frequency on RN visits

Our hospice requires one Rn visit per week. We also have Lpns who do visits as the case manager requests. I have a case load of 21 right now, with Lpns seeing 14 or 15 of them at least once a week also. We still are completely paper based: notes, care plans, orders, IDT notes on each patient bi-weekly. The paperwork component of this job is OVERWHELMING. Maybe when we finally go electronic (in the next 12-18 months), it will go faster. But at this point I work close to 50 hours a week to get in my visits and the required paperwork...then get ******* at for spending too much time in the office (where the charts are!)
And God forbid when someone begins to decline severely and needs 3 or 4 or more visits a week. Or has wounds that need daily attention.

We have a census of 80, with 3 full time Rns, 2 full time Lpns and 1 Rn who works 2 days a week and 2 Rns who work 1 day a week. I have the heaviest case load and also have the patients at the extremes of our territory. Thank God we have a dedicated on-call team now, so THAT is off my plate. One full time case manager has 75% of her case load in one assisted living facility, and the other one has 50% of hers in one facility. Only 25% of my case load is facility based, and those are spread in 3 facilities and MILES apart. My director never seems to understand that nurse A can see 7 patients a day because they are ALL IN ONE PLACE, whereas mine are 35 to 40 miles apart! If I hear the words "time management" one more time, my head will explode. Making all my phone calls while driving {yes, using a voice controlled blu-tooth} and never taking a lunch break is about all the "time management" I am able to do.

Curiousauntie....sounds like it is time for you to invite management out on the road with you. They obviously need a reality check about "time management". I am very serious that before you will be able to be content with your current position, the director must adjust her perspective of the care delivered. As it stands now, you are required to case manage more than the US national standard number of hospice patients with no geographical base. I fear that with your current situation you will become increasingly Hungry, Angry, Lonely, and Tired (HALT) all of which predispose you to burnout. Perhaps your manager needs to take a close look at what it means to travel 100+ miles in the course of your daily care in order to have a more realistic and appreciative opinion of your efforts. If you are in the USA, there is probably already a "requirement" for your agency certification/accredidation/etc that she accomplish such anyway...so be insistent. Otherwise, at the rate you are going, you may end up very unhappy about your position and begin to wonder if you are cut out for hospice at all.

Just as an aside, curiousauntie, where are you geographically and how long have you been in hospice?

Twedles,
I am in southern New Jersey, covering 2 counties (both pretty large counties). For the most part the patients are split in 2 teams, sort of. My mileage runs from 50 to 100+ a day, according to where I am going. And that does not count the miles it is to the office, and the miles after my last patient. I have been in hospice for almost 3 years, been a nurse for 24 years and although I sound like I am complaining, I know it is a much better fit for me then long term care. As an Rn in long term care, I DID get burned out 2 times due to the awful demands of residents, families, paperwork and keeping the administration happy. I found it was impossible to do all that was demanded without taking more shortcuts than I was willing to take. And since I had quit nursing 2 other times, only to go back to be burned out yet again, I looked at hospice. I can use most of the skill set I had from LTC, but have the one on one contact with patients and their families that I want. And I had wanted to do hospice nursing for a long time. The opportunity came up, so I jumped at it.

Now, Tewdles, I have a question for you. What would the "US national standard number of hospice patients" be? Or where could I find that information? We are told by corporate that we should have 15 to 19 patients as full time case managers. I have been at or over 20 for it seems like months. This weekend was not a good one for us...6 out of 80 patients passed, in 2 days. So now I am at 19. That sounds manageable, 4 visits a day, but it never works that way, as we all know. And now the office is trying to demand we take a half hour lunch break. And don't understand that I really don't want to...that means I get home a half hour later then I do now. (8:15 tonight as I had paperwork to finish for team meeting this week), and if I want to eat lunch, I have a sandwich while I am driving (as that is usually 1.5 to 3 hours a day).

I will say that there are 2 things I stick to my guns about and I learned these things after about a year of working in hospice. My cell phone goes off the second I am done for the day, (and is never on for weekends) and I will NOT take paperwork home anymore. At least 2 of the case managers have their cell phones on at all times, and seem to encourage their patients to call them in the middle of the night, insead of the on-call number. I will not do that. We pay a nurse to do on call, and if she is stumped (which almost never happens) she has our home numbers. It has gotten so it seems to be expected that instead of doing paperwork in the office and putting it on our timesheets, we should take it home to do on our off time...it is never openly encouraged, as that would be very illegal, but we are constantly being reminded that excessive office time impacts negatively on our "productivity" numbers. I say fine, as when I am in the office there are always others there and it is known that I don't fool around in there, I am there to work, if you want to have a personal conversation with me, lets go out for a quick ciggie! Then it is back to work!

You thoughts would be greatly appreciated.
Thanks.

curiousauntie... here is a link to the 2007 data from NHPCO.

http://www.nhpco.org/files/public/St...spice_care.pdf

Page 4 of that document indicates that the average case load for a nurse case manager was 11.2. Clearly there is room for an experienced case nurse to comfortably manage more, particularly if the patients reside in a dense residential area or in a facility where travel from case to case is not an issue. Similarly, there are quite a number of agencies who expect the RN case managers to manage 20+ clients but they are often buddied with an LPN to allow them to be responsive to the needs of the patients and their families. Sounds like you are stretched a bit thin.

In my current position I am expected to manage approximately 12-15 patients routinely. Of course, there may be periods of time where my caseload will rise above that, but the agency staffing model is 12-15/case nurse.

kudos to you for standing up for yourself and choosing your battles. I am in complete agreement with you on the phone subject. I DO NOT respond to my work phone/pager/email when I am not on the clock...period and no exceptions. I care deeply for my patients but there are boundaries that are important to me...they insure that I will be able to maintain my own mental health and my personal relationships outside of work. I have recently interacted with 2 hospice agencies who had ZERO respect for their employee's personal time. They actually came right out and verbalized that they expected us to carry out any case management activities at the end of our long days, after we were "off the clock". They used the ol' "professionals" work at home all the time argument. I countered that professionals get paid for their work, otherwise you call them volunteers, and, in hospice volunteers cannot counsel, create POCs, administer meds, or pronounce patients so they might want to rethink that position. You are right, it is not the best idea to give patients and families unfettered access to your phone...most will be okay, but we all know of the few who will dominate your world while that loved one is dying. It is best to keep a receptionist or voicemail between them and direct access to you. I find that most are more than happy to receive a return call from you, especially if you are diligent about prompt response to their inquiries.

Sounds like you have a good handle on your situation. Here's hoping you have daily victories and reasons to rejoice in your work!