Ethical Considerations When Sending a Patient to a Low-Rated Post-Acute

At the American Case Management Association (ACMA) Leadership and Physician Advisor Conference, a question was posed to the speakers from an audience member: “My healthcare organization is pushing us to get patients out of the hospital to improve length of stay, and CMS (the Centers for Medicare & Medicaid Services) requires us to provide quality ratings for post-acute services. What do you recommend when all the top-quality facilities are full, and the only one accepting patients is a low-rated facility?” The person went on to add, “I feel like a salesperson.”

As I sat in the audience struggling not to chime in, I couldn’t help but empathize with the concern of this case manager. Although there is nothing wrong with a career in sales, it can be morally distressing for the case manager, who is under pressure to transition the patient out of the hospital when medically ready, but potentially unable to do so because the options available are places you would not even consider sending your own family members. Knowing enough about some of these facilities, should you try to convince your patient that a poorly rated or recently cited facility is a good idea when you know otherwise? 

Many of our colleagues discuss the ethical dilemmas case managers face, but Dr. Ellen Fink-Samnick’s recent book, “The Ethical Case Manager: Tools & Tactics (2023),” eloquently addresses these issues. The ethical considerations in this scenario are non-maleficence (do no harm) and beneficence (acting in the patient’s best interest). These principles are supported by the Conditions of Participation for Discharge Planning (42 CFR §482.43), which require patients to receive quality information about their post-acute options and be included in the treatment planning and decision processes, ensuring autonomy.

The answer to this question involves not straying from our ethical responsibility, as these occurrences do not typically arise often, and there are many other ways to impact the bottom line without causing further harm to our patients. Instead, we should lean into our primary ethical responsibility as case managers – advocating for our patients.  

So, what should we actually do in this situation? Since this is not an easy one, I thought I would offer some options for consideration; however, there are likely more options, which warrant internal discussions in your healthcare organization.

I would recommend having an understanding of the top nearby facilities and their bed availability: are we talking weeks, or do they have an opening the next day? Technology can often help answer this question. Then I would recommend having an honest discussion with the patient and their family about the available choices. Inform them if their top choice does not have an available bed, and ask for their input. If the patient remains reluctant to be discharged to any of the available facilities, consult with the care team, including the attending physician and physician advisor, regarding the patient’s concerns, weighing in the ethical and financial considerations of bed availability and use of hospital resources. For Medicare patients, this may be an appropriate time to facilitate the discharge appeal process, if the patient is interested, which may also provide more time for a bed opening for their preferred facility, while the hospital awaits the Quality Improvement Organization (QIO) decision. I would also recommend continued discussions with the care team to continue to “rehab” the patient while they are in the hospital, to further facilitate the progression toward a safe discharge plan.  Furthermore, escalate the case to leadership, report the avoidable days attributed to the specific details of the facility, and collaborate with local low-rated facilities to collectively engage in support on how they can improve their standards of care for the community’s benefit. Encourage case management to be forthright with the post-acute facility, explaining the patient’s concerns. Ask for action steps to improve the provision of this information for future patients. Additionally, request a guarantee of the low-rated facility to transfer to the patient’s top choice once a bed opens, if the patient is agreeable to this interim plan. Finally, support the patient in informing their insurance of their limited benefits for quality post-acute services.