As a nurse case manager, you are an RN who coordinates all aspects of the care of individual patients in whatever setting you practice: acute care, long-term care, workers compensation or home care. Most of you have a bachelors degree or another advanced degree.
Most of you also are certified by the professional credentialing centers existing today, including the American Nurses Credentialing Center, the Commission for Case Management Certification and the American Association of Managed Care Nurses.
Because nurse case managers work in diverse capacities (e.g., advocate, coordination of medical services, proper utilization of resources), many potential legal and ethical challenges exist in carrying out these numerous roles. The American Nurses Associations Code of Ethics for Nurses With Interpretive Statements is an essential guide for all nurse case managers to know and to adhere to its guiding principles. The code, and its companion publication, Guide to the Code of Ethics for Nurses: Interpretation and Application, should serve as a constant resource for you as you carry out your responsibilities as a nurse case manager.
Legally, it appears the most common area of liability for case managers, including nurse managers, is basing a decision concerning a patients care on cost savings alone, without regard to the quality of the treatment regimen. A second area of liability is that of lack of follow-through with a physician or other appropriate healthcare provider by the case manager. In one instance, the hospital, through its nurse case manager, failed to inform the patient of the essential need for a follow-up appointment after discharge.
In another unreported case, a nurse case manager, who worked in the area of workers compensation, and the workers compensation insurer, were sued by an employee whose injury the nurse case manager was handling. The allegations of negligence against the nurse involved the manner in which the nurse had directed care, her lack of timeliness and her lack of advocacy. Testimony by a nurse manager expert witness, among other evidence, resulted in a verdict against the case manager and the insurer.
Another interesting area of legal concern for nurse case managers is the documentation of the follow-through done. Not only does actual follow-through need to happen, but so does accurate and complete documentation of what follow-through was in fact done. If follow-through does not occur, because the individual is not compliant, or there is an inability to contact the patient, these actions must also be documented to show whoever reads the medical record that you complied with your legal and ethical responsibilities to the patient.
Other guiding principles exist that are important for the nurse case manager to adhere to as well in todays cost-conscious healthcare delivery systems, as authors Susan Jensen, PhD, RN, CCM, and Carrie Valiant point out. These authors provide several points to consider when case managers, including nursing case managers, must make legally and ethically sound decisions about patient care issues whose boundaries are not clearly marked. They include:
1. Identify your own personal values and the values of your organization about case management hopefully they are compatible to better handle ethical and legal issues that will arise in your role;
2. Know and utilize ethical principles required in healthcare;
3. Know the many laws that impact your role, including The False Claims Act (falsifying a claim for reimbursement by the federal government), HIPAA (privacy and security mandates) and the Stark Law (physician self-referral to services paid by Medicare or Medicaid where physician or family has a financial interest);
4. Always evaluate any ethical [or legal] situation that presents itself before acting;
5. Voice serious issues you identify to your supervisor, if necessary to those in the chain of command, and utilize your compliance officer;
6. Remember that enforcement by such agencies as the Department of Justice, Office of Inspector General of the U.S. Department of Health and Human Services and others is ongoing;
7. Refuse remuneration (e.g., cash, rebates, bribes) for referring patients or inducing purchases, leases or orders;
8. Because cost containment is essential, case management becomes essential but this role can result in increased responsibility and increased risk to the case manager;
9. Constantly monitor patient status and patient documentation; and
10 Certification in case management remains essential.