Help keep staff focused on proper procedures
Case studies reinforce ethical behavior
Helping staff navigate the treacherous waters of legal and ethical dilemmas in home care requires constant reinforcement of agency policies and the reasoning behind them. One way to provide that reinforcement is to hold regular meetings where staff can discuss ethical issues that have come up in the practice and learn ways to cope with future occurrences.
Home Care Providers, a Burlington, NC, agency affiliated with Alamance Regional Medical Center, gathers its entire staff every other month to discuss ethical and legal issues in meetings led by director Dottie Moseley, RN, MPH.
Moseley says the investment of meeting time — about 90 minutes each meeting — is definitely worth it.
"I think that it’s helped our staff tremendously," she says. "I think [staff members] bring issues to us that we have to address. The more you discuss it, the more you make the environment so the staff identifies issues for you, the better off you’re going to be in making sure that staff performance is improved."
Many of the ethical issues Moseley sees in her agency involve admission and discharge. In the years since the Balanced Budget Act of 1997, agencies have been under greater financial pressure, which can translate into pressures to provide care more efficiently.
"Before, the more visits you made the more money you made," she says. "And now, the more efficient you are and the fewer visits you make per beneficiary, the better your bottom line is going to be."
With the stronger emphasis on efficiency and cost savings, it is all too easy for staff to make mistakes in speaking with patients and family or to handle a case inappropriately.
"If you admit patients who require a lot of care over a period of time, then they will burn up a lot of money," she says. "Many people tell their staff, We’re just not going to take any more of those kinds of patients because they require too much care.’ But Medicare says they haven’t changed the coverage issue at all. It’s how you teach your staff to deal with that that keeps you out of trouble."
The purpose of home care
Moseley says that much of her time is spent reviewing the questions staff should be asking upon admission, which could point to patients who shouldn’t be in home care or who will require more resources than the agency can provide.
"I really stress looking at your admission, really scrutinizing that, looking at how your staff walks through your care plan," she says. "Home care is not to keep a patient for life; it’s to get a patient through a transition period."
These issues come up repeatedly in Home Care Providers’ bimonthly ethics meetings, which can take many forms. Sometimes, there’s a lecture format or a video presentation. Often, staff present a case study and then discuss the ethical issues involved.
"If we have a client we’ve been seeing, and the staff is having real difficulty because maybe the client or the family is not following the plan of care, or they see issues in the home that really keep postponing the goals that have been established, we may bring the case into our ethical dilemmas discussion and look at it."
They discuss whether admission criteria were followed. Was the patient appropriate for home care? Were there caregiver issues at admission that should have pointed to problems? Did the patient have a history of not participating in care?
"So we will have those discussions, and then we will try to problem-solve and say, What do we need to do? What kind of action do you need to take with the family?’ And then we try to set some target dates for accomplishing that," she says.
The agency’s medical director usually attends the meetings to provide a clinical perspective. Other resources, such as the agency’s chaplain, can be tapped to give additional insights.
The goal, Moseley says, is to give every staff member an idea of the larger purpose being served by the home health agency and the pitfalls involved in providing care. "If you get the whole staff in this process, then as clients call the office, everyone’s aware of what it is we’re doing. Your secretarial staff can tell a client something that can really get them in trouble."
Another issue was illustrated at a recent ethics meeting when Moseley showed a video that portrayed a home health agency being sued by a man on behalf of his mother, who had been a patient. In the video, the man accused the agency of not providing proper care. The video was about the issue of patient education and how to ensure that caregivers understand the patient care instructions they receive.
"We showed the film and stopped it and said, What do you see? Did the nurse ask the family member how he would turn his mother and get his mother out of bed?’ They said no. So it was real clear to the staff that the caregiver has to demonstrate this care. So that when you leave, when you have documented that they know how to do that, you had seen them do it."
During that presentation, she says, some staff members admitted they had taken the caregiver’s word that he or she knew how to provide the required care. Now, Moseley says, they understand that they need to watch the caregiver demonstrate that care.
Face ethical, legal issues
Again, the issues often return to admission policies and how well they are followed. Was it clear at admission who the caregiver was and whether they were willing or able to provide care? Did the patient require care that the home health agency could not provide?
"You have to decide, Can we care for that patient if there’s no one there, and your client is bedridden and needs to be turned because of bedsores?’" she says. "Is a home health agency an appropriate place for that person to be if no one there can demonstrate care? These are the question marks that come up that help the staff when they go out to see a patient."
The meetings also address other common ethical and legal issues faced by home health staff. A session on patient rights and responsibilities might focus on respecting a patient’s right to participate in care, or to choose not to, and what that means for staff.
The agency might be faced with a patient who doesn’t want to be resuscitated or who wants extraordinary measures taken even when medical professionals have determined that he or she is terminally ill.
"We will discuss that law and what that means and what things we need to do as an agency — that we must respect the patient’s right to participate in care," Moseley explains.
"If the patient doesn’t want that, they don’t have to do that. All we can do is let them know the consequences of their decisions. They still have the right to do it the way they want to do it," she says.
Make errors known
Staff members are encouraged to bring forward ethical problems they’ve encountered, even after the fact, so that the group can discuss them. "When someone makes a mistake, you want to make sure the staff brings that forward, rather than feeling like they can’t because they think they’ll be beaten to death," she says.
While her agency has instituted the regular meetings, she says, the process doesn’t have to be that formalized. Similar ethical discussions also come up regularly in Home Care Providers’ case management meetings. Agencies wanting to encourage such discussions can simply give employees a place to go with questions.
"They can do it as two or three members," she says. "They can come to a manager, and that manager can pull two or three people in."
The important thing is that staff recognize the importance of addressing the issues whenever they come up. "Education of your staff today is just absolutely crucial in dealing with the issues that we have to deal with," Moseley says.
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