How Case Managers Should Handle Clients' Preferences for Caregivers

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By Elizabeth E. Hogue, Esq.

A registered nurse (RN) recently sued a home health agency in Pittsburgh based upon case management practices. Specifically, the RN received copies of case management forms for a specific patient on two separate occasions. Both case management forms included a section in which "special needs" of patients could be noted.

Both forms indicated in this section that "no black RN's" were to care for the patient. The nurse who received the forms and was asked to provide care to the patient is African-American. The RN made one visit to the patient but was never assigned to the patient again. She subsequently sued the provider for discrimination based upon race.

As many case managers know, patient preferences for certain types of caregivers are common. Experienced managers have been asked by patients not to provide caregivers who are "foreign," for example. The question is whether such requests should be honored.

Generally, such requests should be rejected, especially when they involve discrimination based upon race, religion or any other basis commonly used to treat groups of people differently. Legally and ethically, case managers should not engage in such practices.

There is one exception to this general rule that occurs when patients ask for caregivers of the same sex as the patient based upon concerns about bodily privacy. Then it is acceptable to assign only same-sex caregivers to patients who have made such requests.

In addition to concerns about discrimination, case managers must also be concerned about risk management when they honor such requests. Especially in view of increasing shortages of staff, limitations on available caregivers may mean that patients' needs cannot be met by staff members who are acceptable to patients. In view of staffing shortages, the fewer caregivers who are permitted to care for certain patients, the more likely it is that patients needs will go unmet. Unmet patient needs are, in turn, likely to significantly enhance the risk associated with providing care to such patients.

Perhaps the pressure to honor patients' requests is at its greatest when patients receive home care services. Patients who will accept any caregiver assigned to them in institutional settings somehow feel that they have the right to decide who may provide services in their homes. On the contrary, with the exception noted above, assignments of staff should be made without regard to client preference in home care just as assignments are made in institutional settings.

So how should managers respond when patients tell them not to assign any "foreign" nurses to them? First, they should explain that the organization does not discriminate and that to avoid assignments based on cultural or ethnic background may constitute unlawful discrimination. Then staff should explain that if limitations on caregivers were acceptable, the provider may be unable to render services to the patient at all because they may not have enough staff. The "bottom line" is that staff will be assigned without regard to patient preference in order to prevent discrimination and to help ensure quality of care.

Needless to say, patients' requests and managers' responses must be specifically documented in patients' charts. Documentation that says patients expressed preferences for certain caregivers or rejected certain types of caregivers is too general. Specific requests and responses of staff must be documented.

After patients have expressed what may amount to prejudice against certain groups of caregivers, managers must follow up and monitor for inappropriate behavior by patients directed at caregivers who are not preferred. Managers should be alert to the potential for this problem and should follow up with patients and caregivers to help ensure that caregivers are receiving the respect they deserve. Follow up activities and on-going monitoring should also be specifically documented.

Professional caregivers are becoming a scarce commodity. Providers cannot afford to lose or alienate a single caregiver based upon discrimination or inappropriate behavior by patients.

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