Transcript AMA Discharges Considerations for IM Hospitalists

AMA Discharges
Considerations for IM Hospitalists
Lenny Noronha, MD
Assistant Professor of Medicine
9/14/11
Warm up Trivia
Name the 4 current IM specialty fellows who
have worked as UNM Hospitalists?
Carlos Macias
Chris Quintana
Shozab Ahmed
Suzanne Emil
All were honorably discharged!
Warm up Trivia #2
Name the 2 of the 3 current IM faculty who
have worked as UNM Hospitalists (not dualists)?
Mark Rohrsheib
David Garcia
Meg Leiberman
Thanks to:
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Jim Little
Amanda Dronet
Willie Barela
Laura Cicarella
Outline
Considerations
• Background
• Professional/Ethical
• Financial/Legal
Communication/Documentation guidelines
Cases
DAMA
• 0.8-2% of Medical Inpatient discharges
– Higher in ED, psych settings
• Higher readmission
• Higher mortality (outpt and readmission)
Risk factors
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•
Male
“Young”
Uninsured or Medicaid
No pcp
Substance abuse (esp. alcohol)
Chronic mental health
Unemployed/Low socioeconomic status
Minority
Neurology
Ob/Gyn
5
5
5
AMA Discharges
100
13
Internal Medicine Teams
40
Family & Community Medicine
30
Maternal Fetal Medicine
12
Surgery
20
Cardiology
5
Peds
4
Orthopedics
4
Neurosurgery
2
Medicine Critical Care
2
Urology
0
1
Medical Oncology
10
Hematology Oncology
CY 2010 – UNMH AMA Discharges
*AMA Discharges by Admitting Service
94
90
80
70
60
50
32
19
CY 2010 – UNMH AMA vs Total Discharges
*AMA Discharges by Admitting Service
100
253
253
460
708
1,724
537
1,361
1,597
4,124
993
2,518
1,143
1,342
90
4,186
94
80
70
60
50
40
30
32
5
12
13
Orthopedics
Peds
Cardiology
Surgery
Total Discharges
AMA Discharges
Internal Medicine Teams
5
Family & Community Medicine
5
Maternal Fetal Medicine
5
Neurosurgery
19
4
Medicine Critical Care
4
Ob/Gyn
2
Neurology
2
Urology
0
1
Medical Oncology
10
Hematology Oncology
20
0%
0.12%
Urology
Surgery
Neurology
Cardiology
2.25%
Family & Community Medicine
2%
Internal Medicine Teams
0.79%
Medicine Critical Care
Medical Oncology
Hematology Oncology
1%
Maternal Fetal Medicine
% AMA
Discharges
0.52%
0.31%
0.43%
Neurosurgery
0.23%
0.40%
0.56%
0.37%
Orthopedics
Total
Discharges
Ob/Gyn
Peds
CY 2010 – UNMH AMA Discharges
% AMA Discharges by Admitting Service
3%
2.38%
1.66%
1.21%
0.93%
Professional Missions
UNM DHM: The Section of Hospital Medicine at UNM strives to
provide the highest quality of care to hospitalized patients and to promote
the advancement of inpatient medical care through education and clinical
research.
SHM: SHM is dedicated to promoting the highest quality care for all
hospitalized patients. SHM is committed to promoting excellence in the
practice of hospital medicine through education, advocacy and research.
‘Optimal inpatient care’
“…providing care that is respectful
of and responsive to individual
patient preferences, needs, and
values, and ensuring that patient values guide
all clinical decisions.”
“The system… should have the capacity to
respond to individual patient choices and
values.”
Institute of Medicine 2001
Financial Considerations
• Insurance companies DO pay for AMA
discharges
– 57% of physicians incorrectly believe otherwise
• Bill provider discharge (99238, 99239) same as
routine discharge if you saw patient on day of
dc.
- No provider billing for unseen patients.
Legal Aspects
• Searched MEDLINE,
PSYCHinfo and LEXISNEXIS databases
• Reviewed 8 cases
• Not “entirely”
protective
Conclusion: “Since patients are admitted voluntarily to a general hospital, a discharge
against medical advice is merely a withdrawl of the original consent.”
So, why ever DAMA?
• Protects against:
– Charges of abandonment
– Failure to provide standard of care on discharge
Authors Guidelines:
• Careful and thorough documentation
• Assess competency
– Obtain psychiatric consultation if unsure
• Failure to make a genuine attempt at followup or alternative care by be interpreted as a
breach of care
• Documentation waiving the hospital from
responsibility is worthless
Communication Reccs
“Reasons for discharges against medical advice: a qualitative study”,
Onukwugha, Saunders, Qual Saf Health Care 2010
• U of MD Healthcare providers and patients
recruited for focus-group interviews (FGI’s)
– 3 pt only, 1 physician only, 1 RN-SW grp
• 1 hr semi-structured interview
- perceived health consequences, costs, benefits of AMA
• Same moderator + 2 research asst’s
Reasons for Leaving
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Drug seeking/Pain management
Other obligations
Wait time
Doctor’s bedside manner
Teaching hospital setting
Communication
Onukwugha, et al. “Reasons for discharges against medical advice: a qualitative
study”, Qual Saf Health Care 2010
Recommended Improvements
Patients
- communicate more about treatment plan, consequences of leaving AMA
- spend more time convincing to stay
Nurse/SW
- communicate dc orders and lab tests ordered
- explain hospital setting (i.e. teaching rounds)
Physicians
- improved nurse-pt communication
- update pcp
- contact patient advocate
Onukwugha, et al. “Reasons for discharges against medical advice: a qualitative
study”, Qual Saf Health Care 2010
• Use motivational interviewing
• Negotiate, negotiate, negotiate!
• Document “shared decision-making”
Early Attending Contact:
• Review roles of team members
• Give overview of pre-rounding, rounds
• Discuss treatment plan, anticipated plans for
discharge and potential hang-ups
• Assess for underlying emotion:
– Anger, anxiety ?= mistrust/helplessness
If concern for DAMA…
• Communicate time to evaluate pt
– “I can be there in 15 minutes.”
• Contact Patient Assistance Coordinator
– Willie Barela: 2-0943, [email protected]
• Sit down for conversation
• Offer to treat pain, anxiety, etc if reasonable and
reassess
Do NOT
• Use threats about future care
• Introduce financial implications
• Tell patients, “You are making a bad decision.”
Fig. 1: Providers’ Perceptions of Relationships and Professional Roles when Caring for Patients who
Leave the Hospital Against Medical Advice, Windinsh, JGIM, 23(10): 2008
AHRQ Guidelines
Issues
Specific Actions
Decision-making Capacity
• Assess and document capacity
• Document discussion of SOI, potential
consequences of leaving AMA
Follow-up Arrangements
• Discuss specific scenarios
- “if you start bleeding again…”
• Arrange appropriate follow-up
• Provide prescriptions
• Document the above in the chart
Communication
• Provide a written summary of
hospitalization and follow-up plans
• Inform pcp
• With patient’s consent, notify contact
• Document the above in chart
Adapted from AHRQ.gov “Web M&M” May 2005
How to Assess Capacity
• 4 crucial prongs: The patient must…
– Express a consistent choice over time
– Understand the facts of the situation
– Appreciate the risks and benefits
– Use a rational thought process
• Sliding scale of sophistication
– Different kinds of decisions require different
capacities
Hospitalists Best Practices
Determining Decisional Capacity in
Hospitalized Patients
Pierce, Quinn July 2010
Hospitalists Best Practices
Determining Decisional Capacity in
Hospitalized Patients
Pierce, Quinn July 2010
Proposed Documentation Template
I have examined ______________ and judge that
he has appropriate decisional capacity. I have
informed him of the risks of refusing medical
care, including potential risks of _____________.
He understands these risks and voluntarily chooses
to refuse medical care at this time. I have offered
alternatives including ______________________.
He chooses to _________________. I invited him
to return at any time for further treatment.
Adapted from: Against Medical Advice: When Should You Take “No” For an Answer? Catherine A. Marco,
MD, FACEP Professor, Department of Emergency Medicine University of Toledo College of Medicine
Summary of Reccomendations
• Partnership not Paternalism
– Communicate plan early, Negotiate
• Follow AHRQ, Pierce guidelines for DAMA
– Complete HSC form
– Give prescriptions
– Offer phone, DC clinic follow-up
• Add completed template to DC summary
Cases
42ym adm overnt for subacute CP + chr hypoxia
Nonspec sx/EKG/CXR.
pO2: 34, serial troponin neg. hct 55
Pt wants to go home. Declines home O2.
Another Case
56yf c MS, recurr aspiration pneumonia
HD 3: Still spiking to 38.4 ̊C, hr 91, req 3Lnc
CXR: RLL infiltr, small effusion
“I’ve had this before. You guys don’t give me my
meds right here. I know I’m ok to go.”
“Tomorrow is my cat’s birthday.”
Role play (volunteers for pt, attg)
Setting: post-night call rounds in ED.
36ym c h/o IVDU, depression adm for suspected
OM of L3. He is uninsured.
Other cases?
References
Alfandre DJ. “I’m Going Home”: Discharges against medical advice, Mayo Clinic Proc 2009; 84(3): 255-260
Taqueti VR. Leaving against medical advice. N Engl J Med. 2007;357(3):213-215.
Hwang SW, Li J, Gupta R, Chien V, Martin RE. What happens to patients who leave hospital against medical advice?
CMAJ 2003;168(4):417-420.
Wigder HN, Propp DA, Insurance companies refusing payment for patients who leave the emergency department
against medical advice is a myth. Annals of Emerg Med 2010; 55(4): 393.
McClain T, How should you bill an AMA discharge? Today’s Hospitalist. June 2010
O'Hara D, Hart W, McDonald I. Leaving hospital against medical advice. J Qual Clin Pract. 1996;16(3):157-164.
Smith DB, Telles JL. Discharges against medical advice at regional acute care hospitals [published correction appears in
Am J Public Health. 1991;81(5):567] Am J Public Health 1991;81(2):212-215.
Green P, Watts D, Poole S, Dhopesh V. Why patients sign out against medical advice (AMA): factors motivating patients
to sign out AMA. Am J Drug Alcohol Abuse 2004;30(2):489-493.
Devitt PJ, Devitt AC, Dewan M. Does identifying a discharge as “against medical advice” confer legal protection? J Fam
Pract. 2000;49(3):224-227.