frequency on RN visits

tewdles, RN · Aug 16, 2009

I am not sure how to respond to your situation. It is curious to me that your agency does not allow the team to determine what the frequency of the visits should be based upon client/family need. Further, my experience has been the opposite of yours...the agencies that expect that all but the very unstable receive no more than once per week visits, thus allowing the RN case managers to carry a heavier case load. I wonder how the medical director fits into your situation. Is he/she aware of this "requirement"? Have you actually discussed the frequency of nursing visits at the team meetings? Is it possible for you to physically visit your stable patients once and provide phone assessment once during the week?

The issue of completing documentation on your personal time with no compensation is ridiculous but not uncommon. What I would recommend is that you protect yourself as best you can. Knowing that you have routine visits which are very stable I can only imagine that it takes very little time to complete them both physically and in writing. I suggest that you utilize the full hour alloted for a visit to take care of as much documentation and POC maintenance as is possible. Use point of service documentation to your advantage when at all possible. While I understand that it is not always possible or appropriate to whip out the laptop and chart, I do know that when it can be accomplished during the visit it takes less time in general thereby making you more efficient.

Just as a side, where are you located geographically? How long have you been in hospice as an RN case manager?

You have my empathy. Good luck.

angieRN · Aug 18, 2009

Hmmm..we're having caseload/visit issues as well. I don't think it's unreasonable to see your stable patients once weekly, and for a while, we did that as well. Now we're back to the same as your company. Twice weekly, no matter what. They want our caseloads at 14 per RN with only 1 LPN floating amongst 5 nurses. So that's at least 28 visits/week, plus team meetings, careplanning, etc. It's getting hairy!

Angie:banghead:

americanTrain · Aug 18, 2009

Angie, like you, we were told twice a week no matter what. I really think this is a matter

of PR since the company is fairly new, so maybe

I just need to buck up and place my skates on. I want to see the company suceed, but at times

it just gets so hard keeping up with all the demands. We just keep getting told by the managers that

we need to keep our faces seen in the homes and facilities.

Iam located in Texas and I do know that other hospice agencies let their casemanagers manage. Thus the

name Case Manager. Humh.. I would like to see a visit frequency of 1-2x instead of 2x firm.

And when can you use prn freq. on the care plan? I have seen others document 1-2x & prn, thus covering

an extra visit should a problem arrise. That would eliminate having to change the careplan as much, would

it not? Thanks for your responses.

tewdles, RN · Aug 19, 2009

I believe that it is not appropriate to indicate the RN frequency with a range as in 1-2/wk. It would be more approp to give a frequency of 1x/wk with 2 PRN for symptom management. I do understand the company's desire to have the RN in a "client" facility frequently but it is quite a different matter to "require" a minimum of 2x/wk freq when the pt condition does not warrant that frequency. As is obvious to all case nurses, this really ties our hands and makes it less likely that we can be flexible in meeting the on-going and unexpected needs of the patients and company.

saribeth · Aug 19, 2009

What about when a pt is actively dying???? Don't you visit daily???? At our VNA the visits are totally up to the nurse. For documenting frequency in the POC we put 1-5x weekly x13 + 3-4 for sx management. :rolleyes:

DelanaRN, MSN, APRN, NP · Aug 20, 2009

I have 12 patients and see each of them at least 2x each week. It is required that I complete a minimum of 2 skilled nursing visits each week. Additionally, I attend all care plan meetings at the facilities of my patients, go to IDT/IDG, morning meetings on monday and wednesday, and whatever else pops up. It it busy, but I manage. It only really frustrates me when I hear a chaplain or sw complain how busy they are when they don't do half the visits I do each week. They are 1x per month and prn. I am 2x per week and prn.

DelanaRN, MSN, APRN, NP · Aug 20, 2009

PS- I'm also on call at least 2 full nights each week plus every other weekend.

jenkayaker · Aug 23, 2009

I have 17 patients on my case load, no lpn. I feel guilty only seeing my stable patients 1x per week, but when I have patients on daily or watch visits (crossroads hospice watch program) I am forced to do so, so much can happen in a few days time, the most stable patient can decline and change rapidly. We still document on paper & have to update our careplans,mars, keeping up with facility orders/charts & office charts, IDG meeting notes/updates ongoing. I am constantly trying other ways to get organized better.

tewdles, RN · Aug 23, 2009

jenkayaker...don't feel guilty about visiting the stable clients only weekly. That is part of the job. Those are the visits that allow you to complete a great deal of education...leading to families that are more likely to be well adjusted and confident in the last days. Sometimes when nurses come into hospice they are accustomed to families and patients being very dependent upon them for their every need...that is afterall how we see people in the hospital. My general plan for visits is this...when a person first comes on service I tentatively plan for visits 2-3/wk for the first week, maybe two. I plan to taper as quickly as possible to once weekly assuming that the patient is truly stable with all symptoms adequately managed. Any evidence of decline in the patient may result in an immediate increase in RN visits. In essence, I make the front and the end of the hospice experience nursing heavy...the middle is for the patient and the family...I WANT them to go, be, do...without worrying about appointments with me. There are always families for whom this model will not work, but in my experience they are NOT the norm. In a typical case load of 12-20 patients it is pretty common to have approx 1/3 of those patients who are transitioning and perhaps 1/3 who are pretty stable. The other 1/3 is shared by those who are actively dying, having some sort of a symptom crisis, or a caregiver issue requiring your oversight. The ability to organize your schedule along the lines of who needs to be seen based upon clinical judgement and CoPS rather than a corporate mandate is essential to providing the responsive, excellent hospice care that these people deserve. Using paper documentation slows you down...too bad your agency is stuck in the 20th century. You need to make sure that you use the mobile office tools available to you to improve your organization. Make sure that you keep frequently used forms with you AND in your car. If you spend a great deal of time in particular facilities, talk to the management and determine if you can keep things there that will improve your ability to meet the needs of your patients. Paper IDGs are a real bother but a necessary evil. If you don't have a notebook or some such method to keep ongoing notes for your patients give it a try. It may help you to organize your thoughts for IDG prep. I used a spiral steno pad. During my visits I would jot down notes that I thought might be pertinent to the IDG presentation, because they were organized by dates and time it was pretty easy to complete a quick review of the past several visits. Paper documentation doesn't allow you to review previous notes, so the notebook can help to jog your memory about a symptom or issue that you may want to follow-up on. Ask your aides to give you a call the day before IDG to report on any issues that they are seeing. Make sure that if the paper forms are not meeting your needs that you discuss this with management. I am sure that there are improvements that could be recommended by the nursing professionals on your team. Sometimes simple changes can improve your quality of "work life" significantly. Good luck!

curiousauntie · Aug 30, 2009

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.

tewdles, RN · Aug 31, 2009

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?