AMA DischargesConsiderations for IM Hospitalists

Lenny Noronha, MDAssistant Professor of Medicine

9/14/11

Warm up TriviaName the 4 current IM specialty fellows who

have worked as UNM Hospitalists?

Carlos MaciasChris QuintanaShozab AhmedSuzanne 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 RohrsheibDavid Garcia

Meg Leiberman

Thanks to:

• Jim Little• Amanda Dronet• Willie Barela• Laura Cicarella

Outline

Considerations• Background• Professional/Ethical• Financial/Legal

Communication/Documentation guidelines

Cases

What should “M

edical A

dvice” b

e?

DAMA

• 0.8-2% of Medical Inpatient discharges– Higher in ED, psych settings

• Higher readmission• Higher mortality (outpt and readmission)

Risk factors

• Male• “Young”• Uninsured or Medicaid• No pcp• Substance abuse (esp. alcohol)• Chronic mental health• Unemployed/Low socioeconomic status• Minority

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AMA Discharges

CY 2010 – UNMH AMA Discharges *AMA Discharges by Admitting Service

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Total Discharges AMA Discharges

CY 2010 – UNMH AMA vs Total Discharges*AMA Discharges by Admitting Service

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0%

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0.12% 0.23% 0.31% 0.37% 0.40% 0.43% 0.52% 0.56%0.79%

0.93%1.21%

1.66%

2.25%2.38%

Total Dis-charges

% AMA Discharges

CY 2010 – UNMH AMA Discharges% AMA Discharges by Admitting Service

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 guideall 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 LEXIS-NEXIS 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 follow-up 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

• 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, Wbarela@salud.unm.edu

• 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 GuidelinesIssues 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

Determining Decisional Capacity in Hospitalized Patients

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

capacitiesPierce, Quinn July 2010Hospitalists Best Practices

Determining Decisional Capacity in Hospitalized Patients

Pierce, Quinn July 2010Hospitalists Best Practices

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?

ReferencesAlfandre 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.