By Tiffany Ferguson, LMSW, CMAC, ACM 

Case managers frequently face moral dilemmas, especially when arranging post-acute care arrangements. A notable instance occurs when preferred skilled care facilities are not accessible to patients who may need them most, leading case managers to evaluate lower-rated alternatives. This situation tests their dedication to providing top-notch care and puts them in an ethically challenging position, making them feel like they are promoting options they wouldn't choose for their loved ones.

Non-Maleficence and Beneficence

At the core of case management ethics and by the standards we adhere to through the CMSA, this dilemma concerns non-maleficence principles, the commitment to do no harm, and beneficence, the dedication to acting in the patient's best interest. These principles are supported by regulatory frameworks, such as the Conditions of Participation (CoP) for Discharge Planning (42 CFR §482.43), which mandate providing patients with quality information for their post-acute options and ensuring their active participation in care decisions. The CoP underscores the importance of autonomy, enabling patients to make informed choices about their care. However, in doing so, case managers may be caught at the crossroads of patient throughput and patient preference. 

Balancing Ethical Responsibility and Operational Pressures

Case managers often find themselves balancing ethical duties with operational demands. The push to shorten hospital stays and the growing pressure of patients awaiting hospitalization for extended periods in the emergency room stress the case manager's capacity to meet everyone's best interests.  

• They must consider the need to alleviate the ED while ensuring patients in the hospital appropriately receive the care they need.  
• They must consider the financial viability and tight margins hospitals face under a continued fee schedule of acute care reimbursement for services.  
• They must meet their patient's needs and requests for post-acute transitions while allowing patients and their family members enough time to make decisions before discharge. 

CMS's request for quality standards can sometimes conflict with the availability of high-quality post-acute facilities. What if your patient's discharge options are a one-star facility? In such situations, the case manager's role goes beyond just coordinating tasks. It involves advocating for patients' well-being within the healthcare system's constraints internally and with their post-acute external partners.

Promoting Transparency, Collaboration, and Patient-Centered Approaches

Case managers must utilize strategies emphasizing transparency, collaboration, and patient-centered approaches when faced with these obstacles. It is essential to grasp available facilities well and engage in open discussions with patients and their families about their options as an initial crucial step. Involving the care team in these conversations ensures a holistic approach considering ethical principles and financial factors. In cases where it is necessary, guiding Medicare patients through the discharge appeal process may be necessary to leverage extra time and support to secure post-acute placement. This can also offer an opportunity to 'rehab' the patient in-house while awaiting an appeal decision, thus creating a pathway for potential alternative transition options. 

Case managers should consider honest conversations with their low-rated facilities and their patient concerns. This can be escalated to departmental leadership for collaboration and partnership to enhance care standards benefiting the hospital and the wider community, particularly in rural areas. Case managers can also request that the lower-rated facility accept the patient under the condition that they will move the patient to a higher-rated facility when a bed becomes available if the patient consents. 

When appropriate, case managers should inform the patient's insurance of the low-rated options, especially if the selection of one—and two-star facilities is the only 'in-network' choice. Finally, track the avoidable delays because of systemic issues. This information is vital to share across the health system regarding throughput constraints and discharge delays. 

Following the principle of doing no harm, case managers can handle these difficult situations honestly, ensuring patient well-being is a top priority. The ethical dilemma does not need to reside solely on the case manager; open communication with the patient, the interdisciplinary team, leadership, post-acutes, and the payer can help provide solutions. This dedication to our case management principles supports our patients' health outcomes and maintains case management credibility. 

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Bio: Tiffany Ferguson, MSW, ACM, CMAC is CEO of Phoenix Medical Management, Inc. Tiffany serves as an adjunct professor at Northern Arizona University, Department of Social Work, and on the American College of Physician Advisors (ACPA) Observation Subcommittee. Tiffany is co-author of The Hospital Guide to Contemporary Case Management through HcPro. She is a contributor for RACmonitor and Case Management Monthly; she also serves on the editorial board for CMSAToday and Care Management. She is a weekly correspondent on SDoH for the news podcast Talk Ten Tuesday. After practicing as a hospital social worker, she went on to serve as Director of Case Management and quickly assumed responsibilities in system level leadership roles in Health & Care Management, which includes CM, UR, CDI, HIM, and coding. She has held C-level responsibility for a large employed medical group which included value-based arrangements and outpatient care management. Tiffany is a graduate of Northern Arizona University and received her MSW at UCLA.