4/30/2018. The Ethics of Evidenced Based Case Management. Objectives. Evidence - Based Case Management Practice

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1 The Ethics of Evidenced Based Case Management Mary McLaughlin Davis, DNP, NEA-BC, ACNS-BC, CCM Objectives Describe Evidenced Based Case Management List the ethical constructs Identify the ethical constructs linked to selected evidenced based case management standards and practices Evidence - Based Case Management Practice Practice based on the best available evidence constructed on systemic research, patient types preferences, professional values, clinical judgment, and decision making. Tradition, authority, trial and error, personal experiences, intuition, borrowed evidence, and scientific research are sources of evidence. Individual and organizational barriers can prevent adaptation of Evidenced Based Practice (EBP). (Schmidt, Brown, 2012; Mullahy, 2017) 1

2 ACE Star Model of Knowledge Transformation Discovery: The need for acquiring knowledge about a question PICO model P = Patient population or patient condition of interest I = intervention of Interest C = Comparison of interest O = Outcome of interest Summary: Literature search review the evidence Translation: Appraisal of the evidence and level of reliability Integration: Implementation into practice Evaluation: Assessment of value of evidence in practice (Schmidt, Brown, 2012) Pyramid of Evidence: 5 Ss Studies Quantitative Qualitative Case Concept analyses Syntheses: Meta-analyses, systematic reviews, integrative reviews, literature reviews Synopses: brief descriptions of evidence Summaries: Detailed description of evidence Systems: EMR integrated with practice guidelines (Schmidt, Brown, 2012) 2

3 Reluctance to use EBP for CM Lack of value for research in practice Lack of understanding regarding the structure of the various electronic data bases Difficulty assessing research articles Lack of computer skills Difficulty understanding, interpreting and then incorporating the findings into practice Fear factor (Mullahy, 2017) Poor communication- CM are not informed system practices are evidence based, and CM feel they can chose to not follow the practice or follow it properly. CMSA Statement of Philosophy Related to EBP The underlying premise of CM is based in the fact that, when an individual reaches the optimum level of wellness and functional capability everyone benefits: the individual client being served, the client s family or family caregiver, the health care delivery system, the reimbursement source or payer, and other involved parties such as the employer and consumer advocates. Professional CM serves as a means for achieving client wellness and autonomy through advocacy, ongoing communication, health education, identification of service resources, and service facilitation. (CMSA, 2016) CMSA Guiding Principles Related to EBP Implement evidence-based care guidelines in the care of clients, as available and applicable to the practice setting and or client population served. Promote the integration of behavioral change science and principles throughout the CM process. Pursue professional knowledge and practice excellence and maintain competence in CM and health and human service delivery. (CMSA, 2016) 3

4 CMSA Guiding Principles Related to EBP Support systematic approaches to quality management and health outcomes improvement implementation of practice innovations and dissemination of knowledge and practice to the health care community. Demonstrate knowledge, skills, and competence in the application of CM standards of practice and relevant codes of ethics and professional conduct. (CMSA, 2016) CMSA Standard: Professional Responsibilities and Scholarship The professional CM should engage in scholarly activities and maintain familiarity with current knowledge, competencies, CM related research, and evidence supported care innovations. The professional CM should also identify best practices in CM and health care service delivery, and apply such in transforming practice as appropriate. Incorporation of current and relevant research findings into one s practice, policies and procedures, care protocols-guidelines, and workflow processes. Retrieval and appraisal of research evidence, pertinent to one s practice and client population served. Proficiency in the application of research related & evidence-based practice tools and terminologies. (CMSA, 2016) CMSA Standard: Professional Responsibilities and Scholarship Ability to distinguish peer reviewed materials & apply preference to such work in practice Accountability & responsibility for professional development & advancement Participation in research activities which support quantification and definition of valid and reliable outcomes, especially those that demonstrate the value of CM services & their impact on the individual client and population health (CMSA, 2016) 4

5 CMSA Standard: Professional Responsibilities and Scholarship Identification and evaluation of best practices and innovative CM interventions. Leveraging opportunities in the employment setting to conduct innovative performance improvement projects and formally report on their results. Dissemination, through publication and/presentation at conferences, of practice innovations, research findings, evidence-based practices, quality or performance improvement efforts. (CMSA, 2016) CCMC CM Body of Knowledge Professional Development and Advancement Scholarship activities Conducting Research Study the effects of specific aspects of CM practice, programs, and models Add to the collective knowledge and evidence of CM practice CM have a special & critical obligation toward their practice-participation in professional development & advancement of CM. They may accomplish this by engaging in scholarly activities that focus primarily on developing new knowledge for practice or sharing information about existing innovations and services. (CCMC, 2011). Activity Discussion Conducting Research Writing for Publication By participating in original research or research utilization projects and by writing about findings for industry and peer reviewed journals, senior CM can: Develop new knowledge about CM practice Assess the legitimacy of existing practices Study the impact of specific CM intervention on clients/support systems. Promote new ideas and communicate quality data about their own CM practices so that others in the healthcare industry-including clients/support systems-can benefit from them. Necessary for CM Professionals to share knowledge & practices with the CM community at large. Such scholarly activities are an obligation for professional development & advancement. Adds to the collective knowledge base of the CM field. Assists healthcare leaders & other CM in avoiding mistakes or implementing previously tried & failed strategies. (CCMC, 2011) 5

6 Ethical Constructs Related to CM EBP Autonomy: Respect for a patient s right to selfdetermination and personal liberty, including his right to make his own decisions about his care. The right to develop a personal care plan with his own goals. Fidelity: Keeping your word, trustworthiness, duty of care. Justice: Fairness, maintenance of what is right. Non-maleficence-Do no harm. If only harm can occur from an inevitable act or decision ensuring the least amount of harm will occur. Correct harm that has occurred. Veracity: honesty, truth in all transgressions. (Powell, Tahan, 2008; Mullahy, 2016) Ethics CM - EBP Administrators of CM programs should consider the implementation of ethic groups to address ethical issues when they arise. This group should consist of experts in ethical issues. Powell and Tahan write; in considering strategies for ethical behavior CM should examine the literature available through libraries, internet, and state and national professional CM organizations to support their practice. (Powell, Tahan, 2008) Not knowing is not a defense. Accountability and EBP Social: The solution or strategy that gradually stimulates changes in medical sciences and improves public health through influencing professionalism and technical abilities. Duty of Care - The health professional: Will perform to the highest standards of care defined by his or her license and is measured against others with the same education and license. Will use current knowledge, evidence, research, standards, and policies to inform practice. (Kline, Preston-Shoot, 2012) 6

7 Accountability-EBP-Patient Safety Will keep knowledge and skills updated and is responsible for knowing and following the organizations policies and procedures. Will not accept work beyond his/her capabilities, nor delegate work that is beyond the subordinate's level of competence. Will use legal and ethical literacy to insure care is provided safely. The caregiver will report and keep accurate records and document when issues were discussed and who was present. Will follow the chain of command to inform leadership and if necessary, regulatory bodies of unmet standards of care and practice. (Kline, Preston-Shoot, 2012) Accountability and Patient Safety Accountability is: Essential component of professional nursing and social work practice Essential component of patient safety ANA code of ethics: accountability is to be answerable to one s self and others for one s own actions. Relies on both clinical expertise and effective communication skills Excellent clinical skills allows the care manager to identify gaps in care that can negatively affect patient outcomes and to effectively correct these gaps in a timely manner. Care managers are accountable for constantly developing and improving their skills in communication and team effectiveness. (Battie, Steelman, 2014) Accountability and EBP for Continuity of Care Care managers are responsible for the time they spend with a patient but also for ensuring continuity of care after the patient leaves the care manager s area of practice. During handoff report on the patient s immediate care needs, existing health problems, and potential risks for poor health outcomes, readmissions, or ED visits. (CMSA, 2016; Battie, Steelman, 2014) 7

8 Accountability and EBP for Continuity of Care Transfers of patients to the most appropriate health care provider or care setting are coordinated in a timely and complete manner. Documentation reflective of the collaborative and transparent communication between the patient/family and interdisciplinary team, as well as the receiving interdisciplinary team (CMSA, 2016; Battie, Steelman, 2014). Case Studies The health plan (insurance) case manager, Jack understands his company is following an EBP model of care to prevent readmissions by making follow up phone calls to HF patients just discharged from acute care and checking on them and the adjustment from acute care to home. Jack makes his last phone call of the day to a CHF patient just discharged from the hospital 48 hours previously. The patient tells Jack he is having trouble walking because he becomes breathless. He also states that his shoes are not fitting so he is only wearing socks. Jack should: Case Study a) Tell the patient to hang up and call 911, and go home for the day. b) Call the patient s physician s office and request an evening appointment or a tele-health intervention that evening for the patient. Call the patient back and provide direction based on the physician s plan for intervention. c) Instruct the patient on a low salt diet and tell him to call you in three days. d) Leave a message for the patient s daughter that she needs to go to her father s house and help him. 8

9 Case Study Shirley Temple, RN, BSN, CCM, the acute care CM Manger for unit 4-B has dealt with a thorny ethics case all week long on her unit. Shirley feels she is an expert on hospital ethics she took a three day ethics course and she is on the hospital ethics committee. Her hospital is staffed with hospitalists, NPs, and PAs. PCPs do not come to the hospital. Mrs. McGuire, 85 yrs. has been in the hospital 6 times over the past 4 months. She has stage IV HF with renal failure and other co-morbidities. Mrs. McGuire is married with two adult children. Over the past 4 months she has moved from independent living to assisted living to a SNF. Her nephrologist told her she will need to start dialysis and she agreed. Her husband is very protective and committed to doing everything for his wife. They are both retired law professors. After two dialysis treatments, Mrs. McGuire tells the hospitalist she does not want to continue with the tx. Mr. McGuire states that is nonsense and of course she will continue with dialysis. He enlists both his children to agree and they tell the team to continue with dialysis. Mrs. McGuire has another treatment and then she refuses to go again. Mrs. McGuire is assessed for mental capacity by BH and is declared depressed but competent. The ethics team is called in, and determines it is the patient s right to refuse dialysis and agree to call hospice for her. Mr. McGuire is furious and begins to yell at the team. He only likes the nurses on the unit and is angry at everyone else. He demands a family meeting with the hospitalist. Shirley steps in because she knows the CM on the case is the 4 th one this admission and she feels no one else has the time or expertise to manage this difficult situation. 9

10 She calls the hospitalist and arranges a time convenient for the hospitalist to meet with the family. She then calls Mr. McGuire, the daughter, and the son with the time and place. The day of the meeting Mrs. McGuire s daughter calls to state she may be late because she is flying in from out of town. Shirley conveys the message to the hospitalist who responds that she cannot stay past 6 she has commitments too. The daughter arrives at 6:30 and Mr. McGuire demands the family meeting. Shirley knows there is not anyone left to speak with them but her and they will be beyond furious if she tells them the meeting cannot take place, especially after the daughter came in from another city. Case Study Shirley goes into the patient s room with the four family members and explains that the ethic committee agreed with Mrs. McGuire that she did not have to have dialysis and that this was her right. The daughter and Mr. McGuire began to beg Mrs. McGuire to reconsider telling her she will feel better after a few more treatments. The patient continued to refuse tx. 10

11 Mr. McGuire turned on Shirley and began to yell at her for interfering, and stating, what right do you have to be standing here telling us this about my wife? The daughter then screamed at Shirley to get out of the room and that she was a vile and hateful person only concerned about the bottom line for the hospital. What went wrong? Question 1.The Case Management Standards of Practice are good to have in a print copy, but it is not necessary that case managers follow the standards. True False Thank you!!! CMSA 11

12 References Battié, R., & Steelman, V. M. (2014). Accountability in nursing practice: Why it is important for patient safety. Association of Operating Room Nurses. AORN Journal, 100(5), 537. CCMC, Case Management Body of Knowledge. 2011, subscription required. CMSA Standards of Practice. (2016) Kline, R., & Preston-Shoot, M. (2012). Professional accountability in social care and health: challenging unacceptable practice and its management. Learning Matters. Mullahy, C. M. (2016). The Case Manager s Handbook. Jones & Bartlett Publishers. Powell, S. K., & Tahan, H. A. (2008). CMSA core curriculum for case management. Lippincott Williams & Wilkins. Schmidt, N. A., & Brown, J. M. (2014). Evidence-based practice for nurses. Jones & Bartlett Learning. 12