By Greg Freeman
EXECUTIVE SUMMARY
Healthcare organizations should work to prevent patients leaving against medical advice (AMA). These patients risk their health and may create liability for the hospital or provider.
- A signed AMA waiver is not enough.
- AMA patients often are readmitted at higher cost to the facility.
- A care advocate program can help reduce AMA rates.
Patients leaving against medical advice (AMA) put themselves and the hospital at risk. The patient may suffer harm from forgoing needed care, and the hospital may be held liable for that harm.
Discouraging patients from leaving AMA can be difficult, leaving the facility to depend on documenting its efforts to provide care.
Policies and procedures must be in place to reduce the risk to the facility, but paperwork may not be enough, says Bette McNee, RN, NHA, assistant vice president at insurance broker Graham Company in Philadelphia.
“A signed AMA document doesn’t absolve you or the hospital from the adverse outcomes and the harm that can happen with the patient who walked out of the hospital,” McNee explains. “While everybody needs to have a document for the patient wishing for discharge AMA, that’s not a complete solution.”
AMAs may prompt some regulatory scrutiny of improper discharge, particularly if a hospital’s rate is unusually high, McNee says. If the AMA occurred because of an unaddressed patient issue, a signed AMA release is not likely to prevent a lawsuit.
“We know that when someone does a discharge AMA, their needs were not met,” McNee says. “Aside from how many claims come from discharge against medical advice, I think the great disservice is that we haven’t met the patient’s needs.”
Patients who leave AMA often are readmitted through the ED in an acute situation, experience longer stays, and are more expensive to the hospital, McNee notes. A signed AMA document does not address all the potential negative consequences for the hospital, so it is important to reduce the likelihood of patients wanting to leave.
The first step is learning why patients are leaving AMA. People who previously left AMA are at risk for doing so again, McNee says. Other risk factors are alcohol and substance abuse, financial concerns, and dissatisfaction with their care.
Identifying those patients early and addressing their concerns can reduce the risk of leaving AMA. “We have seen the best results in reducing discharge AMA with hospitals that have implemented some form of a care advocate program in which they create something they hand to the patient,” McNee explains. “When someone comes out of the emergency room and is admitted, you know that you’re going to be admitted, but you remember things like why the patient is in the hospital and what has to be done before it is safe to discharge them. I think unless you fully understand what the goals are before discharge, it’s hard to really understand what the impact is of a discharge against medical advice.”
The care advocate also should check with the patient regularly to answer any questions and pass concerns to the clinicians, McNee says.
Determining the root causes of AMAs can lead to possible solutions. If patients are leaving AMA because of long waits for care or testing, there may be ways to improve those services. (For more information, see the story in this issue for more on why patients leave AMA.)
“Also, if the reasons your folks are interested in leaving is because of complaints about particular providers or staffing, then maybe the care advocate can help a little bit more with that,” McNee says. “If they can intervene earlier, that might help patients not take the extreme measure of discharge just because they don’t care for a particular provider.”
Lack of insurance or general concerns about the cost of care also can prompt a person to leave AMA. McNee recommends care advocates establish a relationship with the business office to find possible solutions. It also can be useful to explain to the patient that aside from potential risks to their health, leaving AMA can lead to higher costs when returning to the ED. The length of stay also might be longer.
McNee also recommends asking the care advocate to work with the patient’s nurses so the care team can call the advocate when a patient is about to leave AMA.
Behavioral Health Patients Are Challenging
Preventing people from leaving AMA may be especially challenging with behavioral health patients, says Pamela Garber, LMHC, a therapist in New York City who is familiar with patients leaving behavioral health hospitals AMA.
Patients leave when they believe they have not been treated correctly or they believe medical errors occurred, such as mistakes with medication, breaking confidentiality, or erroneous tests and inaccurate diagnoses. Patients with addiction or psychiatric issues often are involved with legal matters that may be affected by inpatient treatment, which also can motivate a patient to take legal action against a facility.
“For the most part, the likelihood of an AMA occurrence is decreased when a patient believes he has been receiving treatment that is beneficial or potentially beneficial,” Garber says. “There are patients who are already prepared to fight any intervention, and for them, the actual events in the facility are almost irrelevant as they have a predetermined adversarial stance.”
Leaders can prevent patients from leaving AMA by regularly emphasizing how the patient is benefitting from the care provided, Garber says. Progress that may be abundantly evident to the clinician might not be recognized by the patient, so the clinician should note the improvements frequently.
“It’s almost like you have to sell the effectiveness of what the patient is doing,” Garber explains. “Sometimes, a patient can be improving in significant ways, but they are telling themselves that they’re not getting better and there is no reason to continue.”
Garber has seen situations in which a patient’s family sues the provider or facility after a patient leaves AMA, but she notes that at least in behavioral health, the patient it less likely to pursue litigation.
“When a patient leaves AMA, the patient wants nothing to do with the facility, especially in the substance abuse realm. If they come back, actually there’s an argument that having left prematurely was actually a good thing,” Garber explains. “It may enlighten the person about how much their condition is severe and wants treatment. You can make an argument that there could be a therapeutic benefit in terms of an actual lawsuit or any kind of action against the facility from that.”
SOURCES
- Pamela Garber, LMHC, New York City. Phone: (917) 975-6559. Email: [email protected].
- Bette McNee, RN, NHA, Assistant Vice President, Graham Company, Philadelphia. Email: [email protected].
Patients leaving against medical advice (AMA) put themselves and the hospital at risk. The patient may suffer harm from forgoing needed care, and the hospital may be held liable for that harm. Discouraging patients from leaving AMA can be difficult, leaving the facility to depend on documenting its efforts to provide care.
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