Elizabeth E. Hogue, Esq.
Office: 877-871-4062
Fax: 877-871-9739
E-mail: ElizabethHogue@ElizabethHogue.net
Standards governing the practice of case management were first published in 1995 by the Case Management Society of America (CMSA). The standards were revised for the first time in 2002, and again in 2010. This is the first in a series of articles about the legal and ethical implications of the standards revised this year.
The revised standards include clear guidance about the duty of case managers to advocate on behalf of their clients/patients. Advocacy is defined in the standards as: "The act of recommending, pleading the cause of another; to speak or write in favor of." In addition, the section of the standards entitled "Case Management Roles, Functions, and Activities" includes the following language:
Role functions of case managers include: …Advocating for both the client and the payer to facilitate positive outcomes for the client, the health care team, and the payer. However, if a conflict arises, the needs of the client must be the priority. [emphasis added]
The standard related to Advocacy states that "The case manager should advocate for the client at the service-delivery, benefits-administration, and policy-making levels."
According to the standards, case managers are required to demonstrate compliance with this standard through documentation that demonstrates:
- Promotion of the client's self-determination, informed and shared decision-making,
autonomy, growth, and self-advocacy
- Education of other health care and service providers in recognizing and respecting the
needs, strengths, and goals of the client
- Facilitating client access to necessary and appropriate services while educating the
client and family or caregiver about resource availability within practice settings
- Recognition, prevention, and elimination of disparities in accessing high-quality care
and client health care outcomes as related to race, ethnicity, national origin, and migration background; sex, sexual orientation, and marital status; age, religion, and political belief; physical, mental, or cognitive disability; gender, gender identity, or gender expression; or other cultural factors
- Advocacy for expansion or establishment of services and for client-centered changes in organizational and governmental policy
- Recognition that client advocacy can sometimes conflict with a need to balance cost
constraints and limited resources. Documentation indicates that the case manager weighed decisions with the intent to uphold client advocacy, whenever possible.
In view of the above, it is clear that case managers, regardless of practice setting, have an obligation to advocate on behalf of their clients/patients. In fact, the standards make it quite clear that if the best interests of patients/clients conflict with directives, mandates, or even the best interests of their employers, case managers must resolve the conflict by advocating for the needs of clients/patients. If, for example, case managers who work for payors of various kinds receive direction to engage in activities that are contrary to the best interests of patients/clients, but will save their employers money, case managers must clearly safeguard the interests of patients and clients over those of their employers.
Likewise, case managers/discharge planners who take direction from hospital or skilled nursing facility (SNF) employers to "steer" patients to entities owned by these types of institutions must always put the interest of patients first.
Compliance with applicable standards may, therefore, mean that case managers are between the proverbial rock and hard place! Despite the difficulties of this position, the standards are unambiguous and case managers must comply with them. Failure to do so may result in loss of certification and/or licensure.
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Elizabeth E. Hogue, Esq. All rights reserved. No portion of this material may be reproduced in any form without the advance written permission of the author. |
