Case Managers Don’t Demand Discharges – And They Also Face Moral Distress While Working to Solve the Problem

Last week the New York Times published an article titled “The Moral Crisis of America’s Doctors” with a subheading stating, “the corporatization of healthcare has changed the practice of medicine, causing many physicians to feel alienated from their work.”

They then cited the moral distress of “Dr. A,” an ED doctor. One section of the article reads: “appeasing her peers and superiors without breaching her values became increasingly difficult for Dr A. On one occasion, a frail, elderly woman came into the ER because she was unable to walk on her own. A nurse case manager determined that the woman should be discharged because she didn’t have a specific diagnosis to explain her condition and Medicare wouldn’t cover her stay, even though she lived alone and couldn’t get out of a chair to eat or go to the bathroom.” The article then outlined how Dr. A. tried to comfort the patient and had to “plead” with the hospitalist to admit her.

Now, putting aside the fact that this was simply Dr. A’s recollection of the conversation, and I am hoping it is wrong, let me say that no case manager should ever be telling a doctor that a patient should be discharged – and I hope none of you do that. This patient, with the little information presented, did not require hospital care, but that does not mean she gets put in an Uber and sent home. As every case manager knows, patients don’t get discharged without a safe discharge plan. I am hopeful (and fairly confident) that what the case manager was likely trying to convey was that this patient does not warrant inpatient admission, nor even receiving observation services – not that the patient must be immediately sent home.

The last sentence, “pleading with the hospitalist to admit her,” does bring up one issue. When you have such a patient, with no need for hospital care and no safe discharge plan yet, where does that patient go to wait for the development of a safe discharge plan, which by the way will be put together by an amazing case manager who can often solve the unsolvable? Do they stay in the ED? Do they go to the observation unit? Do they go upstairs to an inpatient bed? And then who is going to oversee their care? The ED doc, the hospitalist, someone else? And will that doctor get paid for their visit? How often can they legally bill for a visit if there is no medical necessity?

Well, there are no right or wrong answers. At least for the hospital charges, the only payable services will be those eligible for Part B payment. No insurer is going to pay room charges for custodial care. Location in the hospital therefore should be based on the facility’s resources and staffing. Of course, an ED bed is much less comfortable for the patient than an inpatient bed, but using an inpatient bed for a patient with custodial needs potentially deprives a patient with acute-care needs of access to that bed and the unique skills of the nurse and others who provide care in that unit.

Likewise, the ED staff is specially trained to care for acutely sick and injured patients, and caring for a patient with custodial needs for hours or days takes them away from their other patients. Most importantly, hospital leaders must be aware that this circumstance occurs much more often than anyone would like, but also convey to everyone that caring for such patients is part of our mission as healthcare providers.

Back to this specific case – while it clearly led to moral distress for Dr. A, Dr. A and everyone in healthcare should also experience moral distress over how few resources our country dedicates to those in need, be it this elderly patient without a family, the child whose family cannot afford or access healthy food, or individuals living in marginalized communities, dealing with glaring racial disparities in maternal healthcare that were brought into the spotlight last week with the death of Torie Bowie, an Olympic athlete who died of eclampsia.

We are all doing our best with what we have. And I thank all of you for your devotion to that. Let’s continue to advocate for our patients and always do what’s right.