5.1 Ethical, Legal and Practice Standards Flashcards
This occurs when there is no “right” answer?
Ethical Dilemma
What 3 conditions must be present to be an ethical dilemma?
There is a decision the individual must make, There is a decision the individual must make, and No matter which course of action is taken, an ethical principal is compromised
Case management ethics are demonstrated in the following ways:
Primary obligation is to the client
Respectful relationships with coworkers, employers and other professionals
Recognition that laws, rules, policies, insurance benefits and regulations are sometimes in conflict with ethical principals. In such situations, case managers are bound to address such conflicts to the best of their abilities or to seek appropriate consultation
Awareness of the five basic ethical principals and how they are applied.
What are the 5 basic ethical principles?
Beneficence Non-malfeasance Autonomy Justice Fidelity
What case manager’s role stems from the principle of client autonomy?
Client Advocate
The case manager collaborates with the autonomous client with the goal of fostering and encouraging the clients?
Independence and self-determination
What are the underlying principles of case management?
Placing public interest above one’s own at all times
Respecting rights and inherent dignity of all clients
Maintaining objectivity in relationships with clients
Acting with integrity in dealing with other professionals to facilitate maximum benefit for the client
Maintaining a level of competency that ensures each client will receive services appropriate and consistent for client’s condition and circumstances
Obeying laws and regulations
Board certified case managers are to serve as:
Client advocates
Perform comprehensive assessments to identify needs and offer other options when appropriate
What will board certified case manager’s do prior to termination of case management service?
Document notification of discontinuation to all relevant parties
What assists in clinical management, justifies interventions and expenses, and defends against claims of neglect?
A case manager’s documentation
The following Communication must be documented:
Patient Family Insurer/Payer Vendor Other healthcare providers, both inside and outside the organization
During what phase of the case manager/client relationship do case managers inform their clients that although their conversations are confidential, certain information obtained through the relationship may be disclosed to third parties including payers, service providers, and government authorities?
In the beginning
shared information is
limited to what is necessary and relevant
When storing client records in any form, including written, recorded, computerized, or on other mediums, what must be ensured?
Confidentiality
What does the Health Insurance portability and accountability act (Hippa) cover?
Protected health information that is released, transferred, or divulged outside the agency
When can confidentiality be broken?
When there is a duty to worn
After receiving written authorization from the patient
To comply with a court order
To report suspected neglect/exploitation of child/elder/resident of LTCH
To report births
To report deaths
To report specific diseases as required by public health laws
To report treatment of patients with physical injury that was inflicted by non-accidental means, such as stabbing/gun shot wound
What is the goal of risk management?
To reduce adverse events, decrease malpractice claims, and minimize financial loss
What is root cause analysis?
A tool designed to identify what, how, and why an adverse event occurred by identifying the factors that contributed to the undesired outcome
What steps can a case manager take to reduce the risk of a malpractice lawsuit?
Use only credentialed healthcare providers
Offer the patient several choices for providers
Communicate with the patient and address concerns
Document all communications with patients and others involved in care and decision making
Do not alter records
Use written guidelines when available: if deviating from them, document justification
Document compliance or lack of compliance with treatment plan
Be aware of and comply with professional standards and regulations
How does tort law differ from malpractice law?
Under tort law, a medical professional can be liable if he/she does not obtain informed consent before treating the patient, even if there is no injury or the patient benefited
What criteria must be met for consent to be informed?
Must include discussion of possible side effects, risks, consequences, and benefits of treatment, medication, or procedures including consequences or risks of stoppage of the service
Client must have capacity to make clear, competent decisions
Information must be clear and easy to understand
Information must be given verbally and in writing
Patient must have opportunity for questions and answers
Consent must be self-determined: it cannot be coerced or pressured by the agency or provider of services
Nurse case managers must be licensed
in the state where case management is being provided
What gives Nurses the ability to practice nursing across state lines?
Nurse Licensure Compact
what is a negligent referral?
Referral of a patient to a healthcare provider who is known to be unqualified
Before a referral is made, what is expected of a reasonably prudent case manager?
The case manger will make sure the referred provider is professionally qualified and without physical or mental impairment that could result in harm to the patient
What does a living will specify?
A living will specifies which life-sustaining procedures should be performed or withheld if death from a terminal condition is imminent, or if the client is in a permanent vegetative state
What is a healthcare durable power of attorney?
A document that appoints someone to make healthcare decisions on behalf of the client if the client is unable to make decisions for himself
According to the Americans with disabilities act (ada), How is a person with a disability is defined?
Has a physical or mental impairment that substantially limits a major life activity
Has a record or history of a substantially limiting impairment
Is regarded or perceived by an employer as having a substantially limiting impairment
The ada prohibits discrimination against people with disabilities in which areas?
Employment Transportation Public Accommodation Communication Government activities
Employers with ____ or more employees are prohibited from discriminating against people with disabilities by Title 1 of the ada
15
In general, what employment provisions are required by the ada?
Equal opportunity in selecting, testing, and hiring qualified applicants with disabilities
Job accommodation for applicants and workers with disabilities when such accommodations would not impose “undue hardship” on the employer
Equal opportunity in promotion and benefits
An applicant with a disability must be able to perform ___________ the of the job either on his or her own with the help of reasonable accommodation
“essential functions”
What is the definition of job accommodation?
A reasonable adjustment to a job or work environment that makes it possible for an individual with a disability to perform job duties.
An employer does not have to provide an accommodation that will cause _______ defined as being significantly difficult or expensive for the employer
“undue hardship”
What kind of specialized equipment can be used for accommodations?
Dragon dictation
An elevated desk to fit a wheelchair
Facility modifications (wheelchair ramps)
Adjustments to work schedules or job duties, as well as a range of other creative solutions
What does the Job accommodation network (Jan) do?
Provides free consulting on workplace accommodations
Impairment=
Refers to a problem with a structure or organ of the body
Disability=
A functional limitation with regard to a particular activity
Handicap+
Refers to a disadvantage in filling a role in life relative to peers
What does title 1 of Hippa guarantee?
Health insurance access, portability, and renewal
Eliminates some preexisting conditions clauses
Prohibits discrimination based on health status
HIPPA cover protected health information (PHI)
released, transferred, or divulged outside the agency
In addition to formal records, what else is covered by hippa?
Personal notes and billing information
Osha’s mission is to assure safe and healthful workplaces by setting and enforcing standards and by providing training, outreach, education, and assistance
OSHA covers private sector workers. It does not cover government employees
The family & medical leave act (fmla) provides eligible employees up to ___ workweeks of unpaid leave a year for specified family and medical reasons
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FMLA requires group health benefits…
be maintained during the leave, as if the employee continued to work
What does the Women’s Health and Cancer Rights Act require group health plans providing coverage for mastectomies also cover?
Reconstruction of breast that was removed by mastectomy
Surgery & reconstruction of the other breast to make the breasts appear symmetrical
Breast Prosthesis
Complications at all stages of mastectomy, including lymphedema
What did the affordable care act (aca) put an end to?
Pre-existing condition discrimination
Insurance companies can no longer deny coverage or charge more because of a pre-existing condition
What maximum age does the aca allow adult children to be covered on their parents’ insurance policy?
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The aca requires free preventative care benefits except ____
for grandfathered plans
The ACA
Requires coverage of essential health benefits
Ends dollar limits on care
Closes the Medicare Donut Hole
The aca further expands the mhpea by requiring the coverage of the following:
Behavioral health treatment, such as psychotherapy and counseling
Mental and behavioral health inpatient services
Substance use disorder treatment
Alcohol misuse screening and counseling
Depression screening
Tobacco use screening and cessation interventions
Domestic and interpersonal violence screening and counseling
Behavioral assessment for children
What program did the aca establish by linking payment to quality hospital outcomes?
Value-Based Purchasing (VBP) in traditional Medicare
The aca authorizes medicare to reduce payments in what situations?
Payments under CMS’s inpatient prospective payment system (ipps) will be reduced to acute care hospitals that have an excess of readmissions
What is a clinical pathway?
Provides outcome-focues care within a certain timeframe
Clinical pathways develop ______
algorithms from evidence-based guidelines, standards of care, and protocols for common diagnoses, conditions, and procedures
