Ethics for Case ManagersPage 7 of 12

5. Legal and Regulatory Requirements

It is inherent in the professional role of the case manager to collaborate with multidisciplinary healthcare professionals to promote the health of clients while using resources prudently. Often these two goals conflict, which can bring about an ethical and sometimes legal dilemma. It is therefore vital that a case manager understand the legal and regulatory requirements that impact ethical decision-making.

In addition to the principles and rules that guide case manager conduct, there are CCM standards to help make decisions.

CCM Standards for Decision-Making

Section 1: The Case manager should be a client advocate.

Section 2: The CM has a professional responsibility to maintain professional competence, updated knowledge and skills, disclose conflicts of interest, report misconduct, and comply with any legal proceedings.

Section 3: Client relationship will include explanation of CM services and duties and notification of termination of those services at the appropriate time. CM will withhold sharing personal values and remain objective in services rendered.

Section 4: Confidentiality will be followed including verbal, written, and electronic media and records.

Section 5: Professional relationships will be impartial and legal including disclosure of fees, conflicts of interest, advertising, and research.

Source: CCCM, 2015.

In addition to the CCM codes, principles and standards, all case managers must abide by the state and federal laws in their practice of case management. These include civil law and criminal law. Civil law addresses a dispute between private parties. This can be to make restitution for an injury or simply for one party to seek a court judgment against another. Criminal law deals with threats to society as a whole or to one or more individuals. It can be categorized as a felony, misdemeanor, or juvenile crime. Criminal law supports the orderly existence of the state.

Test Your Knowledge

Which is an example of criminal law?

  1. A nursing assistant forgets to put up the siderails of a bed and the patient falls out and breaks a hip.
  2. A Case manager commits a DUI.
  3. A neighbor sues the HOA for not putting a stop sign on a busy street, which caused a child to be hit by a speeding car.
  4. A Nurse puts on a blood pressure cuff too tightly and causes bruising to a patient’s arm.

Answer: B

Generally, decisions on healthcare have been delegated to the individual states, however some legal rulings have been enacted at the federal level and affect all states. These include the Americans with Disabilities Act of 1990 (and Amendments of 2008), and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (see Module 7).

Disability Legislation

This law offers protection against discrimination for individuals who have disabilities. It allows these individuals equal access to employment as well as to public buildings (eg, wheelchair ramps, bathroom accommodations). The categories of disability have broadened to include physical disabilities arising from diseases such as HIV/AIDS, respiratory and musculoskeletal disorders, diabetes, and even mental health issues (ADA, 2014).

Legal violations that affect case managers may include negligent care, as when a case manager fails to act in a prudent manner that causes harm to the client. Any causation of damages must be proven. Professional negligence, also known as malpractice, is the failure to meet professional standards of care that result in harm to the client. Individual responsibility demands accountability for one’s own actions.

Preventing malpractice or negligence claims include these general practices:

  • Delegating and assigning duties carefully within the legal scope of practice
  • Being self-aware of your speech and actions
  • Following agency policies and procedures
  • Documenting clearly and objectively
  • Detailing incident reports
  • Practicing safely
  • Obtaining professional liability insurance
  • Maintaining skills and continuing education to stay updated
  • Following the chain of command

Documentation and Case Recording

Case managers must document all their actions, phone conversations and people they have communicated with to follow their trail of planning and implementation. Using approved medical abbreviations, writing objectively and thoroughly takes time but can help others identify the actions taken if ever there is a dispute or confusion. Writing out care plans and communications can also help clarify issues that may have originally appeared confusing.

Not only is it ethical to document all of the communications with each case to truthfully record the patient events for other healthcare professionals to coordinate, but it is also a legal responsibility to record all patient encounters correctly and in a timely manner for insurance reimbursement to avoid insurance fraud.

Case managers can help the entire medical team coordinate care with proper case recording and also by addressing legal issues such as obtaining and recording a Physician Order for Life-Sustaining Treatment (POLST), advance directives, power of medical attorney, and do-not-resuscitate (DNR), mechanical ventilation, artificial nutrition, hospice orders, and even organ donation preferences ((POLST, 2016); Fremgen, 2011).

Test Your Knowledge

What is the meaning of POLST?

  1. Provider orientation long statutory testing
  2. Physicians on-call late schedule time
  3. Physician order for life sustaining treatment
  4. Providers or Long-term care service treatment

Answer: C

Meaningful Use and the Electronic Health Record

Under President Obama, the federal government passed The Health Information Technology for Economic and Clinical Health Act (HITECH), authorizing incentive payments through Medicare and Medicaid to clinicians and hospitals when they use electronic health records (EHRs) privately and securely to achieve specified improvements in care delivery.

After a period of gathering data from numerous constituents, meaningful use of EHRs was defined as entry of basic data: patients’ vital signs and demographics, active medications and allergies, up-to-date problem lists of current and active diagnoses, and smoking status. Over time this list has expanded to include more complete information and software has been created to help providers meet the demands of EHRs.

Case managers intersect with these demands as they record their findings electronically. Merely stating a patient has seen his primary care physician is inadequate. It may be important to say that the patient is in therapeutic range with his anticoagulants. Your system will guide how much information you need to provide. For example, in order to receive reimbursement for services, the case manager often has to document appropriate use of medications, durable medical equipment, home care, and so on.

Test Your Knowledge

Which is an example of meaningful use for a case manager?

  1. Documentation of a patient’s coagulation lab results in regular time periods to establish correct therapeutic range for the prescription.
  2. Documenting the patient attended a Dr.’s appt. as scheduled.
  3. Documenting the patient didn’t answer the phone call you attempted.
  4. Documenting the patient’s information from the face sheet.

Answer: A

Back Next