CMSA Today - Issue 6, 2011 - (Page 23)

CMSA Ethics Casebook Advocacy in Case Management: What Are the Limits? BY JOHN BANJA, PH. D. C ase managers pride themselves on being patient advocates and, well, they should. It’s hard to think of any health care professional who oversees and coordinates care to the extent a case manager does. Of course, just about every health professional calls himself or herself a patient advocate, but I’ll stick my neck out and wager that none engages the breadth of care responsibilities and, hence, advocacy responsibilities to the extent a case manager does. We can never know everything that is going on with a client’s case or all that will result from our actions. That being said, it might be worth questioning the limits of case management advocacy. Obviously, the case manager cannot be all things to all people. For one thing, her advocacy is restrained by the scope of her training, licensure, or certification, e.g., case managers typically don’t perform surgery or do medical examinations. For another, case managers can encounter all kinds of obstacles beyond their control that will inevitably constrain what they can do. A client’s extremely limited coverage may limit the case manager’s ability to get that patient all that he or she might require. Or, consider a situation where the resources available to a patient by way of placement options, specialty care, or family support are simply not up to the patient’s needs. We can only ask the case manager to do what is “reasonable” which, again, can wind up considerably short of an ideal arrangement for the client. Further, there are personal, human factors that can constrain the case manager’s advocacy. Suppose the case manager takes a decided dislike to a client for a seemingly good reason, e.g., the client is abusive toward his or her spouse, or is noncompliant with the care regimen, or is clearly out to “game the system” as much as he or she can. It might be very difficult to “advocate” for such people when the case manager can barely tolerate being in the same room with them. Incidentally, we don’t professionally acknowledge and discuss these kinds of psychological phenomena nearly as much as we should. It’s easy to be a good client advocate when you like the client, the client likes you, and the treatment is going marvelously. It can be terribly difficult to be a good advocate when you don’t like the client, the client clearly doesn’t like you, and the treatment is going nowhere. I wonder how often case managers, in the interests of advocacy, are tempted to do something legally problematic if not downright illegal. Perhaps she thinks to herself, “All I need to do to get this client what he needs is fudge the wording a bit on this form” or misrepresent something just a bit, or omit something from a report, or forge someone’s signature. Even if she believes she will achieve a great good by making a small deviation from the law, she should think twice and then desist from doing it. Laws are in place for very good reasons. We can never know everything that is going on with a client’s case or all that will result from our actions. The case manager who is discovered doing something illegal will likely lose more for herself, her employer, and goodness knows how many others who depend on her than any amount of successful advocacy for an individual client could achieve. I always advise professionals to be careful about the way they use the word “advocate.” The only profession I know that can categorically “advocate” for clients are lawyers and part of the reason is that law depends on an adversarial process that in turn allows individuals to employ professionals whose job is to make the best case they can for their clients. In other words, true advocates are allowed to be biased and are singleminded advocates. The defense lawyer who learns his client is guilty and tells the court will lose his or her license. That’s unbridled advocacy! Case managers, however, arguably “owe” their clients less, both legally and ethically. In future columns, I’ll explore some of these very provocative issues. About the Author John Banja, Ph.D. is a professor of rehabilitation medicine and a medical ethicist at Emory University in Atlanta. He sat on the Commission for Case Manager Certification for six years and speaks frequently at case management conferences. He can be reached at Issue 6 • 2011 CMSA TODAY 23

Table of Contents for the Digital Edition of CMSA Today - Issue 6, 2011

PRESIDENT’S LETTER CASE MANAGEMENT WITHOUT BORDERS: Promoting a Global View and a Universal Understanding
Canadian Perspective A Systems Level Approach to Safe and Effective Care
South African Perspective Hospital to Home – Comparative View of Transitions of Care
Cuban Perspective From Cuba to Milwaukee: Community-Oriented Health Care
VIEW FROM CAPITOL HILL PPC’s Busy Schedule Equates to Changes on the Health Care Front
ETHICS CASEBOOK Advocacy in Case Management: What Are the Limits?
MENTORING MATTERS Improving the Mentorship Role through Feedback This Is a Marathon – Not a Sprint
CASE MANAGEMENT AND THE LAW Deploying Case Management Programs to Reduce Legal Risks

CMSA Today - Issue 6, 2011