Patient and Health Care Advocacy Framework with Domains of Competency within Contextual Variables

 

Revised 2024

BCPA Practice Standards

Professional Patient and Health Care Advocates have two primary resources that inform their thinking and decision-making and guide their advocacy practice. First, the Code of Ethics for Board Certified Patient Advocates lists the eight succinct provisions and accompanying interpretive statements that establish the ethical framework for patient and health care advocates across all roles, levels, and settings. Secondly, the 2017 Competencies and Best Practices required for a Board Certified Patient Advocate, outlines the expectations of the professional patient and health care advocate practice. These statements present the framework and context of patient and health care advocacy practice and accompany the Ethical Standards.

The Patient Advocate Certification Board (PACB) recognizes the importance of these Competencies and Best Practices as a guideline for professional practice in the field of patient and health care advocacy and for the development of an assessment process for certification.

The initial draft emerged from a diverse task force of advocacy practitioners and educators drawing on numerous sources and their own professional experiences. The draft was reviewed and edited by the PACB, then posted for a one-month period of public comment, during which time the PACB received valuable feedback from many advocates and other professionals.

Those comments and suggestions led to extensive revisions and clarifications. The 2017 version reflects the broad knowledge and insights of the diverse professional community.

Understanding that no advocate could ever be able to provide every service clients accessing the healthcare system might need or benefit from, the initial lists of competencies/best practices were developed in two categories:

1. Core functions and skills that every advocate must be able to perform;
2. More specialized skills that an advocate may not possess but must be able to recognize and understand so that, when needed, they can refer their clients to the appropriate professionals.

The second category requires advocates to recognize when clients’ needs are beyond their own competencies. This realization is a skill unto itself; therefore, these competencies and best practices were categorized accordingly.

Domains of Patient Advocacy – 2017 – (Also known as the Competencies and Best Practices)

1. Scope of Practice and Transparency
2. Empowerment, Autonomy, Rights, and Equity
3. Communication and Interpersonal Relationships
4. Healthcare Access, Finance, and Management
5. Medical Knowledge and the Healthcare System
6. Professionalism, Professional Development, and Practice

The results of the JTA (Job Task Analysis) study yielded a comprehensive transformation in the framework and model used to define the essential competencies and knowledge, skills, and abilities (KSAs) required within the field. This reimagining was meticulously constructed, drawing upon the original sources underpinning the JTA’s design, the invaluable expertise of Subject Matter Experts (SMEs), and the wealth of data gathered through the JTA Survey. The process followed a theoretically sound, evidence-based sequence of activities.

First, to streamline and consolidate the existing information and new data, the “2017 Best Practices” and the “JTA Tasks” were organized into coherent groupings. Minor adjustments were made to the terminology to ensure it accurately mirrored professional practices while maintaining a sense of consistency. For instance, “conduct research” was aptly modified to “identify evidence-based sources,” aligning it more precisely with professional norms.

Another critical step involved the merging of redundant, overlapping, or superfluous domains, allowing for a more streamlined and effective system. These revised domains were then realigned and categorized into broader competency domains, each with its associated sub- categories. Comprehensive definitions were crafted to give these domains further clarity and meaning. Drawing upon shared knowledge with other health professions.

The next phase was the integration of JTA KSAs with these newly formulated competency domains. This interplay ensured that a solid foundation of knowledge, skills, and abilities substantiated each competency domain.

The development process also benefited from qualitative exemplars drawn from the JTA data. These exemplars served as illuminating anecdotes, shedding light on and validating key elements of the theoretical framework. They brought real-world context to the theoretical underpinnings, enriching the overall understanding of the subject matter.

Noteworthy changes emerged from this process. The first domain, initially named “Scope of Practice and Transparency,” was shortened to “Scope of Practice,” as transparency was deemed inherent to professional and ethical practice. The fourth domain, “Healthcare Access, Finance, and Management,” was retired and woven into the fifth domain, now titled “Health, Medicine, and the Healthcare System,” reflecting their intrinsic interconnectedness.

The sixth and seventh domains, “Professionalism, Professional Development, and Practice” and “Ethics,” found common ground and were merged into a singular domain entitled “Professionalism and Ethics.” This blending aimed to underscore the interdependence of these two vital aspects of professional life, emphasizing their holistic nature within the field.

2024 Domains of Practice with Competency and Task Statements

Domain 1-Scope of Practice (PACB Domain)

Definition: Advocates deliver high-quality, effective patient advocacy services and coordinate services within a defined scope of practice. Advocates have a clear understanding of their role, limitations, and boundaries of their defined duties and responsibilities, reflected in the advocacy plan of care.

 

Advocates:

 

1.1  Demonstrate an understanding of the patient care advocate’s distinct professional perspective (Competency)

1.1a-Provide to potential clients clear, accurate, and complete information about training, education, experience, credentials,
and limitations, as   well as any possible fees and areas of potential conflict of interest

1.1b-Establish and document the scope of advocacy services, including goals, objectives, desired outcomes, and their associated
time frames in collaboration with client and key stakeholders

1.1c-Inform clients about the limits of their scope of practice and advise clients strictly within their defined area of proficiency

1.1d-Develop clear and achievable expectations with the client to encourage a strong working relationship and productive
advocacy

1.1e-Provide a written service agreement to each guarantor and client, both paid and pro bono, that clearly sets forth the nature
and scope of services, fee schedule, terms, projected length of the relationship, and the criteria for appropriate
termination of the relationship

1.1f-Identify clients that meet criteria for patient advocacy services (e.g., acute, or chronic medical and behavioral health
conditions, polypharmacy, social determinants of health issues)

1.1g-Identify barriers that affect clients engagement throughout the provision of patient advocacy services

1.1h-Identify when scope of services is complete

1.1i-Notify client/decision maker and/or authorized client representative of the conclusion of services

 

1.2  Assess individual client needs to develop and implement a plan of care. (Competency)

1.2a-Conduct a comprehensive initial needs and services consultation or evaluation

1.2b-Consider both the clients behavioral and non-behavioral health issues and concerns in the provision of patient advocacy management services

1.2c-Perform a client assessment using established patient advocacy Competencies, Best Practices and Ethical Standards

1.2d-Assess clients social, educational, psychological, and financial/economic status such as income, living situation, and insurance benefits

1.2e-Assess clients understanding, readiness, and willingness to engage in patient advocacy services

1.2f-Review information from various sources about client (e.g., diagnosis, history, language, medications, health insurance status, social determinants of health)

1.2g-Develop goals that identify the clients safety needs in the scope of services document

1.2h-Document client’s progress with the advocacy plan (e.g., goals, objectives, desired outcomes, possible modifications to the plan) including conclusion of service(s)

1.2i-Implement the advocacy action plan

1.2j-Modify the client’s plan to meet changing needs and conditions such as the need for home health services

 

1.3  Recognize professional limitations (Competency)

 

1.3a-Avoid diagnosing or prescribing any medical/mental health treatment for clients, even if the advocate has additional licensure or training

1.3b-Refer clients to qualified alternate professionals if a client’s needs are outside the scope of the advocate’s knowledge or training

1.3c-Recognize the need for advanced expertise in research on medical options and research trials and facilitate client access to qualified professionals when needed

Domain 2-Empowerment, Autonomy, Rights, and Equity

Definition: Advocates strive to create a healthcare environment that fosters clients’ autonomy, upholds their rights, seeks to establish equitable care, and empowers them to be the driver of their own health and healthcare experience. Advocates apply the principles of Empowerment, Autonomy, Rights, and Equity to facilitate client-centered, client-driven care and a meaningful, productive experience among the recipient of care, the healthcare team, and the healthcare system.

 

Advocates:

 

1.1  Honor the ethical principles of Empowerment, Autonomy, Rights, and Equity in all interactions (Competency)

 

2.1a-Offer continuous client-centered services that represent the best interests of the client, as determined by that client (or a legal healthcare proxy)

2.1b-Foster self-determination and client engagement, treating the client with respect and compassion in all interactions

2.1c-Provide clients with information and resources to facilitate informed decision-making regarding care and treatment, including palliative and end-of-life care

2.1d-Respect the right of clients to make their own decisions

2.1e-Assist clients in understanding care and treatment options, including potential risks, benefits, and available alternatives

2.1f-Assist clients with choosing doctors

2.1g-Guide clients through weighing treatment options and alternatives

2.1h-Help clients effectively manage care on an ongoing basis

2.1i- Help clients to actively participate in their own healthcare decisions

2.1j-Provide clients with the information they need to make informed decisions about their healthcare

2.1k-Convey relevant medical history, statutory patients’ rights, and possible care options to any legally designated surrogate, as authorized by the client, including personal conversations in which the client may have expressed certain wishes that might guide informed decisions

2.1l-Avoid making any decision for, or on behalf of, a client

2.1m-Educate clients about important decision-related healthcare documents which may include, but are not limited to: Durable Power of Attorney for Healthcare, Durable Power of Attorney for Financial Affairs, Advance Directives, Living Wills, Do Not Resuscitate orders (both in-hospital and out-of-hospital), and similar documents. Encourage clients to complete and save such documents, as appropriate

2.1n-Provide information regarding Advance directives

2.1o-Treat clients fairly regardless of age, race, religious/spiritual practice, culture, ethnicity, sexual orientation or gender identity, and immigration status

2.1p-Promote equitable access to appropriate and safe health care and treatment

2.1q-Facilitate clients empowerment through the development of self-management and health engagement skills

 

Domain 3-Communication and Interpersonal Relationships (PACB Domain)

Definition: Advocates build trust-based, supportive relationships with clients and facilitate intentional communication among clients, family, providers, and other stakeholders. Collaborative relationships require a coordinated, integrated approach using unique client characteristics, preferences, and values and understanding of psychosocial concepts and of client support systems in order to optimize client care, experience, and health outcomes.

 

Advocates:

 

3.1Engage with the individual in a caring relationship. (Competency)

 

3.1a – Incorporate the influence of the clients multicultural, spiritual, and religious factors into developing the scope of and delivery of advocacy services

3.1b – Use client engagement techniques (e.g., motivational interviewing, health coaching, behavioral change) in the delivery of patient advocacy services

3.ac – Provide empathetic, non-judgmental, supportive listening and interactions that promote self- determination, well-being, resilience, and confidence

3.1d – Utilize appropriate style/approach to meet the client’s cognitive, literacy, and personality characteristics

3.1e – Integrate cultural, gender-based, and religious/spiritual perspectives that may influence the client’s experience of illness, pain management, treatment, and health

3.1f – Recognize when cultural, gender-based and/or religious/spiritual perspectives will significantly affect client outcomes and facilitate client access to advanced expertise in this area when needed

3.1g – Counsel client on coping with health condition(s) and care intervention options

3.1h – Evaluate clients understanding of care recommendations and health instructions and/or insurance benefits (e.g., verbalize, demonstrate, teach-back)

3.1i – Provide emotional support

 

3.2  Collaborate with others (Competency)

 

3.2a – Collaborate effectively with other members of the healthcare team, both in and out of the hospital, to ensure appropriate and compassionate care for the client

3.2b – Include the family and caregivers in the client’s planning process according to the client’s wishes

3.2c – Utilize basic conflict management skills in interactions between the client and family, health professionals, or other relevant stakeholders

3.2d – Recognize the need for advanced skills in conflict management or professional mediation and facilitate client access to such resources when the situation warrants

3.2e – Reinforce care and health instructions given by involved providers

3.2f – Act as liaisons between providers and clients/patients and families to improve the communication between all the parties

3.2g – Clarify clients care and health instructions

3.2h – Communicate evaluation/research findings and scope of services plan to client and key stakeholders (e.g., family, healthcare proxy, healthcare providers)

3.2i – Communicate progress in achieving the goals, objectives, and desired outcomes of the advocacy plan to the client and key stakeholders (e.g., family, healthcare proxy, providers)

3.2j – Establish working relationships with the clients care team or other designated stakeholders

3.2k – Collaborate with healthcare team to clarify restrictions and limitations related to client’s physical or mental functioning

 

3.3  Choose effective communication tools and techniques, including information systems and communication technologies (Competency)

 

3.3a – Provide any written communication and documentation requested by the client in a timely, appropriate, and professional manner

3.3b – Incorporate into communications the complex interplay of biological, psychological, and social factors that enhance the client’s functioning and well-being

3.3c – Interact with the care team across modalities (in person or remotely)

3.3d – Communicate to clients the end of a given service or the transition from advocacy service to other care

 

 

Domain 4-Health, Medicine and the Healthcare System (PACB Domain)

Definition: Advocates understand health and medical concepts. Advocates also understand nuances of various healthcare payment systems, financing options, and other related resources. They also understand the broader complex systems and the environment of care in which medical care and healthcare are delivered, including access, finance, and management of healthcare services and research and referral treatment options.

 

Advocates:

4.1  Apply knowledge of concepts related to human growth and development and wellness/illness in daily practice. (Competency)

 

4.1a – Maintain familiarity with basic medical terminology, major life-threatening illnesses, and chronic diseases

4.1b – Identify evidence-based sources to provide reliable medical information relevant to each client

4.1c – Educate client regarding health condition(s), care choices and resources

 

4.2  Apply knowledge of healthcare systems to work effectively across the continuum of care. (Competency)

 

4.2a – Explain the structure and functionality of healthcare facilities and provider groups to clients and expose resources available through each system

4.2b – Access the full range of healthcare providers and care delivery models and enable second opinion options

4.2c – Assist clients to coordinate care among many clinicians, settings, and affiliated providers

4.2d – Promote safe care and the patient’s awareness of patient safety issues at all times, which may include but are not limited to diagnostic accuracy, and prevention of hospital-acquired infections, pharmaceutical and biologic drug or medical device errors, care coordination errors, radiologic (imaging) errors, and other potential health care related hazards and errors

4.2e – Facilitate the client’s navigation through the complexities of the healthcare system continuum

4.2f – Clarify care transitions and assist clients in appropriate aspects of these changes

4.2g – Recognize barriers to care coordination and work with clients and providers to overcome them, requesting provider-to-provider conversations and other client-focused collaboration as required

4.2h – Discuss with client and health care team treatment options, including cost comparisons and alternative services

4.2i – Consult with health care team (e.g., medical, vocational, rehabilitation, life care planning) based on the client’s need and scope of advocacy services

4.2j – Discuss appropriateness of level of care with the healthcare team

4.2k – Assist clients in understanding the cost-effectiveness of treatment options and services

4.2l – Identify evidence-based resources to help clients better understand and evaluate all available treatment options

4.2m – Identify providers in their local area who best meet the clients treatment needs

 

4.3  Apply Knowledge of Healthcare Access, Finance, and Management (Competency)

 

4.3a – Understand and be able to communicate generally how the healthcare system functions, and the roles, responsibilities, barriers, and constraints of patients, payers, and providers within the system

4.3b – Gain fluency in basic medical bill interpretation and apply the general provisions of insurance coverage to each client’s situation

4.3c – Comprehend and apply the fundamentals of prescription drug costs and coverage for all clients

4.3d – Understand and communicate to the client the basics of health insurance, Medicare, Medicaid, and other programs that affect payments for the client’s medical needs, including appropriate state variations and differences among programs

4.3e – Utilize appropriate grievance, appeals, and complaints processes

4.3f – Integrate community-based resources to support and sustain the client’s well-being

4.3g – Offer information and empathy to clients experiencing the financial, emotional, and/or physical impact of medical debt

4.3h – Recognize the need for advanced expertise in health insurance coverage regarding such issues as omissions, impediments, shortfalls, subsidies and tax credits, metrics, potential penalties, and alternative insurance providers, and facilitate client access to qualified professionals in this area

4.3i – Recognize the need for advanced expertise in medical billing, claims, denials, or other payment-related issues and facilitate client access to appropriate expertise when needed

4.3j – Recognize limitations in standard grievance, appeals, and complaints processes and facilitate client access to appropriate legal expertise when needed

4.3k – Recognize and/or refer (as necessary) if insurance was applied incorrectly.

4.3l – Assess for errors or overages and investigate denials (or refer as appropriate)

4.3m – Educate client on private and public sector funding sources and limitations of services

4.3n – Educate client about utilization of resources in accordance with established criteria (e.g., clinical, financial)

4.3o – Recognize the need for and provide information/referrals to programs, services and funding (e.g., SSI, SSDI, Medicare, Medicaid, Affordable Care Act, Veterans Administration benefits, third party insurance)

4.3p – Help clients understand their insurance coverage

4.3q – Help clients with billing questions, issues, claims and payments

4.3r – Identify actual and potential delays in service and mitigate where possible

4.3s – Identify clients that would benefit from additional types of services (e.g., community resources, physical therapy, durable medical equipment, counseling, assistive technology)

4.3t – Identify formal and informal community resources and support programs

4.3u – Assist clients who have difficulties completing paperwork or understanding information

4.3v – Assist clients with connecting to other resources (i.e., complete Medicaid applications, slide enrollments, payment agreements, etc.)

4.3w – Recognize the scope and limitations of client’s health benefits including appropriate referrals

 

 

Domain 5-Professionalism and Ethics (PACB Domain)

Definition: Advocates understand the values base of the profession and adhere to ethical, legal, and practice standards that impact practice. Advocates understand how to apply professional, legal, and ethical frameworks in practice. Advocates recognize personal values and the distinction between personal and professional values; and how their personal experiences influence their professional judgment and behavior.

 

Advocates:

5.1  Demonstrate a commitment to professional standards and professional development. (Competency)

 

5.1a – Work within the scope of the BCPA credential and obtain continuing education credits, as required

5.1b – Apply patient advocate competencies, best practices and ethical standards in the provision of advocacy services

5.1c – Adhere to established resources of accountability (e.g., ethical standards, codes of professional conduct) that govern patient advocacy practice and certification

5.1d – Maintain, update, and provide proof when required of all credentials, liability, and business insurance, legal contracts, and other practice-related requirements

5.1e – Continue to develop skills and maintain competence in all specific areas of expertise

5.1f – Take the initiative to seek out colleagues, mentors, and other experts regarding challenging client situations

5.1g – Maintain ongoing communication with client and key stakeholders (e.g., family, healthcare proxy, providers)

5.1h – Document patient advocacy services with accuracy and in a timely manner

5.1i – Use cost effective strategies in the delivery of the advocates services 

 

5.2  Apply the relevant laws and regulations, and models for ethical decision-making as appropriate to context (Competency)

 

5.2a – Keep abreast of laws, policies, research developments, and trends that affect the practice of patient advocacy

5.2b – Assess the client relationship on a regular basis, continue to recognize, develop, and maintain professional boundaries as defined in the Code of Conduct and Ethical Standards for a Board Certified Patient Advocate and avoid situations that may jeopardize those boundaries

5.2c – Adhere at all times to the Ethical Standards defined by the Patient Advocate Certification Board

5.2d – Advocate to alleviate suffering, promote health, promote safe care, and encourage well-being whenever and wherever possible

5.2e – Understand and apply current and appropriate laws, documents, and approaches (e.g., the national standards for Culturally and Linguistically Appropriate Services (CLAS); Beauchamp and Childress’ Four Principles of Biomedical Ethics; or state and/or institutional statements of Patient Rights) to protect client’s rights and choices

5.2f – Educate clients regarding patient bill of rights

5.2g – Practice based on legal and regulatory standards (e.g., informed consent, Health insurance Portability and Accountability Act, American with Disabilities Act) that govern patient advocacy practice and certification

5.2h – Coordinate accommodations for persons with disabilities by adhering to Americans with Disabilities Act

5.2i – Advocate for the provision of health and human/social services in the least restrictive and most appropriate setting

 

5.3  Report Ethics violations. (Competency)

 

5.3a – Document actions taken by the patient advocate relative to an ethical concern

 

5.4  Safeguard privacy and confidentiality in all interactions. (Competency)

 

5.4a – Obtain, maintain, and protect the privacy of any and all medical records required to serve the client’s needs, sharing them with the client and anyone designated by the client

5.4b – Abide by all relevant laws and regulations related to confidentiality of medical and identity information including, but not limited to, HIPAA*

 

*The Office for Civil Rights has stated that independent patient advocates are not subject to federal HIPAA regulations [source]; but advocates within health care organizations would be expected to adhere to HIPAA regulations, and independent advocates should understand the basic principle of privacy undergirding HIPAA and the influence it has on information sharing in provider/client relationships.