Legal Issues in Case Management:

Discuss confidentiality mandates and HIPPA.

Kassandra Malivert

Professor Falk

Case Management

New York City College of Technology

November 28, 2012

Case Management has been a very important part in patient care in hospital settings and community settings. Case managers assess, plan, organize, and facilitate through collaboration with other health care providers in order to meet the health needs of their patients.  They monitor and evaluate the progress of the client to be sure that their needs are met and that it was cost effective.  The case manager starts this process with the client when they admit them and coordinate discharge planning to ensure that the client transitions from the hospital back to the community. Case managers especially focus on the patients who are at high risk of illness or injury.

Essential skills that is important in case management is to have good communication skills and to learn that advocating for your clients’ rights is the number goal.  In Case management every aspect of the clients health needs are explored in order to find the best resources to manage the client’s health.  It is important in Case management to build a relationship with the client and have them trust you. The topic I chose to right about is Legal issues in case management: Discuss confidentiality mandates and HIPPA.  I will discuss different points which are Confidentiality, Knowledge about the law, Patient’s rights, HIPPA and Importance of culture that are part of legal issues in case management.

Confidentiality in the health care has been a major issue to deal with because of the different record systems used to keep patients information.  Confidentiality is the agreement between the patient and the health care professional to keep everything involving the patient private unless the patient gives permission for their information to be release.  The information about the client is to be kept private unless it poses a threat to the public. The clients’ needs for confidentiality and privacy are important. It is estimated that about 60 to 100 people in a hospital setting look at a patient’s health records (Allender, Rector, Warner, 2010).  Confidentiality mandates are put in place in order to protect patients’ records. The law state that patients need to be aware that their health records are protected and that there are penalty if they are release without permission.  With technology advancing, it is easier for patient’s health record to be available to anyone.  Electronic records are included when it comes to patient’s confidentiality.

When patients are admitted to the hospital, they are given information on the laws and regulation of Confidentiality.  Many patients do not give all health information necessary because of fear that their information will be disclosed.  Patients not relaying all information about their health condition will delay good quality care.  The patient and their family can agreements with healthcare professionals before any information is shared amongst them. Patients need to be treated with respect and should have a say in what they want others to know or not know about their health conditions. Reasons why a patient’s health information can be release and communicated to the public are  if they have communicable diseases, child or elder abuse cases, domestic violence cases, and/ or bioterrorism to appropriate law enforcement authorities.

Case managers especially need to make patients aware that they are advocating for the patients best interest. A breach of confidentiality result when a client’s trust is violates by the healthcare professional.  Often times the breach of confidentiality occurs when the client shared something with the nurse or physician and the conversation is shared with another. The person must face severe consequences for their action.  Different facilities deal with Breach of Confidentiality according to their guidelines.

Another important point is being knowledgeable about the Law.  According to Kay Ely-Pierce, Author of “Legal Issues for Case Managers: What You Don’t Know Can Hurt You” being a Case Manager comes with many responsibilities and challenges which comes with more liability.  Learning about the different rules and regulation will help the case manager to perform the duties of the job.  The case manager can better protect the client from having their privacy right and confidentiality rights from being violated.  Case Managers need to be aware of different resources in order to better meet the needs of the client.  They need to understand “Medicare, Medicaid insurance law, federal regulatory requirements, workers compensation and other guidelines” (Ely-Pierce, 1999). The nurse case manager builds a relationship with their client which establishes trust.  If the nurse was to break that relationship by not meeting the needs of the patient, it is called Breach of Duty.

In an article titled, “Balancing Safety and Privacy: The Case of Room Locks in Assisted Living” by Leslie A. Morgan, the issue of patients making their own decision and safety comes up.  Patients usually encouraged to get involve in their health care plan. But the challenge comes about when there is a dilemma between what the patient wants and what is best for them.  The article talks about an elderly woman who lives in an assisted living setting.  She feels that she should have the right to lock her doors at night, in order to control who comes in and out of her room.  Her daughter wanted to have someone go in at night to her mother’s room to check on her.  The assisted living management decided to go with the decision of the daughter instead of the patient.  “Patients’ rights to privacy and dignity in the NHS” by Woogara, states if patients are treated with respect and dignity, their outcome are more likely to be a positive one.  Woogara emphasize on how important it is for an individual to have their privacy.   It is viewed as a necessity.

Another point that falls under legal issues in case management is the Health Insurance Portability and Accountability Act. The Health Insurance Portability and Accountability Act were created in 1996 in order to protect patient’s medical records. HIPPA became effective in 1997.A study conducted by Wall Street Journal, stated that about 29% of people were concerned about the loss of their privacy. HIPPA was started by Sen. Edward Kennedy and former Sen. Nancy Kassebaum.  The healthcare professional and those who were in charge of that patient were the only ones allowed to view their records.  Many people are covered with health insurance coverage because of this is act.  HIPAA also help with medical finances, access to different healthcare services and explaining the different types of health insurance that are available to patients. HIPPA also allows certain enrollment when a patient is faced a situation and cannot afford the cost of the programs available to them.  One problem that was occurring in the workplace was that people would get fired according to their health status.  Employees had to   disclose their medical information to their employers. Many HIV positive would not be allowed to work.  HIPPA protected these employees and others from being discriminated against.

HIPPA is most important today because of it’s the protection on electronic medical records and how they are for stored and transmitted.   This act allowed people to renew their insurance policy.  It also protects people from fraud and mishandling the payments received for health care and regulates all health care delivery and health insurance.  The main purpose of The HIPPA act is to improve the efficiency of the health care system.

In Case Management, understanding the client’s culture and traditions are important part of understanding their human behavior. Patients make decisions based on their belief, tradition and practices.  As a case manager, understanding that culture and legal system can create a conflict.  In an article titled, “The doctrine of informed consent: A tale of two cultures and two legal traditions, the author compares western legal system with the traditional Jewish system.  He states that western traditions focus on self-decision making and independence when it comes to their health, whereas Jewish traditions base their decisions on their belief and their faith.   The Jewish faith believes that they do not have control over themselves and cannot make medical choices without consenting God or religious authorities.  Cultural competence will improve legal issues in case management because, the case manager will be aware of the reasons why people make or not make certain decisions when it comes to their health.

Legal issues in case management are important to know and understand in order to better provide quality care for our patients as healthcare professionals.  Confidentiality and privacy laws are there to protect the clients.  As healthcare workers, it is our responsibility to ensure that these laws and regulations such as HIPPA, Confidentiality and Patients’ rights are being enforced. Then we can build trusting relationships with our patients.

References

Ely-Pierce, K. (1999). Legal issues for case managers: what you don’t know can hurt you.               Family & Community Health, 22(3), 78-91.

Giacalone, R., & Cacciatore, G. (2003). HIPPA and its impact on pharmacy practice. American Journal Of Health-System Pharmacy, 60(5), 433-445.

Morgan, L. (2009). Balancing safety and privacy: the case of room locks in assisted living. Journal of Housing for the Elderly, 23(3), 185-203.

Smith, S. (2000). Are you protecting your patients’ confidentiality? Nursing Economic$, 18(6), 294

Walter, P. (1999). The doctrine of informed consent: A tale of two cultures and two legal traditions. Issues in Law & Medicine, 14(4), 357.

Woogara, J. (2005). Patients’ rights to privacy and dignity in the NHS. Nursing Standard, 19(18), 33-37.