Power Point Presentation by Dr. Janet Williams on the Ethics of Discharge Planning. Nursing home placement should be the last resort of anyone with a disability. And, only if it is the person's choice. There are many community resources available to assist people with the most significant disabilities to live in their own home.

1. The Ethics of Nursing Home Placement
Janet Williams, MSW, PhD

2. Janet M Williams MSW, PhD
Imagine If…
• You hated oatmeal but had to eat it every morning
at 6am AND you hated getting up early.
• You had to EARN the right to take a walk in your
neighborhood.
• You valued your privacy, but always had a
roommate AND it was someone you didn’t pick.
• You had to WAIT until it was your turn for most
anything you needed, even the most basic of
needs.
• You had to ask permission to watch a favorite TV
show, have a pop, make a phone call, or smoke a
cigarette.

3. The mission of social work
• The primary mission of the social work
profession is to enhance human well­being
and help meet the basic human needs of all
people, with particular attention to the needs
and empowerment of people who are
vulnerable, oppressed, and living in poverty.

4. Common issues in Discharge
planning
• Hospital Discharge planners
– Short window of time
– Limited view of resources
– Too many vendors with an angle
• Nursing Home Social Workers
– Discharge planning one part of busy job
– Person versus Family wishes

5. Ethical Dilemmas
• Occur when an individual has to choose
between two or more conflicting ethical
standards.

6. Janet M Williams MSW, PhD
Development of Services
Dichotomy Medical Model Independent Living
Diagnosis discrete categories Universal needs
Assessment for deficits or problems excludes people from
services
Definition of the
problem
Phys/ cog problems of the
individual
dependence on the
environment
Social Roles patient Consumer/ customer
Solution to the problem Fix or cure the person,
more ROM
Removal of barriers/
change the person
Locus of control Professional and others Consumer

7. Janet M Williams MSW, PhD
Tension for People with Brain Injuries
• Diagnosis- Can be important in distinguishing from other issues…but how
important ongoing?
• Assessment- Can be useful if done in context, assessing functional strengths
to build goals.
• Definition of the problem-
• The context silly, the context.
• Social Roles- Varies depending on ongoing medical issues, context and needs.
• Solution to the problem- The person and environment fit.
• Locus of control- When can a person make decisions?
• Who was I? Who am I?
• Who can I be?

8. NASW Code of Ethics
• 1.05 Cultural Competence and Social Diversity
• (c) Social workers should obtain education about
and seek to understand the nature of social
diversity and oppression with respect to race,
ethnicity, national origin, color, sex, sexual
orientation, gender identity or expression, age,
marital status, political belief, religion,
immigration status, and mental or physical
disability.

9. NASW Code of Ethics
• 4.02 Discrimination
• Social workers should not practice, condone,
facilitate, or collaborate with any form of
discrimination on the basis of race, ethnicity,
national origin, color, sex, sexual orientation,
gender identity or expression, age, marital
status, political belief, religion, immigration
status, or mental or physical disability.

10. NASW Code of Ethics
• 6.04 Social and Political Action
• (d) Social workers should act to prevent and
eliminate domination of, exploitation of, and
discrimination against any person, group, or
class on the basis of race, ethnicity, national
origin, color, sex, sexual orientation, gender
identity or expression, age, marital status,
political belief, religion, immigration status, or
mental or physical disability.

11. The mission of the social work profession is rooted in a
set of core values.
• service
• social justice
• dignity and worth of the person
• importance of human relationships
• integrity
• competence.

12. NASW Code of Ethics
• The Code identifies core values on which social work’s mission is based.
• The Code summarizes broad ethical principles that reflect the profession’s core
values and establishes a set of specific ethical standards that should be used to
guide social work practice.
• The Code is designed to help social workers identify relevant considerations when
professional obligations conflict or ethical uncertainties arise.
• The Code provides ethical standards to which the general public can hold the
social work profession accountable.
• The Code socializes practitioners new to the field to social work’s mission, values,
ethical principles, and ethical standards.
• The Code articulates standards that the social work profession itself can use to
assess whether social workers have engaged in unethical conduct. NASW has
formal procedures to adjudicate ethics complaints filed against its members.* In
subscribing to this Code, social workers are required to cooperate in its
implementation, participate in NASW adjudication proceedings, and abide by any
NASW disciplinary rulings or sanctions based on it.

13. Ethical Principles
• Value: Service
• Ethical Principle: Social workers’ primary goal
is to help people in need and to address social
problems.

14. Ethical Principles
• Value: Social Justice
• Ethical Principle: Social workers challenge
social injustice.

15. Ethical Principles
• Value: Dignity and Worth of the Person
• Ethical Principle: Social workers respect the
inherent dignity and worth of the person.

16. Ethical Principles
• Value: Importance of Human Relationships
• Ethical Principle: Social workers recognize the
central importance of human relationships.

17. Ethical Principles
• Value: Integrity
• Ethical Principle: Social workers behave in a
trustworthy manner.

18. Ethical Principles
• Value: Competence
• Ethical Principle: Social workers practice
within their areas of competence and develop
and enhance their professional expertise.

19. Ethical Standards
• Commitment to clients
• Self determination
• Informed Consent
• Competence
• Cultural competence
• Conflicts of interest
• Privacy and confidentiality

20. Ethical Standards
• Access to records
• Sexual relationships
• Physical contact
• Sexual Harrassment
• Derogatory language
• Payment for services
• Clients who lack decision making capacity

21. Ethical Standards
• Interruption of Service
• Termination of Services

22. Each Ethical Standard
• Commitment to clients
– clients’ interests are primary
– Special attention to health and safety
– Medical model or independent living philosophy?

23. Each Ethical Standard
• Self determination
– assist clients in their efforts to identify and clarify
their goals.
– professional judgment, clients’ actions or
potential actions pose a serious, foreseeable, and
imminent risk to themselves or others

24. Each Ethical Standard
• Informed Consent
– the purpose of the services, risks related to the
services, limits to services because of the
requirements of a third­party payer, relevant
costs, reasonable alternatives, clients’ right to
refuse or withdraw consent, and the time frame
covered by the consent.
– extent of services and about the extent of clients’
right to refuse service.

25. Each Ethical Standard
• Competence
– only within the boundaries of their education,
training, license, certification, consultation
received, supervised experience, or other relevant
professional experience.

26. Each Ethical Standard
• Cultural competence and social diversity
– Social workers should obtain education about and
seek to understand the nature of social diversity
and oppression with respect to race, ethnicity,
national origin, color, sex, sexual orientation,
gender identity or expression, age, marital status,
political belief, religion, immigration status, and
mental or physical disability

27. Each Ethical Standard
• Conflicts of Interest
– Social workers should inform clients when a real
or potential conflict of interest arises and take
reasonable steps to resolve the issue in a manner
that makes the clients’ interests primary and
protects clients’ interests to the greatest extent
possible.

28. Each Ethical Standard
• Privacy and Confidentiality
– Social workers may disclose confidential
information when appropriate with valid consent
from a client or a person legally authorized to
consent on behalf of a client.

29. Each Ethical Standard
• Clients Who Lack Decision­Making Capacity
– When social workers act on behalf of clients who
lack the capacity to make informed decisions,
social workers should take reasonable steps to
safeguard the interests and rights of those clients.

30. Value Assessment Questions
• To what extend did my personal values or philosophies influence the
preferred choice of action?
• To what extent did legal obligations influence my decision in this case?
• Was I willing to act outside of legal obligations if doing so meant serving the
client best interests?
• To what extent did adhering to agency policy influence my decision in this
case?
• If agency policy conflicted with outer obligations to the client, was I willing to
act outside of agency policy?
• To what extent did my role in the agency influence my choice of action?

31. Now that you know about
ethical dilemmas in general
and potential ethical
decision making models…
…Let’s consider some specific
ethical dilemmas commonly
arising when working with
people needing assistance.

32. Person’s perspective
– Most often don’t have any recollection of the injury itself, the early hospital
stay and possibly rehabilitation.
– Relearning everything over, even how to relate to family members
– May not have a full realization of what the family has been through (bedside
vigil, lost work, complete devotion to the person).
– All decisions are made by the family early on and there is no map of when the
person starts getting decision making authority back over their own life.
– Person may begin to exert desire to make decisions which can cause friction
within the family.
– May begin to make decisions about wanting more independence without
being able to see things from their family’s perspective.
•

33. Professional Perspective
– Good intentions of teaching the family in the hospital or facility but that
doesn’t always transition to home.
– Little training on family systems and haven’t been where the family has been.
– Most have seen many families go through this but fail to realize this is the first
time for THIS family.
– Only knows the person as they are now, not how they were before the injury.
– Spends time with the person, not the family which gives a one sided view.
– Or, may acquiesce to address the family only, and not the consumer setting
the stage for future tension.
– Pressure to help the person be “more independent”

34. Assimilating Perspectives
• Understand there are multiple perspectives.
• Include the person and family in the same conversations from day one- don’t
exclude the person or the family.
• Support the person to speak to their family, don’t speak for them. Example,
the moving out conversation.
• Marathon not a sprint- the family will be there forever and your job is to
leave situations better than you found them.
• Have big picture discussions- where you started, where you are now.
• Acknowledge and celebrate successes.

35. Transition is the car ride home

37. About the shift from
professional to personal
control

38. What about Bob?
• Lived in a nursing home for 13 years
• Moved to his own apartment on the
tbi waiver using communityworks
• Now uses the physical disability waiver in the same home through with tcm
through communityworks and FMS through Independence Inc.
• Manages his own staff, calendar and payroll after learning those skills
• Used communityworks for case management, independent living skills and
all therapies
• Now uses communityworks for IL Counseling and Indy Inc for payroll

40. communityworks inc tls training January
2005
“It’s all about Bob”
Bob provides us with the vision of life
outside of an institution with
communityworks as the silent
partner in making sure it all
works…

41. Get a CLUE…
• Create positive environments with control
and choice
• Listen to the consumer and develop goals
based on what you hear, not on what
assessments reveal.
• Understand what is happening from the
person’s perspective
• Expect that every day brings struggles,
surprises and successes.

42. Inclusion means
• Being at the table
• Being a part of the discourse
• Being respected for who you are, not held
accountable for what others expect you to
be
• Acknowledges that people may be
different and pushes us to respect diversity

43. Finding a place in the community

44. Perspectives
• Family
• Person
• Professional

45. Man’s search for meaning
• An abnormal reaction to an
abnormal situation is normal behavior.
Victor Frankl

46. The easy way out: labeling families
• In Denial
• Overprotective
• Dysfunctional
• Unrealistic

47. Transition is the car ride home

48. Person’s perspective
– Most often don’t have any recollection of the injury itself, the early hospital
stay and possibly rehabilitation.
– Relearning everything over, even how to relate to family members
– May not have a full realization of what the family has been through (bedside
vigil, lost work, complete devotion to the person).
– All decisions are made by the family early on and there is no map of when the
person starts getting decision making authority back over their own life.
– Person may begin to exert desire to make decisions which can cause friction
within the family.
– May begin to make decisions about wanting more independence without
being able to see things from their family’s perspective.
•

49. Professional Perspective
– Good intentions of teaching the family in the hospital or facility but that
doesn’t always transition to home.
– Little training on family systems and haven’t been where the family has been.
– Most have seen many families go through this but fail to realize this is the first
time for THIS family.
– Only knows the person as they are now, not how they were before the injury.
– Spends time with the person, not the family which gives a one sided view.
– Or, may acquiesce to address the family only, and not the consumer setting
the stage for future tension.
– Pressure to help the person be “more independent”

50. Assimilating Perspectives
• Understand there are multiple perspectives.
• Include the person and family in the same conversations from day one- don’t
exclude the person or the family.
• Support the person to speak to their family, don’t speak for them. Example,
the moving out conversation.
• Marathon not a sprint- the family will be there forever and your job is to
leave situations better than you found them.
• Have big picture discussions- where you started, where you are now.
• Acknowledge and celebrate successes.

51. Money Follows the Person
MFP
• For any person who has 90 days of continuous
hospitalization or nursing facility or a
combination of both.
– The person cannot give up a bed within those 90
days.
– The last bed a person occupies must be a skilled
nursing bed (SNF)

52. MFP
• Must be Medicaid eligible 30 days prior to
receiving MFP services
• Must meet the functional eligibility for waivered
services (LOC score of 26 or greater for FE,PD, TBI
waivers)
• Intensive case management will be available for
these residents. Case Management services can
begin 60 days prior to transition & will continue
once someone is in the community.

53. Benefits of MFP
• Transition services- up to $2500.00 start up cost.
• Home modification/Assistive Technology services
above the $7500.00 lifetime cap on waivers (that are
now frozen)
• The program allows the state to pull down a higher
federal match for the MFP candidates for the first
365 days of them living independently in the
community.

54. Other community resources
Resources
• Social Security
• Presumptive disability
• Medicaid/ Medicare
• Vocational Rehabilitation
• Home and Community based waivers
• Housing
• Transportation
• Brain Injury Associations
communityworks, inc 5/07/05 54

55. Williams/ Wilkerson 5/16/07 Soldiers
with traumatic brain injury
55
We all teach consumers how to be a part of the community.
• Occupational Therapist
– Modifications
– Sequencing
– Upper body/fine motor
– Memory
• Physical Therapist
– Walking, Transfers,
– Gross (large) motor
movement
• Speech Therapist
– Communication of any
type
– memory
– cognitive skills
• Cognitive Therapist
– problem-solving
– thinking skills
– specific skill building

56. Examples of referrals
• C from X called concerning T. T. is at Big
Hospital and will be discharging sometime
today or tomorrow. T. has had 3 strokes and is
in need of case management. C didn’t have
very much information on him, but she said
that you can call him to schedule the
assessment.

57. Example
• Tonya with Big Hospital called concerning B. B.
shot himself in the head and does not yet
have a release date scheduled. Once released,
he will be returning to his home in Kansas City
KS. Tonya said that you could call her and/or
B.’s wife S. to schedule the referral.

58. Referral example
• Lee with Mental health center called
concerning M. M. was assaulted and kicked in
the head in May of 2011. Please call M.
directly to schedule the assessment. Lee said
that you could also call him if you have any
questions.

59. Example
• J. called concerning her mother-in-law N. N. is
76 and has moved in with her son and
daughter-in-law because she has had a few
falls and now must use a walker. She also has
a feeding tube because she has a problem
with her gag reflex. J. would like for you to call
her to schedule the assessment.

60. Example
• D. called concerning her husband D. D. had a
stroke in June and is now paralyzed on his left
side and is in a wheel chair. He was in a
hospital for 27 days and was then transferred
to Rapid Recovery. His release date from
Rapid Recover will be 10/21/11. D. would like
for you to call her to schedule an assessment.
She stated that using her cell phone number
would probably be the best way to reach her.

61. Self Direction
• A law in the State of Kansas allowing people
with disabilities to hire, train and supervise
employees to provide the assistance needed
to live in the community, even the tasks
traditionally provided by a registered nurse.
61

62. Common Ethical Dilemmas Arising
in Discharge Planning