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![Page 1: AMA Discharges Considerations for IM Hospitalists Lenny Noronha, MD Assistant Professor of Medicine 9/14/11.](https://reader035.fdocuments.us/reader035/viewer/2022062517/56649edc5503460f94becdaa/html5/thumbnails/1.jpg)
AMA DischargesConsiderations for IM Hospitalists
Lenny Noronha, MDAssistant Professor of Medicine
9/14/11
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Warm up TriviaName the 4 current IM specialty fellows who
have worked as UNM Hospitalists?
Carlos MaciasChris QuintanaShozab AhmedSuzanne Emil
All were honorably discharged!
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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
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Thanks to:
• Jim Little• Amanda Dronet• Willie Barela• Laura Cicarella
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Outline
Considerations• Background• Professional/Ethical• Financial/Legal
Communication/Documentation guidelines
Cases
What should “M
edical A
dvice” b
e?
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DAMA
• 0.8-2% of Medical Inpatient discharges– Higher in ED, psych settings
• Higher readmission• Higher mortality (outpt and readmission)
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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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Hem
atol
ogy
Onc
olog
y
Med
ical
Onc
olog
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Uro
logy
Neu
rolo
gy
Ob/
Gyn
Med
icin
e Cr
itica
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Neu
rosu
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Ort
hope
dics
Peds
Card
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Surg
ery
Mat
erna
l Fet
al M
edic
ine
Fam
ily &
Com
mun
ity M
edic
ine
Inte
rnal
Med
icin
e Te
ams0
10
20
30
40
50
60
70
80
90
100
1 2 2 4 4 5 5 5 512 13
19
32
94
AMA Discharges
CY 2010 – UNMH AMA Discharges *AMA Discharges by Admitting Service
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Hem
atol
ogy
Onc
olog
y
Med
ical
Onc
olog
y
Uro
logy
Neu
rolo
gy
Ob/
Gyn
Med
icin
e Cr
itica
l Car
e
Neu
rosu
rger
y
Ort
hope
dics
Peds
Card
iolo
gy
Surg
ery
Mat
erna
l Fet
al M
edic
ine
Fam
ily &
Com
mun
ity M
edic
ine
Inte
rnal
Med
icin
e Te
ams0
10
20
30
40
50
60
70
80
90
100253 253 460 708 1,724 537 1,361 1,597 4,124 993 2,518 1,143 1,342 4,186
12
2
4 4 5 5 5 5 1213
19
32
94
Total Discharges AMA Discharges
CY 2010 – UNMH AMA vs Total Discharges*AMA Discharges by Admitting Service
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Peds
Ob/
Gyn
Ort
hope
dics
Neu
rosu
rger
y
Hem
atol
ogy
Onc
olog
y
Uro
logy
Surg
ery
Neu
rolo
gy
Med
ical
Onc
olog
y
Med
icin
e Cr
itica
l Car
e
Card
iolo
gy
Mat
erna
l Fet
al M
edic
ine
Inte
rnal
Med
icin
e Te
ams
Fam
ily &
Com
mun
ity M
edic
ine
0%
1%
2%
3%
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
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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.
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‘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
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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.
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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.”
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So, why ever DAMA?
• Protects against:– Charges of abandonment– Failure to provide standard of care on discharge
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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
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Communication Reccs
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“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
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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
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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
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• Use motivational interviewing
• Negotiate, negotiate, negotiate!
• Document “shared decision-making”
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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
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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
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Do NOT
• Use threats about future care
• Introduce financial implications
• Tell patients, “You are making a bad decision.”
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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
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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
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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
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Determining Decisional Capacity in Hospitalized Patients
Pierce, Quinn July 2010Hospitalists Best Practices
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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
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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
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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.
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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.”
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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.
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Other cases?
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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.