“I don’t care … I’m leaving here!” “I didn’t want to come to rehab to start with.” “The hospital/doctor told me I had to come here on my insurance company wouldn’t pay for my hospital stay.”
At some point in our healthcare careers (either in the past or assuredly in the future), we will all hear these exact words or some iteration of them. Long- and short-term rehab facilities are experiencing an increase in the number of Against Medical Advice (AMA) discharges. As patients (residents) become more informed, they also become more willing to advocate for themselves in the decision-making process, both to their benefit and detriment. The facilities are then tasked with walking the fine line between the residents’ right to refuse and safe discharge mandates from federal and state governing bodies.
While there are many contributing factors that can result in an AMA discharge, it is ultimately the responsibility of the Interdisciplinary Team to put forth their best practice in effort to develop a safe discharge plan. Co-morbidities such as substance abuse and mental illness, in addition to clinical diagnoses and cognitive decline, often leave facility staff between “a rock and a hard place,” weighing professional liability versus patient autonomy. Appropriate screening and ongoing assessment are pivotal components when planning a safe discharge.
A culture of crisis
AMA discharges are, by their definition, generally unplanned and thus create a culture of crisis among those staff trying to prevent them. This “crisis mode” mentality does not lend itself to retrospective thoughts processes to identify potential risk factors that led up to that moment and thus provides little actionable intel that could allow staff to identify the precipitating factors and mitigate them. An “in the moment” root cause analysis of the AMA, may help the staff identify the event horizon that has led to this moment.
While most residents are agreeable to facility admission and have realistic expectations, others can display a defensive or disagreeable approach with little interest in collaboration on their plan of care. Risk factors generally include previous AMA discharge(s); denial of diagnosis and/or physical deficits; substance abuse; and failure to understand disease/healing process. Some residents make their discontent known by voicing it while others can become aggressive, confrontational and/or make attempts to exit the building (elopement) with little, to no warning. Assessing for potential risk factors and appropriate care planning moving forward can help staff prepare for and mitigate a potentially unsafe discharge. Developing rapport with a resident and family from the time of admission is critical because it fosters a trusting relationship that can potentially defuse a crisis.
Know the RULE
Motivational Interviewing is a method of communication and counseling that is best used when you have an established rapport with the resident demonstrating high-risk behaviors. The Principles of Motivational Interviewing include; RULE: Resist the righting reflex; Understand the patient’s own motivations; Listen with empathy; and Empower the patient.
“Recent meta-analyses show that motivational interviewing is effective for decreasing alcohol and drug use in adults and adolescents and evidence is accumulating in other areas of health including smoking cessation, reducing sexual risk behaviors, improving adherence to treatment and medication and diabetes management.” (Hall K, 2012) By maintaining a guided and structured conversation, facility staff in any discipline are better able to maintain control in a crisis as well as promote safe discharge planning.
Lastly, utilizing community resources is not only beneficial for documentation purposes, but gaining an outside perspective can potentially decrease the anxiety the resident may be experiencing. Many counties offer Mobile Crisis Intervention Teams that can provide assistance on site when a resident is demonstrating high-risk behaviors. Additionally, a PCP or home care agency often have long established rapport with their patients and may be able to offer further interventions. Adult Protective Services are usually the last line of defense after the resident has left the facility as a follow up measure.
As healthcare providers, we strive to provide every resident with the best possible outcomes while in & discharging from our care. AMA discharges create an environment that is not conducive to providing the best possible outcomes nor ensuring that the discharge is as safe as possible even if completed on a shorter timetable than originally anticipated. By utilizing a team approach for brainstorming and identification of risk factors in tandem with an individualized person-centric, rapport-based delivery method staff are able to provide the potential AMA participant with a team-developed, individualized assessment & discharge plan/timetable. This respects both the residents desire to return to familiarity as expeditiously as possible while also weighing appropriate outcomes as well as resident safety at the highest importance.
Hall, Kate & Gibbie, Tania & Lubman, Dan. (2012). Motivational interviewing techniques: Facilitating behaviour change in the general practice setting. Australian family physician. 41. 660-7. Retrieved from: https://www.researchgate.net/publication/230827341_Motivational_interviewing_techniques_Facilitating_behaviour_change_in_the_general_practice_setting
Rebekah Bray, MHA, is a certified dementia practitioner as well as a certified sex offender treatment provider. She has seven years of long-term care experience including administration, social work and recreation. She is the assistant administrator and director of social services at Oneida Center in Utica, NY.