Part III: Legal and Ethical Considerations - dhs.state.mn.us · Part III: Legal and Ethical Considerations Goal: Understand the legal issues that affect the practice of children’s

Part III: Legal and Ethical Considerations

Goal: Understand the legal issues that affect the practice of children’s mental health case management.

Objective: Demonstrate the ability to navigate ambiguity surrounding matters of mandated reporting, confidentiality, rights of minors, and civil commitment.

Legal Dimensions

Group Activity: Think about the most legally challenging situation you have faced in your work. What concerns/questions were involved? How did you handle the matter?

Legal Dimensions

When a person in a helping role has reasonable

suspicion that child abuse has occurred or is occurring

Amount of time that has passed since abuse does not matter

What if a parent reports that he/she was abused?

Discussion: Should you inform a parent when you intend to file a report against him/her

Mandated Reporting

Health Information Portability and Accountability Act

(HIPAA): Protected health information (PHI): Includes all identifying

information about a client When can PHI be disclosed? Discussion: Can a diagnostic assessment be “re-released”?

Legal Dimensions: Data Privacy

Situation:

You receive a subpoena from the attorney of your client’s non-custodial parent. The parent’s rights are intact but he has not had contact with the child for several years. He is petitioning the court to establish visitation with your client. How would you proceed?

Subpoenas

Have you received a legally valid request for information?

(subpoena is not a court order) If valid, contact client to discuss implications

If client consent to release, are there any reasons why

information should be withheld?

If client does not consent, attempt to negotiate with requester

If requesting party continues to demand information, seek guidance from the court

Subpoena Steps

According to Rule 79, the child him- or herself has the right to make the decision about whether to accept case management and other mental health services, and be included in planning case management services if: The parent or legal guardian is hindering or impeding the child’s

access to mental health services and the child is at least 16 years of age

The child has been married or borne a child; is living separate and

apart from the parents or legal guardian and is managing own financial affairs; at least 16 but under 18 and has consented to treatment as specified by Minnesota Statutes, section 253B.03; at least 16 but under 18 and has been authorized by a county board for independent living pursuant to court order

Rule 79 further specifies that case management clients under age 12

have the right to receive relevant notices and information about their services unless a mental health professional determines such sharing is clinically inappropriate.

Mature Minor Legislation

Annual court review hearing for children in foster care age 16 and older

must take place to determine progress toward or accomplishment of 11 specific transition goals (Bulletin #09-68-12). http://www.dhs.state.mn.us/main/groups/publications/documents/pub/dhs16_151788.pdf

Youth must be advised of the availability of foster care benefits up to age

21. If the youth chooses to continue benefits, county has obligation to develop a plan to keep youth in foster care until age 21.

Youth 18-21 who had been under state guardianship may request

continued foster care services and benefits (e.g., case management) at any time regardless of whether they left care or continued in care at age 18.

In situations where there is no longer either court involvement or a

voluntary placement agreement, the independent living plan (e.g., Casey Life Skills Assessment) is the mechanism under which continued benefits remain the responsibility of the county social service agency.

Fostering Connections

http://www.dhs.state.mn.us/main/groups/publications/documents/pub/dhs16_151788.pdf

http://www.dhs.state.mn.us/main/groups/publications/documents/pub/dhs16_151788.pdf

Activities reimbursable as mental health targeted case management: Diversion planning (assessment and planning) Participation in commitment hearings and related negotiations

(assessment and planning) Follow up reporting to the court after commitment or as part of a

continuance or stay (monitoring and related activities and coordination)

Discharge planning (planning and referral) Request for revocation of provisional discharge or stay, extension of

commitment or stay, and associated notices to client and others (monitoring)

Final report to court prior to discharge of commitment (planning and

monitoring)

Civil Commitment

Activities not reimbursable as MH-TCM:

Pre-petition screening

Court-appointed independent examiner’s role activities

Substitute decision maker role activities

Court reports for persons who are under commitment in the facility to which they were committed (facility is responsible for court reports)

Civil Commitment

Legal Dimensions: Evaluation

Goal: Understand dimensions of ethical practice and apply consistent methods for addressing ethical dilemmas.

Objectives:

a) Define major principles and dimensions of ethical practice.

b) Demonstrate the ability to apply ethically-sound decision making to case management work.

Ethical Concepts and Dilemmas

Group Activity: Think about a time when you struggled to decide what course of action would be in your client’s best interests. How did you attempt to resolve your uncertainty? What did you end up doing and why?


The Basic Principles of Ethical Decision Making:

Autonomy

Beneficience

Non-maleficence

Justice


Dimensions of Ethical Practice: Competency Confidentiality Client Welfare Recordkeeping Fees and billing


Competence: Working within the boundaries of one’s

education, training, and supervised experience. Key questions to consider: “What am I capable of doing?” “What am I qualified to do?” “Am I staying within the role I am authorized to perform?”


Confidentiality: Sharing client information only with proper written consent. Releasing information on a need-to-know basis and releasing no more information than necessary to complete a transaction. Informed consent: Appropriate permission from a legally

responsible person to provide a service. Includes notifying client about foreseeable uses of information, risks and benefits of the service, anticipated course of the service, and alternatives available to him/her

Limits of confidentiality: If you believe client is in imminent

danger of harming self or others, you can disclose information to the extent needed to protect him/her.

Duty to warn: If a client poses a clear and imminent danger to an

identifiable victim, you have an obligation to notify authorities and the intended victim.

Self-disclosure: Sharing something from own life in order to build

trust, model effective behavior, or encourage identification. Key consideration: Is the disclosure being made to benefit the client?

Client Welfare: The primary purpose of a helper is to do no harm. The helper should place constant focus on best interests of client. Dual relationship: A provider functioning in a professional role concurrently or consecutively with another definitive and intended role, professional or otherwise. For example: You provide case management services to a teenager who shovels your sidewalk in the winter.


Group Activity: What might be some of the “adverse effects” of being the case manager for a child whom you also pay to shovel your sidewalk.


Impairment: Any qualities, behaviors, attitudes, or circumstances that prevent you from being as effective as possible.

Clear-cut instances (addiction, severe physical or mental illness)

Everyone waging a daily struggle with own “stuff,” must assess extent to which it interferes with helping efforts

Limit, suspend, terminate responsibilities if necessary


Recordkeeping: Beyond that which is legally required, what information should be included in the client’s record? Is the information relevant to the case? Is the information needed to ensure continuity of care? Agencies generally have an obligation to keep client records

until the client turns 25. Fees and billing: Billing arrangements should be explained to client in advance Any billing for services not actually rendered is a fraudulent act

that can carry severe legal consequences


1. Identify the problem or dilemma

2. Identify potential issues involved

3. Review applicable guidelines

4. Obtain consultation

5. Consider possible and probable courses of action

6. List consequences of various decisions

7. Decide on what appears to be the best course of action

Steps in Making Ethical Decisions

Group Activity: Addressing Ethical Dilemmas (handout)


Ethical Concepts and Dilemmas: Evaluation

Goal: Understand how to broach emotionally-charged issues with clients in a caring and constructive manner.

Objectives:

a) Identify effective ways to respond when clients initiate difficult conversations.

b) Demonstrate the ability to use supportive communication with clients.

Difficult Conversations

Group Activity: Share examples of difficult conversations you have had to initiate and ones that were initiated by clients. Describe how you handled (or mishandled) these conversations.


“It is not difficult to communicate positively – to express confidence, trust, openness – when things are going well and when people are doing what they should. But when someone else’s behavior must be corrected, when negative feedback must be provided, or when the shortcomings of another person must be pointed out, communicating in a way that builds and strengthens the relationship is more difficult.”

Kim Cameron: “Positive Leadership”


Example = Descriptive statements: 1. Provide objective account of event (can be confirmed by someone else; focus on behavior under person’s control; based on accepted standards and not opinions/preferences) 2. Emphasize reactions to or consequences of behavior 3. Suggest a more acceptable alternative Counter example = Evaluative statements: - Make a judgment or place label on individual and his/her behavior

Supportive Communication

Incoming!

Facilitating Difficult Conversations

- Client-initiated

- Provider-initiated


When someone initiates a difficult conversation with you: Move to a more appropriate venue Keep breathing Keep listening Be grateful, not defensive If feel threatened or think you might become reactive, ask to talk at

a different time If you realize you have had a negative impact, apologize, even if

your action was unintentional. Ask what, if anything, you can do Offer options

When you have to initiate a difficult conversation:

Clarify the need for the conversation. Conduct a self-assessment: how are you feeling about the person

and yourself? Provide feedback on the impact the person or event has had on

you. Invite the other person to do the same. Tell it all, tell it yourself, tell it early. If you’ve messed up, don’t try

to hide it, expect someone else to explain it, or hope that the matter will fade away.

Let go of the outcome. Attempting to control or manipulate the

situation can lead to undesirable results.

Work toward win/win resolutions.

Play Acting Scenarios:

1) Parent is angry that you told school about her losing her job

2) Parent is hesitant to place child residential program despite the recommendation of the current treatment team

3) Parent disagrees with decision that child no longer needs case management services


Difficult Conversations: Evaluation

Goal: Assess risk situations accurately and provide effective crisis assistance .

Objectives:

a) Define stages of crisis and accompanying response strategies.

b) Identify the components of valid safety plans.

Risk Assessment and Crisis Assistance

Group Activity: Recall a time when you had to deal with a client crisis. What was the situation? What kind of feelings did it evoke? How did you address it?


Definition of Crisis: Any situation that overwhelms a

person’s coping resources

Subjective, individually determined

Danger and opportunity


Do: - Listen - Empathize - Project hopefulness - Model calmness (breathe!) - Stay flexible Don’t: - Become defensive or take client’s words and actions personally - Judge or discount client’s experience - Get “cornered” (physically, emotionally, or intellectually) - Get “preachy” or demanding - Belittle the client - “Catch” the client’s hostile or negative affect - Hold your breath

Use of Self in Crisis: Dos and Don’ts

Stages of Crisis and Appropriate Responses:

1. Baseline

2. Disagreement

3. Resistance

4. Refusal


Risk Assessment Guidelines:

HALT

Suicide Risk

SAD-PERSONS


Probing Beneath the Surface

- Have you ever felt/do you feel like there’s no point in living?

- Things ever so bad wish you were dead or felt like you’d be better off dead?

Other Suicide Risk Factors

Sexual Risk


Conventional wisdom had been that the “personal fable” (e.g.,

“Nothing bad can happen to me”) led to risk-taking among adolescents.

“Fatalistic thinking” provides a more accurate explanation for

adolescent risk behavior One in seven teenagers (14%) in grades 7-12 expect to die

young (e.g., before age 35)

Expectation even higher among poor and minority teenagers The more pessimistic the youth, the more likely they are to

place themselves in danger (e.g., take drugs, attempt suicide, have unprotected sex). “Fatalists” are 7 times more likely to be diagnosed with HIV/AIDS.

Teenage Pessimism

The “3Ps” (Perfect Storm of Risk)

- Pressure

- Pain

- Perturbation

Limitations of “Safety Contracts”


Warning Signs in Children:

Fear, inhibition

Anxiety and depression (sleeping and eating difficulties; somatic complaints)

Ambivalence and confusion

Decline in school performance

Increased risk behavior (fighting, using chemicals)

Domestic Violence Guidance

Keeping Children Safe:

Teach them not to get in middle Teach them how to get to safety, call 911, give address and phone to

police Identify whom they can call for help Tell them to stay out of the kitchen during tense situations (kitchen is

most dangerous room in home) Work with school officials (designate a “point person” at school;

provide copy of court order, picture of perpetrator; insist child not be released to anyone without first contacting parent)

Use password so children can be sure it’s you on the phone


Planning for Mother’s Safety: Women are at high risk of being seriously hurt or killed when leaving

an abusive relationship. Can refer to National Domestic Violence Hotline 1-800-799-SAFE, www.ndvh.org, Minnesota Coalition for Battered Women 651- 646-6177, 651-646-0994 (crisis line) www.mcbw.org Identify a safe area of home to go to if attacked (e.g., room with an

outside door or window) Be prepared to leave at a moment’s notice (car fueled; spare car key;

emergency cash, clothes, important phone numbers/documents stored in a safe place such as a friend’s home)


http://www.ndvh.org/

http://www.mcbw.org/

Practice escaping quickly and safely. Include children in rehearsals. Come up with a code word to signal children, neighbors, friends, co-

workers that you’re in danger and police should be called Use a land line, prepaid phone card, or a friend’s telephone charge

card to call for help

Memorize a list of emergency contacts Document abuse (taking pictures if injured) If communicating by computer, use one outside of home


Case Scenario: Deborah


Risk Assessment and Crisis Assistance: Evaluation

Goal: Manage termination and processes effectively. Objectives: a) Identify the conditions under which clients can be terminated from case management services.

b) Define the appeal rights granted to case management clients by rule and statute. c) Demonstrate the ability to weigh subjective factors (e.g., client’s self-navigation skills) into continuing service and discharge decisions.

Termination and Appeal

Group Activity: How do you determine when it is time to close a case management case? Describe some of the emotions you experience as you prepare to close a case.


Review of Statutory Language on Termination: Mental health professional indicates via written opinion

that client no longer meets eligibility criteria Case manager, child’s parent, or child mutually agree that

client no longer needs case management services Child’s parent, legal representative, or child refuse further

case management services Except if child is in a residential treatment program, a

regional treatment center, or an acute care hospital for treatment of severe emotional disturbance outside of county of financial responsibility, there has been no contact between case manager and child for 90 consecutive days.

Review of Statutory Language on Appeal Client who applies for or receives case management services has

the right to a fair hearing if county/tribe/MCO terminates, denies, or suspends case management services or does not act within 5 days upon a request for case management services

Written notice must be sent to child’s parent, legal representative,

and child at least 10 days before denying, reducing, suspending, or terminating client’s case management services

Clients have the right to appeal action within 30 days after receipt

of notice or within 90 days if person has good cause for delaying Client’s MCO is responsible for sending denial, termination,

reduction (DTR) notice Child shall continue to receive case management services pending

resolution of appeal

Use a blend of objective and subjective indicators Data-driven decisions (level of care – CASII/ECSII score; SDQ

results; meeting IFCSP goals) Has the client acquired necessary resources, natural supports,

and skills to assume case manager’s functions more independently? Revisit “Self-Navigation Skills Assessment” from Monitoring section of the training.

How long a period of stability has the client experienced? Does the client have the capacity to address any new needs or

problems that might arise? Are there pressing situational factors or stressors? (e.g., family

crisis, major transition) that suggest a need for continued support despite a prolonged period of stability?

Evaluating Client Readiness for Discharge

Other Discharge Considerations Honor the relationship - Endings can be emotionally difficult for client and provider - Explore ways to memorialize your relationship (e.g., take pictures) and celebrate how far client has come (e.g., create a timeline) Relapse prevention - Highlight goals that were achieved - Note remaining areas of vulnerability and how to manage them - Explain how to access help if needed in the future. Complete a written discharge summary - Strengths and skills developed during service period - Goals completed, resources accessed, remaining areas of need - Recommendations for other services and resources

Case Scenario: Kevin


Discussion:

1. Should this case be discharged? Provide a rationale for keeping the case open or discharging it. What additional information would be helpful in making a decision?

2. If this case is left open, should any changes be made to justify continued stay?


Termination and Appeal: Evaluation

Goal: Appreciate the importance of personal and professional wellness in service delivery.

Objectives:

a) Identify risks for compassion fatigue and burnout

b) Develop a self-care plan

Self-Care

Group Activity: What factors make helping professionals vulnerable to burnout?

Self-Care

Practitioner Resilience: A Top Ten List 1) Recognize the signs of compassion fatigue 2) Stay connected 3) Forgive 4) Structure a healthy lifestyle 5) Maintain curiosity 6) Tolerate ambiguity 7) Be flexible 8) Celebrate successes 9) Maintain humility and a sense of humor 10) Focus on the big picture

Self-Care

Developing a Self-Care Plan (handout)

Assessing the hazards

Formulating a “diagnosis”

Personalizing a plan

Self-Care

Group Activity:

What did you find worthwhile or difficult about this self-care plan activity?

Is anyone willing to share the “diagnosis” they wrote for themselves.

Create a comprehensive list of “Self-Care Best Practices” based on the strategies participants identified

Self-Care

Documents

Part III: Legal and Ethical Considerations - dhs.state.mn.us · Part III: Legal and Ethical Considerations Goal: Understand the legal issues that affect the practice of children’s