be a patient advocate and avoid conflicts of interest," she says.

Look to the professional organizations for help with ethical issues, Sminkey says. The CCMC has created an advisory service for certificants and offers opinions or case studies to answer questions about potential ethics violations.

In addition to its efforts to educate people in the healthcare field about the roles and responsibilities of case managers, the CCMC is expanding its efforts to the policy and regulatory levels of government to make sure that everyone understands that the case manager's primary responsibility is to the patient, Sminkey says. "As new models of care, such as the patient-centered medical home and Accountable Care Organizations (ACOs) are developed, it is increasingly important to be clear about the roles and responsibilities of professional case managers," she says.

Care coordination is frequently mentioned in The Affordable Care and Patient Protection Act, "but the legislation doesn't include a definition of care coordination or spell out who will do it," says Sminkey, who adds that care coordination is one function of case managers, but they also have to assess and evaluate before they can coordinate. A case management assessment is different from a physician's assessment. "It's not about diagnosis of a disease, but it looks at the person from all perspectives and all issues so the care coordination plan will work," she says.

"We want to make sure that the new models don't result in that kind of lack of clarity we found in the past where people are combining utilization review and care coordinating, or coding and utilization review, and calling it case management. As the voice of certified case managers, we want to make sure people understand the roles and responsibilities of case managers," says Sminkey.