frequency on RN visits

[americanTrain]

At our company we have a policy that all patients must be seen by a nurse no less that 2 days

per week if stable. I feel this is unreasonable since as an RN I usually do both visits.

Shouldnt an RN only have to visit pt once every 2 weeks. We only have 1 LVN:3RNs.

Im told not to use LVN for visits unless I have more than 5 visits per day. I carrry the

biggest caseload. I have to save the LVN for extra visits or continued care.

This is very difficult even with the most stable pt. Caseload of 10, and only allowed to

work 32 hrs (4days) Budget cuts. Thats 20 visits per week in just 4 days. With not enough time

for anything else. I never have a good day anymore, its almost always hectic since these changes.

I have to do my careplans on the weekend on my time off ( usually 5-6 hours to complete).

I tried to ease my workload by placing 3 of my most stable pts

to once a week and got reprimanded severly. Anyone think this is unreasonable?

Can anyone share visit frequency and requirments of other hospices.

[curiousauntie]

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.

[tewdles, RN]

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

http://www.nhpco.org/files/public/Statistics_Research/2007_natl_summary-hospice_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!

[conniep]

Not sure if anyone said this yet or not, but especially for hospice and home health, the frequency and requirements of the RN visit is mandated by Medicare conditions of participation, which the certifying bodies also adhere to. But peace to you as you work hard in an often thankless job!