Published in the May 2017 issue of Today’s Hospitalist
HOSPITALISTS AROUND THE COUNTRY have been struggling with new twists on an old problem: how to handle patients who leave the hospital against medical advice (AMA).
Are patients AMA, for instance, if they go home instead of transferring to a post-acute care facility you recommend? If that home-bound patient bounces back in 30 days, Medicare will penalize your hospital for that readmission—but not if you document the original discharge as AMA.
How about patients you want to keep in observation status who would rather take their chances at home and avoid additional outpatient co-pays? You may think they are making a bad choice and worry that they might turn around and sue. Should you ask them to sign out AMA?
Then there’s this perennial dilemma: What’s your obligation to patients who want to leave against your advice? Should you provide them the same care as patients with traditional discharges, including prescriptions and arranged follow-up?
“I don’t believe it’s my way or the highway.”
Bioethicists answer that question with an unqualified “yes,” but that may not be the reality in many groups. “From a cultural standpoint, that is not what we usually see,” says Ada Offurum, MD, who directs a team of close to 30 hospitalists at the University of Maryland Medical Center’s hospital in downtown Baltimore.
“When a patient is formally discharged and you forget a prescription, you bend over backwards to get them that prescription,” says Dr. Offurum. But it doesn’t necessarily follow that doctors do the same for patients leaving AMA. “Some providers do, and some don’t.”
Readmission penalties and growing observation units have some hospitalists looking more closely at the legal and financial implications of AMA patients. Others view AMA discharges as a canary in a coal mine: an early warning that something may be wrong with the care being provided. Instead of using a label that some patients may see as punitive, these hospitalists are working harder to create care plans that more patients can embrace.
A range of options
When it comes to AMA patients, physicians may struggle to balance patients’ needs with those of their institution. David Alfandre, MD, a hospitalist at the VA New York Harbor Health Care System and a health care ethicist at the VA National Center for Ethics in Health Care, urges physicians to view AMA discharges as a sign the health care team can do better. Such discharges, Dr. Alfandre adds, may be a potential marker of low-quality care, and they can reduce patients’ likelihood of follow-up.
As he sees it, physicians have a responsibility to provide informed consent for patients with “a range of available options and make it clear what the differences are between those options, including no inpatient treatment.” Physicians are further obligated to make sure that patients understand those options and are making a voluntary choice. “Patients make tradeoffs all the time about care that better fits their values and preferences.”
“Patients might not want your plan A, but there is usually an acceptable Plan B.”
Moreover, given the potential stigma of an AMA discharge, the variability in the use of that label can be problematic. “There is no agreement clinically about what is AMA,” he points out. “One doctor’s AMA discharge is another’s ‘I don’t recommend that, but that is within the range of medically accepted options.’ ”
The reasons why patients leave AMA provide insight into the role physicians can play. Eberechukwu Onukwugha, PhD, MS, of the University of Maryland’s department of pharmaceutical health services research, has researched predictors of AMA discharge and readmissions. In AMA focus groups, some patients squarely point the finger at themselves. She’s heard, for instance, “I had to get a hit of heroin” and “I was afraid I was going to lose my job.”
But others mention miscommunication, feeling disrespected and not having their needs met, including pain that wasn’t effectively managed. One patient said she left AMA because she requested a female doctor, but no one paid attention.
“Some AMA discharge reasons are actionable,” says Dr. Onukwugha. “We miss an opportunity to improve if we ignore these.”
An AMA “warning shot”
Still other AMA discharges are avoidable. Studies—like one published in the January 2017 issue of the Journal of Hospital Medicine—show that one fifth of AMA patients commonly “fire some sort of warning shot” to signal that they are thinking about leaving before they actually sign out AMA.
Lead author Cordelia Stearns, MD, a hospitalist at Alameda Health System’s Highland Hospital in Oakland, Calif., interprets that finding to mean that providers have a chance to convince some patients to stay in the hospital or make alternative treatment plans for those who choose to leave.
“Many patients tell us they are going to leave, but then don’t,” Dr. Stearns says. “That’s an opportunity for us to improve care.” Maybe all patients need is for the doctors to be more “transparent” about their thought processes, she adds, like explaining they need the patient to stay an extra day for a creatinine check. Or doctors may need to be more creative in post-acute care planning, figuring out how to arrange outpatient physical therapy rather than automatically going along with physical therapy’s recommendation for inpatient rehab.
“Rather than looking at patients as if they’re being ‘difficult,’ we need to look at them differently,” says Dr. Stearns. “They are high risk, and patients might not want your Plan A, but there usually is an acceptable Plan B.”
Balancing care with financial metrics
At the same time, doctors are thinking about how to balance patient care with hospital performance on a growing list of metrics that can affect finances.
Miguel Villagra, MD, hospitalist medical director at White River Medical Center in Batesville, Ark., confronted that issue when his group analyzed its readmission rates. “A significant proportion of the patients being readmitted were those who refused to go to a SNF or an inpatient rehab facility” against the recommendation of physical or occupational therapy, Dr. Villagra says.
He and his colleagues discussed different options that focused on improving their communication with patients and family, including rounding with nurses at the bedside. They also discussed the option of letting patients leave AMA when all attempts to keep them in the hospital had been fulfilled.
Dr. Villagra and his team also developed a new form in their electronic medical record to use when patients plan to leave AMA. The form prompts providers with a checklist of mandatory items, including whether patients are competent to make decisions and what time was spent explaining the risks of what might happen if patients go home. The form also includes space for additional documentation.
A second form is automatically generated for the nurses to complete before any discharge can occur. This form includes reminders for medication reconciliation, prescription preparation and follow-up appointments, just like for a standard discharge. Nurses can also document how they explained risks to patients considering leaving AMA.
The decision to label a discharge as AMA for patients who refuse recommended post-acute care is made by patients’ primary hospitalist. But according to Dr. Villagra, “after we implemented this, the majority of patients ended up accepting placement, and we rarely have to discharge anyone AMA.”
The next step in this discharge quality improvement process, he adds, is a long-range plan to develop a multidisciplinary “high-risk” team. Among other duties, that team could be called to assist with patients who threaten to leave AMA.
Avoiding the AMA label
In Milwaukee, Rupesh Prasad, MD, a hospitalist and physician advisor for quality and utilization management at Aurora Sinai Medical Center, has also come to believe that the best way to handle patients resisting recommended post-acute placements is to deploy a multidisciplinary high-risk team “to find out why.”
“You have 70-year-olds in the hospital for the first time who have always been independent and now you think they need some rehab. Their first question will be, ‘Will I lose my independence?’ ” Dr. Prasad explains. “They need to have a good understanding that this is just a short-term placement.” Other times, he says, learning “why” means discovering that “they have a valid reason. Once we understand that, we might be able to work with them.”
Madhulika Lall, MD, medical director of resource utilization at Mary Washington Hospital in Fredericksburg, Va., and a weekend hospitalist at Inova Fair Oaks Hospital in Fairfax, Va., says there’s another problem: Many doctors don’t understand the difference between subacute nursing facilities and nursing homes and acute rehabs. “So we just automatically follow the physical therapist’s recommendations.”
Dr. Lall admits that she herself didn’t understand those differences until she became personally involved a few years ago in her mother’s care. Now, she adds, when patients resist her post-acute care recommendations, “I help them understand the nuances” among different types of facilities. She also explains more clearly why she is making her recommendations and, perhaps most importantly, emphasizes that they can change their minds and leave a post-acute facility at any time.
“I generally do not call these patients AMA,” says Dr. Lall. “I don’t believe it’s my way or the highway.”
In Milwaukee, Dr. Prasad similarly prefers not to automatically label these patients as AMA. He worries that the designation might deny patients access to outpatient therapy. He also worries that leaving AMA might lead to insurance denials, something providers apparently warn patients about when patients threaten to leave. A study published online in January 2012 by the Journal of General Internal Medicine concluded, however, that the claim is a “medical urban legend.”
Prompted by a director interested in improving quality at the VA hospital in Albuquerque, N.M., where she works as the hospitalist section chief, Holly Fleming, MD, recently took on the challenge of trying to create a better AMA discharge system.
At her facility, patients who leave AMA—1% of all discharges from the medical/surgical wards—have an incredibly high readmission rate: as much as 44% at 30 days, according to data Dr. Fleming collected in 2014.
She presented an abstract at the 2016 Society of Hospital Medicine annual meeting on the “best-practice process” her team developed. That process centers around two electronic note templates—one for physicians, one for nurses—to make sure “assessment and documentation of decision-making capacity and the informed consent discussion” actually happen for AMA patients. Her team is now analyzing nearly two years of data using that process, and her sense is that “overall, we have been successful in creating a patient-centered culture that focuses on optimizing this transition of care.” According to Dr. Fleming, compliance with those best-practice elements has improved over the study period.
“We cannot force patients to remain in the hospital,” she notes. “People can leave, but these are our patients. If, after an informed consent discussion, patients still choose to leave AMA, we must make every effort to arrange appropriate follow-up for them.”
For instance, Dr. Fleming had a patient with bacteremia and endocarditis who could not be convinced to stay in the hospital. Providers documented their conversations with the patient, including his understanding of possible consequences, using the new template.
And “the next day, we made a good faith effort to contact him,” including “e-mailing his primary care team and asking them to try to reach out to him,” she points out. The providers also recommended specific outpatient oral antibiotics as alternative therapy. “This may not be the standard of care,” she says, “but in this situation, it is better for the patient to be on oral antibiotics as opposed to no therapy.”
As Dr. Alfandre in New York sees it, “Patients bring up AMA all the time. Some intend to leave without further discussion, but some just say they want to leave because they are frustrated with some aspect of their care. In that situation, you can say, ‘OK, here’s the form. Let me get you a pen.'”
Or you can choose to engage patients and see if they’ll discuss their concerns. “It’s actually an opportunity to improve their care by getting their input,” he notes. “They could just as easily get up and go”—elopement—”rather than wait to be discharged AMA.”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.
WHEN PATIENTS WANT to leave the hospital against medical advice (AMA), physicians and nurses feel pretty comfortable that they know what they should do. A recent study, however, illustrates that providers know less and do less than they think.
Publishing in the January 2017 issue of the Journal of Hospital Medicine, hospitalist Cordelia R. Stearns, MD, and her colleagues at Alameda Health System’s Highland Hospital in Oakland, Calif., analyzed AMA discharges, which occurred nearly 3% of the time at their inner-city, safety-net hospital in 2014. These were among the disconnects they found:
• Although nearly all doctors and nurses told researchers they were “comfortable” assessing whether patients have decision-making capacity, including whether to leave a hospital against medical advice, they documented decision-making capacity in the medical record only 29% of the time. The authors even found instances where physicians had documented that a patient did not have that capacity, but those patients were still discharged AMA.
• While virtually all physicians said they believed it’s their responsibility to arrange medications and follow-up care for patients discharged AMA, the study found that such “arrangements were seldom made.” Only 21% of the patients leaving AMA were given prescriptions, while only 26% left with some sort of follow-up care arranged.
• A majority of physicians and nurses reported that they “usually know why a patient wants to leave AMA.” But just over one-third of AMA discharges had a documented reason.
And the biggest disconnect may be what the study found in terms of what physicians believe about AMA discharges vs. nurses. Fewer than 10% of the doctors believed that patients who leave AMA shouldn’t have medications and follow-up arranged for them.
But that belief was held by almost 40% of the nurses. That’s a big issue, says Dr. Stearns, “because nurses are the people at the bedside the most and are usually the ones who first know that the patient wants to leave.” They may also be the first ones trying to convince patients to stay.
“If doctors and nurses aren’t on the same page,” Dr. Stearns notes, “that decreases our ability to provide good care.”
The pros and cons of AMA forms
AS PART OF A PROJECT to design a better AMA discharge system, Holly Fleming, MD, hospitalist section chief of the VA Medical Center in Albuquerque, N.M., says she abolished the use of the AMA forms that patients leaving AMA are asked to sign.
“The literature suggests that such forms create an adversarial relationship unnecessarily,” says Dr. Fleming, “and they are not really protective” against liability.
A study published online in June 2011 by the Journal of Emergency Medicine suggests that such forms can help protect hospitals and physicians—as long as the forms are templates that drive comprehensive documentation of the consequences of leaving AMA, as well as recommendations for follow-up care, among other items.
In Baltimore, Ada Offurum, MD, directs a team of close to 30 hospitalists at the University of Maryland Medical Center’s hospital in downtown Baltimore. Dr. Offurum says that she and her group have been trying to get some legal input into whether patients should be asked to sign out AMA.
“Our AMA form is very generic,” she notes. “It says that the patient has agreed to relieve the hospital of further responsibility for his or her care, now that he or she signed this paper. However, the form does not say anything about patients’ right to get prescriptions or have an appointment made for them, and it does not prompt us to do those things.” Does she believe her group needs a template or checklist to guide better documentation? “That is what I am exploring with our physician advisory group.”
A single-site study published in January in the Journal of Hospital Medicine about AMA discharges found that providers at Alameda Health System’s Highland Hospital in Oakland, Calif., were very good at making sure patients signed AMA forms. In 84% of cases, signed forms were included in the medical record.
“We have a lot of physicians getting patients to sign these forms, but we are not using them to actually improve our documentation or care for these patients,” says Cordelia R. Stearns, MD, hospitalist and lead author. Most experts in biomedical ethics and law, she adds, say “these forms are not necessary and are definitely not sufficient.”
Dr. Stearns also points out that the forms tend to shut down any conversation that might change patients’ minds about leaving AMA. Having patients sign also stops providers from rethinking their care plans to perhaps better address patient needs.
In fact, her study found that providers “documented a patient’s plan to leave AMA before actual discharge 17.3% of the time,” she notes. That means, she explains, that there is “a significant chunk of patients who are saying ‘I’m going to leave,’ and the doctor is able to go talk them down, at least temporarily.” Once a patient signs a form, however, that discussion tends to stop.