Implement a policy for discharging violent patients, but be careful
Proposed rule changes give more latitude for involuntary discharge
If you ask a group of home health care workers and volunteers if they’ve ever felt threatened or uncomfortable when paying a visit to a client’s home, it’s likely that each would have a story to tell.
In the days following the 1992 Los Angeles riots, hospice workers from Cedars-Sinai Medical Center Hospice Program continued to care for the patients who lived in South Central Los Angeles despite the simmering anger that was palpable among its residents. Still, there are instances when hospices are justified in discharging a patient, says Michele Evans, RN, BSN, CHPN, clinical associate manager at Cedars-Sinai Medical Center Hospice Program.
According to Evans, Cedars-Sinai’s hospice policy states that patients who fall under the following categories should be discharged:
- patients and/or caregivers who fail to follow the plan of care;
- patients, family, caregivers, or surroundings that pose a threat to hospice workers.
But what’s the difference between feeling threatened or uncomfortable and actually being in danger? And if a hospice worker truly finds himself or herself in the home a patient, family member, or caregiver who is potentially violent, what recourse is available to remove the patient from the hospice’s care?
The short answer is that little can be done and hospices must exhaust every option to continue providing the care the patient and family need. Only in rare instances should hospices discharge patients, says Evans.
Despite Cedars-Sinai’s broad hospice discharge policy, Evans says about three patients per year are discharged for cause. Patients are very rarely turned down because they live in high-crime neighborhoods. "We’ve had patients on skid row; we just try to come up with a plan that works," she says.
Hospice administrators must balance the care needs of the patient and family with their responsibility to keep their workers safe on the job. Because current Medicare regulations favor the patient, hospices have felt pressured to keep patients despite the potential for worker injury.
The Center for Medicare & Medicaid Services is proposing to change the rules of hospice discharge to allow hospices more latitude to dismiss patients for cause without threat of being punished for denying care.
Under the proposed changes, hospices may discharge a patient if:
- the patient moves out of the hospice’s service area or transfers to another hospice;
- the hospice determines that the patient is no longer terminally ill;
- the hospice determines, under a policy set by the hospice for the purpose of addressing "discharge for cause," that the patient’s behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the hospice to operate effectively is seriously impaired.
Medicare has had strict regulations on the books for years regarding discharging patients. Discharge regulations mostly focus on eligibility. If the patient is no longer terminally ill, then the hospice must discharge the patient. All that is required is the absence of recertification of terminal illness by either the medical director or the patient’s physician.
This point is clearly stated in the Medicare hospice manual. It says the "hospice benefit is available only to individuals who are terminally ill and so a hospice may discharge a patient if it discovers that the patient is not terminally ill."
The hospice and the patient part ways, but the patient can resume being covered for life-sustaining services that were waived when hospice care was elected. That can include skilled nursing facility care, hospital services, and home health services.
Other than a patient’s turn for the better, hospices have little recourse for discharging patients. They cannot discharge a patient because the primary caregiver is no longer available to the patient, even if the hospice’s policies and procedures indicate that a caregiver is mandatory for acceptance in the program. Medicare Conditions of Participation obligate the hospice to furnish covered services that are needed by terminal patients. The loss of a caregiver is not sufficient grounds for the discharge of a patient, regardless of the hospice’s internal policies.
Nor can a hospice discharge a patient to a nursing home or other program without the patient’s consent. Again, Medicare regulations state that a hospice may only discharge a patient if the patient’s illness is no longer considered to be terminal or if the patient moves out of the hospice’s service area.
The same holds true for potential patients and others in a home that may be prone to violent behavior. Unless the patient is no longer ill, the hospice is obligated to provide the care established by Medicare’s Conditions of Participation.
Evans says a policy must be put in place that guides hospices to try to resolve the situation without having to discharge a patient. "We had a patient who lived in a neighborhood where the home health aide had to walk past drug dealers and the patient locked the door behind the home health aide while she smoked crack," Evans recalls. "We discharged her."
The patient was discharged without following a set procedure, however. The patient was warned that her behavior would result in a discharge if it continued. When the patient’s behavior did not change, the patient’s physician was notified and told of the potential for discharge. Finally, when the patient was notified of the discharge, she was given alternative hospice programs to contact if she wished to continue in hospice care.
Policies that address threatening, abusive, or violent patients should include a mechanism to provide sufficient notice, and supporting documentation must be provided by the hospice prior to involuntary discharge. In addition, a grievance mechanism should be in place within the organization to give the patient a method of reconciling differences with the provider.
Ann Jackson, MPH, executive director of the Oregon Hospice Association in Portland, warns that discharge policies can become excuses to discharge patients. "Hospices need to bend over backwards to provide the care each patient needs," she says. "There may be a reason to discharge a patient, but in most cases a hospice must be creative to find a solution. Unfortunately, hospice workers are overworked and don’t have the time or energy to be creative, so it just becomes convenient to discharge the patient."
Refer to OSHA guidelines
Medicare’s current hospice regulations are seemingly at odds with worker safety principles established by the Occupational Safety and Health Administration (OSHA) that call for taking necessary measures to avoid placing employees in dangerous situations. In 1998, the agency issued its Guidelines For Security and Safety Of Health Care And Community Service Workers. While these are not regulations that hospices and others must follow, they offer guidance in the absence of rules that would allow hospices to discharge patients who present a danger to staff.
OSHA advises:
- To provide some measure of safety and to keep the employee in contact with headquarters or a source of assistance, cellular car phones should be installed/provided for official use when staff is assigned to duties which take them into private homes and the community.
- Hand-held alarm or noise devices or other effective alarm devices should be provided for all field personnel.
- Beepers or alarm systems that alert a central office of problems should be investigated and provided.
- Other protective devices should be investigated and provided, such as pepper spray.
- Employees are to be instructed not to enter any location where they feel threatened or unsafe. This decision must be the judgment of the employee. Procedures should be developed to assist the employee in evaluating the relative hazard in a given situation. In hazardous cases, the managers must facilitate and establish a "buddy system." This buddy system should be required whenever an employee feels insecure regarding the time of the activity, the location of work, the nature of the client’s health problem, and history of aggressive or assaulting behavior or potential for aggressive acts.
- Employers must provide field staff with personal safety education. This program should be at least provided by local police departments or other appropriate agencies and should include training on awareness, avoidance, and action to take to prevent mugging, robbery, rapes, and other assaults.
- Procedures should be established to assist employees to reduce the likelihood of assaults and robbery from those seeking drugs or money, as well as procedures to follow in the case of threatening behavior and provision for a fail-safe back-up in administration offices.
- A fail-safe back-up system is provided in the administrative office at all times of operation for employees in the field who may need assistance.
- All incidents of threats or other aggression must be reported and logged. Records must be maintained and utilized to prevent future security and safety problems.
- Police assistance and escorts should be required in dangerous or hostile situations or at night. Procedures for evaluating and arranging for such police accompaniment must be developed and training provided.
Still, current Medicare regulations do not provide a safe haven for hospices that have policies in place to discharge patients for anything other than improved health or movement from the coverage area. There is also no guarantee federal or state regulators will accuse a hospice of denying care.
"I would rather suffer the consequences than send a nurse into a dangerous situation," says Evans. "I’m responsible for a nurse’s safety. A dead nurse doesn’t do anyone any good."
If you ask a group of home health care workers and volunteers if theyve ever felt threatened or uncomfortable when paying a visit to a clients home, its likely that each would have a story to tell.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content