BY KATHLEEN FRASER, MSN, MHA, RN-BC, CCM, CRRN
“Courage is being scared to death and saddling up anyway.” – John Wayne
Ethics are moral principles that guide a person’s behavior. All decisions have an ethical or moral dimension for a simple reason: They have an effect on others. In case management, ethical behavior exists to foster and preserve our clients’ welfare. Unethical behavior, by definition, fails to do so because it is self-serving.
Case managers are routinely confronted by gray ethical areas due to having to deal with multiple stakeholders or points of view. Case management is neither linear nor a one-way exercise, with assessment responsibilities occurring at all points in the process. Facilitation, coordination and collaboration occur throughout the client’s healthcare encounter.
Regardless of a professional’s title or area of expertise, the case manager is dealing with complex cases in which there may not be a clear right and wrong. If we want to preserve the ethical ethos of case management, case managers must know the ethical standards/scope of practice to which they are held and comply with them.
In professional case management, the Case Management Society of America’s (CMSA) Standards of Practice for Case Management (rev. 2016), is the gold standard in which a majority of case management departments in the world base their policies, procedures and ethical guidelines. Developed and sustained by CMSA, the Standards of Practice for Case Management require that the case manager empowers the client to problem-solve by exploring options of care, when available, and alternative plans, when necessary, to achieve desired outcomes. They encourage case managers in the appropriate use of healthcare services and to strive to improve quality of care, maintaining cost effectiveness on a case-by-case basis. The Standards cover how to assist the client in the safe transitioning of care to the next most appropriate level and to strive to promote client self-advocacy and self-determination. Finally, the Standards guide case managers to advocate for the client, employer and the payer to facilitate positive outcomes for all stakeholders. However, if a conflict arises, the needs of the client must be the priority. A case manager’s primary obligation is to his or her clients.
Ethical Principles of Case Management
It is critical to be aware of the five basic ethical principles in case management, which include:
Beneficence: Always do good.
Non-malfeasance: Do not purposefully do harm.
Autonomy: Treat each person as an individual. One size does not fit all!
Justice: Assist clients to obtain what they deserve, in a good way.
Fidelity: Do not make promises you cannot keep.
Case managers are financial stewards and are responsible and fiscally thoughtful in their management of resources. Because cost containment is essential, case management becomes essential; however, this role can result in increased responsibility and increased risk to the case manager. Case managers basing a decision concerning a patient’s care on cost savings alone, without regard to the quality of the treatment regimen, must not occur. A perceived lack of advocacy for the client/patient, challenges in the area of timeliness and not holding a license in the state where case management is performed are also areas that can leave case managers at risk.
Timely follow-through is one of the essentials areas of the case management practice. A lack of follow-through with a physician or other appropriate healthcare provider by the case manager is problematic, as is the failure to inform the patient of the essential need for a follow-up appointment after discharge. This type of follow-through should be present throughout service.
However, follow-through alone is not enough! Not only does timely follow-through need to occur, accurate and complete documentation of the follow-through must as well. Timeliness alone also is not enough. If the individual is not compliant, or there is an inability to successfully contact the patient, these actions must also be documented to show whoever reads the medical record that you complied with your legal and ethical responsibilities to the patient.
The case management process is carried out within the ethical and legal realm of a case manager’s scope of practice, using critical thinking and evidence-based knowledge. “The ethics of excellence are grounded in action—what you actually do, rather than what you say you believe. Talk, as the saying goes, is cheap.” – Price Pritchett
Client-centric case management involves individualized and goal-directed care — a collaborative, partnership approach. Whenever possible, case managers should facilitate self-determination and self-care through the tenets of advocacy, shared decision making and education. In other words, turn the passenger into a driver!
It is important to use a comprehensive, holistic approach. Practice cultural competence, with awareness and respect for diversity. One example of this cultural competence would be if you have a patient/client who is entering a religious holiday or period in which he or she is not allowed to eat from sunrise to sunset. However, the patient is on many medications which must be taken with a snack or food three to four times daily. Compliance issues are likely to occur, if not untoward side effects; therefore, the case manager should alert the physician in case there may be long-acting alternative medications.
Another element can occur when communicating with non-English speaking patients. In this case, use a professional medical translator if at all possible. This way, the communication is less likely to be affected by “false fluency” with medical phrases. However, even with a translator, case managers should use words or phrases that are more easily understood by lay people. Also inform a translator you want translation as literal as possible, and for them to tell you if there is not a literal translation, to avoid confusion. Ensure in advance the translator understands the need for confidentiality and, in turn, make sure the patient understands the conversation will be confidential. Be sure to watch the patient while the translator speaks, and when the patient replies, pay attention to the body language. And lastly, speak directly to the patient as if the translator were not present, allowing your words to be translated exactly as spoken.
Enhanced Nurse Licensure Compact (eNCL)
The Enhanced Nurse Licensure Compact (eNCL) increases access to care while maintaining public protection at the state level. The eNLC was implemented as of January 19, 2018.
When RNs, and therefore RN case managers, practice (onsite or telephonically) across state lines, they are required by law to be licensed in each state in which their patients receive treatment, not the state in which the patient resides (although it is usually the same thing). The individual RN who is not licensed currently does not meet the Nursing Licensure Standards of Care and in fact is engaged in criminal behavior as seen by the law, rules and regulations, because he or she is practicing without a license in that particular state.
For a registered nurse to qualify to be considered in the compact, he or she must reside/live in a compact state. Holding a license in a compact state while not residing in a compact state does not qualify. Penalties for providing nursing services (which again includes case management) without a license range from a $1,000 fine to 1 year in jail to lifetime prohibition from practice. This situation leaves the case manager:
In an ethical conflict
In a legal conflict
With his/her own professional license on the line
With his/her personal and family assets at risk in case of an incident causing harm to a patient
The eNCL is important, as it enables nurses and nurse case managers to provide care to patients in other eNCL states, without having to obtain additional licenses.
Trust Your Ethical Intuition!
Case managers have the responsibility to emphasize communication and collaboration across multiple points of interface over our healthcare continuum. We can expect to maneuver gray areas and have the opportunity to review ethical dilemmas as a positive. If a case manager feels uncomfortable being asked to do something he or she thinks is unethical, it probably is! To help during times of conflict with ethical decision making, speak to a coworker, friend or supervisor. Another suggestion can be to create an ethical decision-making tree. There are many types of such trees, and one can google “decision-making tree” and choose as to how detailed or how broad.
“Be the thermostat, not just the thermometer” – Dr. Martin Luther King.
Don’t just sit around and complain about a situation; do something about it! When it comes to ethics, as in most situations, go back to the basics. Use the critical thinking steps you’ve learned over your years of practice, suspend judgment and deconstruct the situation. Then reflect on the situation and synthesize to create the solutions we as case managers were born and taught to create.
Case Manager Survival Skills:
Recognize your worth
Keep a sense of humor
Keep things in perspective
Always have a plan B, C, D or E!
And remember, “You are never wrong to do the right thing!” – Mark Twain.
Kathleen Fraser, MSN, MHA, RN-BC, CCM, CRRN, is a Registered Nurse, a Certified Case Manager, Certified Rehabilitation Registered Nurse and Board Certified in Case Management with the American Nurses Credentialing Center. She holds a Masters’ Degree in Nursing and also a Masters’ Degree in Health Care Administration.
Kathy served a two-year term as the National President of Case Management Society of America from 2014-2016 and currently serves as the Executive Director of CMSA.
In June 2016, Kathy was presented CMSA’s prestigious National Case Manager of the Year Award.
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