Delia" had been successfully managing her health since being diagnosed with multiple sclerosis 20 years ago. But a stroke and a suspected malignancy in her lungs created an acute care episode in which Delia suddenly needed more medical resources and a case management plan for her hospitalization and postdischarge. Her weeklong acute care treatment became complicated by a breakdown in communication among members of the hospital care team, which resulted in incomplete and sometimes contradictory information being conveyed to Delia's family members who lived out-of-state. This presented an ethical dilemma for me as the case manager: How to bridge these communication gaps without crossing professional boundaries with the hospital staff.

Just as advocacy for Delia underscored the ethical principle of autonomy-as defined by the Commission for Case Manager Certification's (CCMC) Code of Professional Conduct for Case Managers (Code)-so, too, did it encompass supporting the professionalism of the other members of Delia's care team. Most important were Delia and her goals, as she and her family/support system made decisions, including for Delia to return to independent living with the resources she needed. Therefore, the team needed to come together around patient-centered care in support of Delia and her desired outcomes. As the case manager, my role was to be the hub of the care team, with Delia at the center.

A Breakdown of Communication

The problem was that, early on in Delia's hospitalization, communication broke down. Within the hospital care team, there was confusion. For example, the treating physician ordered an MRI of Delia's chest. The nurse was under the impression that the MRI had not been completed, although Delia was quite certain she'd had that radiological procedure. When the nurse checked the electronic record, however, it did not indicate that the MRI had been completed. Believing the electronic record to be accurate and complete, the nurse resisted inquiring about the test with the hospital's radiology department. With subsequent prodding, the nurse did check and found that the MRI had been completed but the record had not been updated. Verification provided an accurate placemark, regarding her workup. This was an example of the confusion and inconsistent information surrounding Delia's case, which if not addressed could have led to the costly duplication of tests (such as a second MRI), and potentially even serious errors.

There also seemed to be a lack of awareness among some of the care team members about the decline in Delia's cognitive status during this acute episode. This was troubling for Delia's family, who lived out-of-state. Inconsistent and sometimes inaccurate information from the hospital team exacerbated their confusion. It became clear that the more efficiently and smoothly the interdisciplinary team worked together, the better it would be for Delia, her family, and other stakeholders. The Code states,

"Board-certified case managers embrace the underlying premise that when the individual reaches the optimum level of wellness and functional capability, everyone benefits: the individual served, their support systems, the health care delivery systems and the various reimbursement systems. (CCMC, Code, 2015, p. 4)

This underlying value of case management practice made it imperative that I, as the case manager hired to be the "eyes and ears of the family," find a way to work with the hospital staff and do my best to promote communication among all parties.

Taking a Team Approach

Communication is a key component in case management practice and is central to its underlying values. The Code specifically names communication as a means for improving client health, along with advocacy, education, identification of services resources, and service facilitation (CCMC, Code, 2015). In managing Delia's case, a team approach needed to be fostered, starting with someone on the hospital staff. I reached out to the social worker on the unit where Delia was admitted and explained the inconsistent information and confusion it created for the family. The social worker agreed that she would be the point of contact within the hospital to obtain information about Delia's ongoing treatment, including her discharge plan, and I would be the point of contact for the family and their gateway for information about Delia's care and progress.

I remained in contact with the social worker at the independent living facility where Delia lived, providing timely information about the discharge plan and the support services Delia would need when she returned to the facility. Delia and her family were kept informed about the options for resources postdischarge, as well as what insurance (Medicare) would cover and what would have to be paid out-of-pocket. The family's decision was to have one agency provide physical therapy, occupational therapy, and speech therapy for Delia, as well as overnight skilled nursing. They paid privately for a home health aide and medication setup and reminder services. These arrangements may not have been the most cost-effective, but these were the decisions made by Delia and her family with full knowledge of the fiscal impact. Ethical practice required me to educate them, but the decisions were theirs to make in the spirit of autonomy.

Even though not everything was 100% ready for Delia when she was discharged-for example, not all the durable medical equipment was on premises when Delia returned to the independent living facility-the care transition was a success overall. Most important, Delia achieved the goal set by her and her family: returning to independent living with the coordination of resources that would make this possible. Only by overcoming confusion and breakdowns in communication could her care team support that outcome.

Respecting Boundaries

The experience with Delia's hospitalization and discharge planning is an illustration of everyday ethics. Ethics are such an integral part of professional case management practice; CCMC has increased the number of CEUs required in this area for recertification (see https://ccmcertification.org/sites/default/files/docs/2017/renewal_guide_6.12.17; CCMC, Criteria, 2017). Ethical practice requires case managers to empower clients in a matter that is supportive and objective (CCMC, Code, 2015). There needed to be respect among the health care team, even when errors were made (such as the missing MRI in the electronic record). To keep Delia's goals and desires at the center, her care plan had to involve an interdisciplinary team working together. With a deep belief in experiential learning, I sought to use certain interactions as "teachable moments," which required me to make observations and suggestions to the hospital staff in nonthreatening ways: What do you think about this approach? Going forward, what do you think about doing things this way? Would you be comfortable if I did this part and you did that part? The team engaged with me and took my coaching.

Eventually, working together, we resolved problems, cleared up the confusion, and provided the best care possible for Delia in an efficient manner. Frustrations, including my own, did not matter. Throughout this episode and well beyond discharge, the most important thing was to remain patient-centered while practicing in accordance with quality and ethical standards.

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