Q&A: A framework for handling duty-to-warm circumstances

Q: Do you have any advice for what to do when confronted with a duty-to-warn situation?

A: Duty-to-warn circumstances are exceptionally tough ones for case managers to reconcile. Knowing the right thing to do in the moment is not as easy to define as it might seem. Now, the duty-to-warn laws are consistent across the majority of licensed professions, where all are beholden to report concerns of child or adult abuse, neglect, or exploitation. However, even amid the clear direction of the law, these situations can and will elicit strong feelings and responses. There are times when despite what presents as blatant physical abuse or neglect, a case manager receives explicit messaging from a colleague, or even superior, not to report. Although the case manager knows the right thing to do, the opposing stance of a physician, manager, or colleague can be a compelling force to mitigate:

• “You know calling child protective services won’t lead to anything.”
• “Adult protective services won’t touch the case since the client is in the hospital; don’t waste your time.”
• “Oh, the client’s son was just frustrated with her dementia. I’ve been working with them in the office. Reporting him isn’t necessary.”
• “Nothing is going on here. Trust me when I tell you that stealing her Social Security check is the last thing her daughter would do.”

Mandatory duty-to-warn situations also evoke their own special sort of confusion. Remember, these are the situations where case managers might be involved to assess or intervene with clients at risk of suicidal or homicidal intent, if not also action. Professionals often wish they could reach for a crystal ball to ensure their assessment accuracy in these circumstances. The disparity of related state laws makes these situations even more complex to address.

When a client is at potential risk of harming him- or herself or the public, the stakes are especially high. The intensity of mass casualty events have heightened the urgency for the workforce to be involved in these situations. There is a common cycle that occurs following mass shootings: initial horror and tragedy transition to personal and professional outrage, with blame directed at any involved professionals who intervened with the perpetrator. With the increasing number of assessments conducted via remote or virtual platforms, risk and concern for liability put these situations front and center of every organization’s radar.

E-ACTS was developed as a framework to guide a case manager’s actions with the often convoluted, multifaceted, and mandatory duty-to-warn situations. The model is an acronym that involves five concrete steps:

• Engage in the moment
• Assess risk
• Contemplate and then act
• Transcribe notes
• Seek to process

Completion of each step leverages a case manager’s ability to focus and organize their actions, contemplate the facts, compartmentalize the details, and ultimately move forward with the appropriate actions. It is essential that case managers know how to accurately assess and intervene across the ethical landscape.

For more information, see The Essential Guide to Interprofessional Ethics in Healthcare Case Management . Need expert advice? Email your questions for consideration in the Revenue Cycle Daily Advisor. Note: We do not guarantee that all questions will be answered.