Use behavior contracts to avoid abandonment claims
Use behavior contracts to avoid abandonment claims
Realign relationships if family doesn't cooperate
The home health aide who has been tending to an 80-year-old patient for four weeks reports to you that she wants to quit. Upon questioning the aide, you learn that the patient's sister treats the home health aide like a maid. Although the family needs the aide's help daily, the sister is ruining the patient-caregiver relationship. On weekends, she leaves dirty laundry and dishes for the aide to clean up on Mondays. She clutters the bathroom with medicine bottles, cosmetics, towels, newspapers, and magazines, making it difficult for the home health aide to appropriately care for the client.
Mercy Home Care in Urbana, OH, in this case, recognized the untenable situation and acted to remedy it with a behavior contract. Once the family understood that the duties of the aide did not include housekeeping chores, the patient's sister agreed to sign a behavior contract. Her behavior changed, conditions in the home improved, and Mercy remained involved in the case.
The above example demonstrates not only that home care must be a reciprocal agreement between patient and caregiver, it also shows the value of behavior contracts when that relationship becomes strained by noncompliance issues.
When situations go too far, private duty providers may terminate services using their patient noncompliance policy. However, they may legitimately fear patient abandonment charges, given today's litigious society and negative home care environment. Patient behavior contracts may help realign out-of-balance relationships and clarify termination decisions.
Mercy Home Care began using behavior contracts about three years ago to help manage a variety of difficult situations, ranging from clients viewing home health aides as maids to aggressive animals in the home, says Patricia Haley, manager of personal care services.
"It is not [something we] use often, but it's wonderful when needed. It protects the patients and agency," she adds.
"It's a very useful tool," agrees Elizabeth Hogue, an attorney specializing in home care in Burtonsville, MD. "It helps staff and patients clarify exactly what needs to be done," she adds.
Mercy uses behavior contracts only after failing to improve behavior using other means, says Haley. Usually, field staff first attempt to resolve any problems in the home themselves. When this proves unsuccessful, a Mercy manager then discusses the situation with the client on the telephone or in person. When no changes again result, then a final meeting is held to discuss the problems, solutions, and behavior contracts.
Mercy staff discuss the purpose of the meeting with patients in advance. "We don't want any surprises for anyone," says Haley. Case conferences include all Mercy field staff involved in the home, as well as any other providers and family members. Mercy social workers also often attend to help address other issues patients may be dealing with.
"A lot of people have trouble dealing with conflict. This lets everyone take a step back and say, 'Here's what we see going on in the home and what needs to be changed.' It takes away confrontation. And you don't have to depend on wit when you get in," Haley adds.
The goal is an open discussion and documentation of problems, with a defined remedy and time line. Patients may disagree with the problem and solution, but they must sign the behavior contract during the meeting. "They can accept or reject [the agency's requirements]. If they accept, their behavior [must] change. If they don't, then you have a legally very appropriate [basis for terminating]," says Haley.
"And most importantly, [behavior contracts] can be tailored to meet any situation," says Haley. (See sample contract, p. 88.)
Sometimes behaviors initially improve but eventually again become problematic. In such circumstances, Mercy usually issues another behavior contract, with a much shorter corrective time line, reference to the first contract, and termination as the next action. But this may be overly generous, suggests Hogue. When behavior lapses, hold a case conference, determine a reasonable notification period, and terminate services, she advises.
Contracts should be "simply drafted so that all can understand," says Hogue. "And once agencies put it in writing, they must really stick to their guns." Make it clear that you will terminate if the situation does not improve, she adds.
Pre-contract documentation is also important, Hogue cautions. Simply noting patient "noncompliance" is too vague. Instead, specifically describe the problematic behavior in objective but realistic terms, she advises.
Mercy attaches a copy of its discharge policy and patient rights and responsibilities to behavior contracts. Hogue agrees with this action but cautions providers not to go beyond Medicare requirements when drafting rights and responsibilities. Other-wise may set themselves up," she says.
Hogue supports behavior contracts and believes they are "wonderful" under the right circumstances. However, she advises that providers inform patients of certain absolutes. "There are behaviors and conduct that will not be tolerated under any circumstances. For example, it would be inappropriate to draft a behavior contract in which the parents of a pediatric patient agree to not require that nursing staff turn off ventilator or apnea monitor alarms."
Since it began using behavior contracts, Mercy has not encountered any problems when terminating patients. "Its just like a disciplinary issue with an employee. If it's well-documented, there's no problem. And it so nice to know that when staff say 'I don't know what else to do,' there's a solution."
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