Ethics, Case Managers, and the Value Proposition
May 1, 2020
By Jeanie Davis
The pressures case managers face are a reality in a value-based healthcare system. Cost of care and penalties for readmissions are the bottom line in every institution, and that pressure will affect how well case managers perform in their everyday duties, says Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP, principal at EFS Supervision Strategies.
To uphold their ethical tenets, and advocate in the best interests of their patients, a case manager must be prepared to handle these pressures. They must be leaders in their teams, with a strong sense of self and self-confidence.
Leadership is difficult for many case managers to grapple with, she says, but they must rise to the challenge. “Case managers are front and center in the care coordination process,” Fink-Samnick says. “Whether they are in a formal leadership position or not, they have to act as a leader.”
Self-confidence is essential in coordinating a team and managing the dynamics, Fink-Samnick says. “That is complicated by a backdrop of workplace bullying and lateral violence,” she adds.
Bullying Aimed at Case Managers
Healthcare institutions must recognize the pressures on case managers, she explains. “Too often, case managers are pushed to follow discharge templates, don’t ask questions, don’t advocate, and move the patient along. The result is the case manager is not set up to practice ethically and legally.”
Workplace bullying is defined as a persistent pattern of mistreatment from others in the workplace that causes either physical or emotional harm. Lateral violence is a co-worker exhibiting harmful, hostile, or aggressive behavior toward other co-workers.
“There has been a dramatic uptick in these behaviors, with the highest surge in hospitals,” says Fink-Samnick. “For close to the past decade, healthcare professions have seen the highest levels of workplace bullying. Seventy-five percent of workers are impacted by bullying, whether target or witness, while $200 billion annually is spent on lost productivity from bullying alone; for example, increased sick days, medical claims, legal costs, and staff turnover,” she explains.
Example 1: A case manager is discussing a patient with a physician, acute care nurse practitioner, physician advisor, or hospitalist. “The case manager asks whether the patient needs to stay at the current level of care,” says Fink-Samnick. “They simply want clarification of the treatment plan or code status.”
The response they get is often “a biting, devaluing comment from anyone in that discussion — typically the physician, but often another team member,” she says.
Example 2: The case manager is working with an elderly couple, Mr. and Mrs. Smith. He is 75 years old and underwent a hip replacement. The plan is to transfer him to a subacute rehabilitation nursing home.
When the physician comes into the room, Mrs. Smith says Mr. Smith is complaining of pain, and mentions she saw drainage from the wound. Mrs. Smith then says, “But you know better, doctor, shouldn’t we do something?”
The case manager approaches the doctor outside of the patient’s room to inquire about the drainage. The doctor’s words to the case manager: “What’s the big deal? You know Mrs. Smith is a complainer.” Then, the doctor aims a series of comments berating the case manager, who is left feeling defeated.
“At that point, the case manager gives up, issues the discharge order, gets the transfer order signed, and the patient goes to the nursing home,” Fink-Samnick explains. “In 48 hours, the patient spikes a fever, blood test shows an infection, and the patient is readmitted.”
Disruption Drives Readmission Rates
A 2017 study revealed hospitals that employ surgeons with high numbers of patient complaints experience higher readmission rates.1 “It’s arrogance that costs hospitals the big bucks in readmission penalties,” Fink-Samnick explains. “If a case manager cannot talk to a physician, that’s a big problem.” There is a ripple effect, she says, as that case manager will be more inclined to leave the workplace due to bullying.
Workplace bullying is especially prevalent in healthcare, Fink-Samnick says. As a result, patient care suffers because communication is fragmented, she adds.
Frustration is at the heart of this bullying and bad behavior, she explains. “All over the country, hospitals are struggling. Hospitals have been acquired by bigger hospitals, and this leaves hospital systems in turmoil. Along with the focus on value-based care and penalties for readmissions, people are under a lot of pressure.”
In some situations, one case manager might be handling the job of two people, working a full schedule plus one weekend every month. The hospital cannot justify hiring two case managers. The case manager gets frustrated with being overworked, and it shows.
“That’s when a nice team with good communication deteriorates,” says Fink-Samnick. “People begin placing blame on each other. That’s the definition of lateral violence.”
One study revealed the healthcare industry experiences the highest incidence of workplace bullying for any industry sector. “I was shocked when I saw that,” says Fink-Samnick.
Typically, a hospital case manager earns $85,000 annually; if that case manager leaves due to bullying, the cost of replacing that person is estimated at more than $120,000 per employee. The cost of employee turnover from workplace bullying is calculated by multiplying the combined salaries of departed workers by 1.5, she explains.
Readmissions are affected when the case manager feels bullied, says Fink-Samnick. “Their attitude and behavior changes,” she explains. “Their decisions degenerate, becoming less ethical, less competent, especially if they are not mature professionals. They will be less accountable in their actions. That’s when we see poor outcomes related to care coordination, handoffs, and readmissions.”
Research over the past decade shows consistently that 70% of all patient handoffs are flawed, says Fink-Samnick. A Joint Commission 2017 alert highlighted ineffective communication during patient handoffs as a major contributing factor to more than 1,700 deaths and $1.7 billion in additional costs for the healthcare system.2
“That means all those readmissions are preventable,” Fink-Samnick adds. The readmissions are due to incidences like Mr. and Mrs. Smith — and the doctor who brushed away their concerns.
If case managers are not comfortable and confident in their role, and if they are not trained properly, there will be trouble, she says. In that situation, the patient may file a lawsuit against the case manager for unethical behavior, as they did not advocate on the patient’s behalf.
Serious Repercussions for Case Managers
When a case manager does not advocate for a patient, it could prompt a hospital readmission, says Fink-Samnick. “The family is furious, and files a grievance against the CCMC or National Board for Case Managers against the case manager’s credentials,” she explains. “If they find that the case manager did not advocate for the patient appropriately, it goes against the values of the profession, and is potentially sanctionable. You could lose your license; you could lose your credentials.”
A complaint is filed with the case management credentialing entity claiming the case manager did not perform due diligence, knew of a conflict of interest, or knew ethical standards were being violated. The stakes are higher when a patient is set up for harm — especially when the case manager did not advocate for the patient to experience a safe discharge or transfer, whether to home or another facility.
Core Ethical Behaviors
All ethical behavior can be distilled into what Fink-Samnick calls the 3 Cs and 2 Ds:
- Competence;
- Confidentiality;
- Conflict of interest;
- Dishonesty;
- Dual relationship.
“Conflict of interest” and “Dual relationship” must be understood clearly, she explains.
Dual relationship is a nurse giving a patient the name of a lawyer he or she used for personal matters, which could affect the impartiality of the professional relationship. Conflict of interest is a set of circumstances that clash between self-interest and professional or public interest, like recommending a home care agency owned by a friend.
At the heart of the issue, says Fink-Samnick, is whether the case manager is adequately informed, credentialed, and trained.
Also key: “Does the case manager know they are ethically accountable to follow through in reporting abuse and exploitation?” she asks. “They are responsible for advocating on behalf of the patient in any situation with a physician, staff member, facility, or healthcare agency. Advocacy is the primary ethical tenet of a professional case manager.”
Workplace bullying can be endemic to the culture of an organization, especially in healthcare, says Fink-Samnick. “However, healthcare organizations are recognizing the impact on patient safety and care quality, as well as the dramatic toll it is taking on the workforce. Organizations can no longer afford the financial and human toll of this disruptor.”
On the personal level, Fink-Samnick is a fan of Eleanor Roosevelt, who said: “No one can make you feel inferior without your consent.” Fink-Samnick adds: “You don’t handle these situations initially through direct confrontation but by discussion.”
Fink-Samnick advises those targeted by bullying to follow these steps:
- Perform a self-check to assess how you came across;
- Approach the person who allegedly bullied, to check in. Perhaps he or she experienced a tough day, or are stressed.
She also recommends following these five steps:
- Address the bullying behavior, perhaps with a witness;
- Seek employer resolution (use all available resolution routes; e.g., leadership, human resources);
- Consider filing a complaint with a credentialing body if no other resolution can be reached;
- Seek an independent legal consultation;
- Obtain an independent mental health consultation.
Leadership training can help case managers cope with bullying, says Fink-Samnick, adding that many hospital leaders could benefit from training to change their bullying behaviors. “It’s part of a larger conversation, but too often, their negative behavior is their response to pressures they experience.”
REFERENCES
- Cooper W, Guillamondegui O, Hines J, et al. Use of unsolicited patient observations to identify surgeons with increased risk for postoperative complications. JAMA Surg 2017;152:522-529.
- The Joint Commission. Inadequate hand-off communication. Sentinel Event Alert 2017 Sep;1-6.
The pressures case managers face are a reality in a value-based healthcare system. Cost of care and penalties for readmissions are the bottom line in every institution, and that pressure will affect how well case managers perform in their everyday duties. To uphold their ethical tenets, and advocate in the best interests of their patients, a case manager must be prepared to handle these pressures.
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