ethics of discharge planning

The Ethics of Nursing Home Placement

Janet Williams, MSW, PhD

Janet M Williams MSW, PhD

Imagine If…• You hated oatmeal but had to eat it every morning

at 6am AND you hated getting up early.• You had to EARN the right to take a walk in your

neighborhood.• You valued your privacy, but always had a

roommate AND it was someone you didn’t pick. • You had to WAIT until it was your turn for most

anything you needed, even the most basic of needs.

• You had to ask permission to watch a favorite TV show, have a pop, make a phone call, or smoke a cigarette.

The mission of social work

• The primary mission of the social work profession is to enhance human well being and help meet the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty.

Common issues in Discharge planning

• Hospital Discharge planners– Short window of time– Limited view of resources– Too many vendors with an angle

• Nursing Home Social Workers– Discharge planning one part of busy job– Person versus Family wishes

Ethical Dilemmas

• Occur when an individual has to choose between two or more conflicting ethical standards.


Development of Services

Dichotomy Medical Model Independent Living

Diagnosis discrete categories Universal needs

Assessment for deficits or problems excludes people from services

Definition of the problem

Phys/ cog problems of the individual

dependence on the environment

Social Roles patient Consumer/ customer

Solution to the problem Fix or cure the person, more ROM

Removal of barriers/ change the person

Locus of control Professional and others Consumer


Tension for People with Brain Injuries

• Diagnosis- Can be important in distinguishing from other issues…but how important ongoing?

• Assessment- Can be useful if done in context, assessing functional strengths to build goals.

• Definition of the problem- • The context silly, the context.

• Social Roles- Varies depending on ongoing medical issues, context and needs.

• Solution to the problem- The person and environment fit. • Locus of control- When can a person make decisions?

• Who was I? Who am I? • Who can I be?

NASW Code of Ethics

• 1.05 Cultural Competence and Social Diversity• (c) Social workers should obtain education about

and seek to understand the nature of social diversity and oppression with respect to race, ethnicity, national origin, color, sex, sexual orientation, gender identity or expression, age, marital status, political belief, religion, immigration status, and mental or physical disability.

NASW Code of Ethics

• 4.02 Discrimination• Social workers should not practice, condone,

facilitate, or collaborate with any form of discrimination on the basis of race, ethnicity, national origin, color, sex, sexual orientation, gender identity or expression, age, marital status, political belief, religion, immigration status, or mental or physical disability.

NASW Code of Ethics

• 6.04 Social and Political Action• (d) Social workers should act to prevent and

eliminate domination of, exploitation of, and discrimination against any person, group, or class on the basis of race, ethnicity, national origin, color, sex, sexual orientation, gender identity or expression, age, marital status, political belief, religion, immigration status, or mental or physical disability.

The mission of the social work profession is rooted in a set of core values.

• service• social justice• dignity and worth of the person• importance of human relationships• integrity• competence.

NASW Code of Ethics• The Code identifies core values on which social work’s mission is based.• The Code summarizes broad ethical principles that reflect the profession’s core

values and establishes a set of specific ethical standards that should be used to guide social work practice.

• The Code is designed to help social workers identify relevant considerations when professional obligations conflict or ethical uncertainties arise.

• The Code provides ethical standards to which the general public can hold the social work profession accountable.

• The Code socializes practitioners new to the field to social work’s mission, values, ethical principles, and ethical standards.

• The Code articulates standards that the social work profession itself can use to assess whether social workers have engaged in unethical conduct. NASW has formal procedures to adjudicate ethics complaints filed against its members.* In subscribing to this Code, social workers are required to cooperate in its implementation, participate in NASW adjudication proceedings, and abide by any NASW disciplinary rulings or sanctions based on it.

Ethical Principles

• Value: Service• Ethical Principle: Social workers’ primary goal

is to help people in need and to address social problems.

Ethical Principles

• Value: Social Justice• Ethical Principle: Social workers challenge

social injustice.

Ethical Principles

• Value: Dignity and Worth of the Person• Ethical Principle: Social workers respect the

inherent dignity and worth of the person.

Ethical Principles

• Value: Importance of Human Relationships• Ethical Principle: Social workers recognize the

central importance of human relationships.

Ethical Principles

• Value: Integrity• Ethical Principle: Social workers behave in a

trustworthy manner.

Ethical Principles

• Value: Competence• Ethical Principle: Social workers practice

within their areas of competence and develop and enhance their professional expertise.

Ethical Standards

• Commitment to clients• Self determination• Informed Consent• Competence• Cultural competence• Conflicts of interest• Privacy and confidentiality

Ethical Standards

• Access to records• Sexual relationships• Physical contact• Sexual Harrassment• Derogatory language• Payment for services• Clients who lack decision making capacity

Ethical Standards

• Interruption of Service• Termination of Services

Each Ethical Standard

• Commitment to clients– clients’ interests are primary– Special attention to health and safety

– Medical model or independent living philosophy?


• Self determination– assist clients in their efforts to identify and clarify

their goals.– professional judgment, clients’ actions or

potential actions pose a serious, foreseeable, and imminent risk to themselves or others


• Informed Consent– the purpose of the services, risks related to the

services, limits to services because of the requirements of a third party payer, relevant costs, reasonable alternatives, clients’ right to refuse or withdraw consent, and the time frame covered by the consent.

– extent of services and about the extent of clients’ right to refuse service.


• Competence– only within the boundaries of their education,

training, license, certification, consultation received, supervised experience, or other relevant professional experience.


• Cultural competence and social diversity– Social workers should obtain education about and

seek to understand the nature of social diversity and oppression with respect to race, ethnicity, national origin, color, sex, sexual orientation, gender identity or expression, age, marital status, political belief, religion, immigration status, and mental or physical disability


• Conflicts of Interest– Social workers should inform clients when a real

or potential conflict of interest arises and take reasonable steps to resolve the issue in a manner that makes the clients’ interests primary and protects clients’ interests to the greatest extent possible.


• Privacy and Confidentiality– Social workers may disclose confidential

information when appropriate with valid consent from a client or a person legally authorized to consent on behalf of a client.


• Clients Who Lack Decision Making Capacity– When social workers act on behalf of clients who

lack the capacity to make informed decisions, social workers should take reasonable steps to safeguard the interests and rights of those clients.

Value Assessment Questions

• To what extend did my personal values or philosophies influence the preferred choice of action?

• To what extent did legal obligations influence my decision in this case?• Was I willing to act outside of legal obligations if doing so meant serving the

client best interests?• To what extent did adhering to agency policy influence my decision in this

case?• If agency policy conflicted with outer obligations to the client, was I willing to

act outside of agency policy?• To what extent did my role in the agency influence my choice of action?

Now that you know about ethical dilemmas in general

and potential ethical decision making models…

…Let’s consider some specific ethical dilemmas commonly arising when working with people needing assistance.

Person’s perspective– Most often don’t have any recollection of the injury itself, the early hospital

stay and possibly rehabilitation. – Relearning everything over, even how to relate to family members– May not have a full realization of what the family has been through (bedside

vigil, lost work, complete devotion to the person).– All decisions are made by the family early on and there is no map of when the

person starts getting decision making authority back over their own life. – Person may begin to exert desire to make decisions which can cause friction

within the family. – May begin to make decisions about wanting more independence without

being able to see things from their family’s perspective.

•

Professional Perspective– Good intentions of teaching the family in the hospital or facility but that doesn

’t always transition to home.– Little training on family systems and haven’t been where the family has been. – Most have seen many families go through this but fail to realize this is the first

time for THIS family.– Only knows the person as they are now, not how they were before the injury. – Spends time with the person, not the family which gives a one sided view.– Or, may acquiesce to address the family only, and not the consumer setting

the stage for future tension.– Pressure to help the person be “more independent”

Assimilating Perspectives• Understand there are multiple perspectives.• Include the person and family in the same conversations from day one- don’t

exclude the person or the family. • Support the person to speak to their family, don’t speak for them. Example,

the moving out conversation. • Marathon not a sprint- the family will be there forever and your job is to

leave situations better than you found them. • Have big picture discussions- where you started, where you are now. • Acknowledge and celebrate successes.

Transition is the car ride home

About the shift from professional to personal

control

What about Bob?

• Lived in a nursing home for 13 years• Moved to his own apartment on the tbi waiver using communityworks • Now uses the physical disability waiver in the same home through with tcm

through communityworks and FMS through Independence Inc.• Manages his own staff, calendar and payroll after learning those skills• Used communityworks for case management, independent living skills and

all therapies• Now uses communityworks for IL Counseling and Indy Inc for payroll

communityworks inc tls training January 2005

“It’s all about Bob”

Bob provides us with the vision of life outside of an institution with communityworks as the silent partner in making sure it all works…

Get a CLUE…

• Create positive environments with control and choice

• Listen to the consumer and develop goals based on what you hear, not on what assessments reveal.

• Understand what is happening from the person’s perspective

• Expect that every day brings struggles, surprises and successes.

Inclusion means• Being at the table• Being a part of the discourse• Being respected for who you are, not held

accountable for what others expect you to be

• Acknowledges that people may be different and pushes us to respect diversity

Finding a place in the community

Perspectives

• Family• Person

• Professional

Man’s search for meaning

• An abnormal reaction to an abnormal situation is normal behavior.

Victor Frankl

The easy way out: labeling families

• In Denial

• Overprotective

• Dysfunctional

• Unrealistic

Transition is the car ride home

Person’s perspective– Most often don’t have any recollection of the injury itself, the early hospital

stay and possibly rehabilitation. – Relearning everything over, even how to relate to family members– May not have a full realization of what the family has been through (bedside

vigil, lost work, complete devotion to the person).– All decisions are made by the family early on and there is no map of when the

person starts getting decision making authority back over their own life. – Person may begin to exert desire to make decisions which can cause friction

within the family. – May begin to make decisions about wanting more independence without

being able to see things from their family’s perspective.

•

Professional Perspective– Good intentions of teaching the family in the hospital or facility but that doesn

’t always transition to home.– Little training on family systems and haven’t been where the family has been. – Most have seen many families go through this but fail to realize this is the first

time for THIS family.– Only knows the person as they are now, not how they were before the injury. – Spends time with the person, not the family which gives a one sided view.– Or, may acquiesce to address the family only, and not the consumer setting

the stage for future tension.– Pressure to help the person be “more independent”

Assimilating Perspectives• Understand there are multiple perspectives.• Include the person and family in the same conversations from day one- don’t

exclude the person or the family. • Support the person to speak to their family, don’t speak for them. Example,

the moving out conversation. • Marathon not a sprint- the family will be there forever and your job is to

leave situations better than you found them. • Have big picture discussions- where you started, where you are now. • Acknowledge and celebrate successes.

Money Follows the PersonMFP

• For any person who has 90 days of continuous hospitalization or nursing facility or a combination of both. – The person cannot give up a bed within those 90

days. – The last bed a person occupies must be a skilled

nursing bed (SNF)

MFP• Must be Medicaid eligible 30 days prior to

receiving MFP services• Must meet the functional eligibility for waivered

services (LOC score of 26 or greater for FE,PD, TBI waivers)

• Intensive case management will be available for these residents. Case Management services can begin 60 days prior to transition & will continue once someone is in the community.

Benefits of MFP

• Transition services- up to $2500.00 start up cost.• Home modification/Assistive Technology services

above the $7500.00 lifetime cap on waivers (that are now frozen)

• The program allows the state to pull down a higher federal match for the MFP candidates for the first 365 days of them living independently in the community.

Other community resources

Resources• Social Security

• Presumptive disability• Medicaid/ Medicare• Vocational Rehabilitation• Home and Community based waivers• Housing • Transportation• Brain Injury Associations

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Williams/ Wilkerson 5/16/07 Soldiers with traumatic brain injury 55

We all teach consumers how to be a part of the community.

• Occupational Therapist– Modifications– Sequencing– Upper body/fine motor– Memory

• Physical Therapist– Walking, Transfers, – Gross (large) motor

movement

• Speech Therapist– Communication of any

type– memory– cognitive skills

• Cognitive Therapist– problem-solving– thinking skills– specific skill building

Examples of referrals

• C from X called concerning T. T. is at Big Hospital and will be discharging sometime today or tomorrow. T. has had 3 strokes and is in need of case management. C didn’t have very much information on him, but she said that you can call him to schedule the assessment.

Example

• Tonya with Big Hospital called concerning B. B. shot himself in the head and does not yet have a release date scheduled. Once released, he will be returning to his home in Kansas City KS. Tonya said that you could call her and/or B.’s wife S. to schedule the referral.

Referral example

• Lee with Mental health center called concerning M. M. was assaulted and kicked in the head in May of 2011. Please call M. directly to schedule the assessment. Lee said that you could also call him if you have any questions.

Example

• J. called concerning her mother-in-law N. N. is 76 and has moved in with her son and daughter-in-law because she has had a few falls and now must use a walker. She also has a feeding tube because she has a problem with her gag reflex. J. would like for you to call her to schedule the assessment.

Example

• D. called concerning her husband D. D. had a stroke in June and is now paralyzed on his left side and is in a wheel chair. He was in a hospital for 27 days and was then transferred to Rapid Recovery. His release date from Rapid Recover will be 10/21/11. D. would like for you to call her to schedule an assessment. She stated that using her cell phone number would probably be the best way to reach her.

Self Direction

• A law in the State of Kansas allowing people with disabilities to hire, train and supervise employees to provide the assistance needed to live in the community, even the tasks traditionally provided by a registered nurse.

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Common Ethical Dilemmas Arising in Discharge Planning

ethics of discharge planning

Healthcare