I'm an home health administrator in need of some feedback. My company has had a bit of turnover of late. Of course, my goal is to minmize the turnover, improve job satisfaction, improve patient care, etc. All of the nurses who've left had said they are just working too much. I've been a case manager so I know the work can be tiresome. But I've been committed to making things better at my agency. I'm looking for feedback from other case managers and administrators. I live in rural america. Our nurses do have to travel which does extend their day. I've been able to drop the expected case load down to 30 to 35 patients. We have computerized records and give all RNs laptops and wifi cards. I try to hire them to cover the region they live in in order to maximize their efficiency. On average they have 2 to 3 visits per day unless they have lots of sup visits. We don't staff more than 4 visits per day ever. The most travel they would have in a day might be 2 hrs but it's averaging to be 1hr for the group. We also build in 1 office day each week to allow them time to get caught up. I have streamlined processes so they can email their calendars, their HH care plans, and labs requests and don't have to come to the office. I can even scan/email their start of care information to them. They really only have to come to the office 2 times per week. We have a triage nurse who actually manages getting all labs faxed to the docs, updates the orders, and projected visits. She then scans and emails the lab to the RN so she has it. When fully staffed, they only do call 1 week out of 10 weeks and are paid quite well for this time. If they are on call, then they are off the following Monday. I really think we are working diligiently to try to be the employer of choice and to allow RNs to have a healthy work-life balance. I've read some of the other threads on productivity and think that 5 or 6 visits a day are for metro areas. I'd love some feedback on what you think. Are we truly asking too much of our RNs? Any suggestions or tips?
In all honesty, if you come across to your nurses as you do to me here, then I don't think that the problem is you. I see that you are definitely interested in making the situation better and wanting to stop the high turnover rate. Perhaps the nurses weren't cut out for home health?
The more I read, the more I think that I would love to work for such as place, but you never know until you're in it. I love my job, but I don't have a tenth of the perks that your nurses do. I wouldn't know what to do with mileage, a company car, no fight for supplies, computerized charting, and the chance to have my charts reviewed. We have absolutely no QI/QA process at my agency.
In any case, best of luck to you. And many thanks for describing all the things that I know to look for in my next job. :)
Wow, can I work for you? I'm supposed to be a part time care manager, 32 hours per week. I get paid an hourly rate based on per visit, ie; an admission is considered 3 hours, a revisit 1.5, a recert 2.5, etc. I am committed to 4 - 8hour days, from 8am till 5pm. I have to be on call once monthly from Monday at 5p till Friday at 8a, have Friday off (which basically means I don't do visits), then work the weekend. I've been working an average of 83 hours per week.
We see an average of 8 patients a day, including admissions, which equates to a 12 hour day. I often do not see the patients I case manage, cannot follow my own schedule, and we do not have computers, etc. They don't even plan to have computers in the next few years! We have virtually no support at the office, and have to follow our own bloodwork results, etc. after hours, even when not on call.
I've been a home health nurse for 12 plus years. I tried to get out of it(home care) in December because I didn't want to put more miles on my car, but I worked for 2 weeks with a new employer, and was not paid. I took the first job I could get, and was hired by this agency in January. I am, of course, looking elsewhere now. I may even step back to casual for 2 different companies to get away from this mess.
I wish I could talk with your nurses and find out what exactly it is that they're looking for. I've worked for bad and good agencies, and yours sounds supportive and progressive. Have you done exit interviews?
one question that comes to mind is - how many patients are they case managing? are they able to effectively case manage their patients if they're only seeing 4 patients/day. is your part time staff case managing too? are the majority of their visits spent following their own patients. it can be very frustrating if your staff is unable to see their patients themselves and may lead to dissatisfaction/burnout.
what type of visits are they doing? would 3 admissions and 1 recert be considered 4 visits? your agency sounds great, but obviously something is wrong.
as far as the discharges. i can see where a nurse would feel offended if pressed about each discharge. after all, they are the ones actually in the home performing the assessments. i have been approached in regards to the oasis questions answered on discharge and i found that offensive. it does feel as though your judgement is being questioned. not a good feeling and generally doesn't lead to a group hug.
Specializes in HH, ER, Primary Care, QI, Risk Mgmt,.
We have a neutral party conduct the exit interviews in order to get the most accurate info so I do believe their opinions that they are working too much are valid to them. I'm struggling with how to make effective changes for a happy medium and still have a financially healthy company. I believe our computer system is a huge part of the problem. We use Misys which is a powerful system. But it takes longer than paper. The IT staff and I have priortized updating Misys and streamlining it to reduce the duplication of documentation. For us, a start of care averages about 3 hrs- maybe more if there are lots of meds to be entered or care to be coordinated. One bit of info we received from the exit interview from one of the RNs was that that a start of care took her about 7 hrs and we expected her to do 2 of them a day. I wasn't sure how to comment to that. Once again, I questioned how I might have failed her in her orientation process. A start of care should not take anyone 7 hrs.
AnnemRN posed the question about whether they are effectively case managing their patients. Some are and some aren't. Our QI department is finding all sorts of things we need to improve upon. And that's OK... I'm tickled we have a QI department. We have office support for them to send faxes, write orders, note orders, make schedule changes. We scan and email the faxes to the RNs so they will be informed. Yet we've still had some incidents where the Case Manager didn't read an email and missed an order. We're all human and that's bound to happen on occasion. Our outcomes need some improvement.
We really manage our type of visits using productivity points. A nurse for our agency should never have 3 starts and a recert. That's way too much. She could have 2 recerts and 2 supervisory (routine) visits. However, that's recently been changed. Our nurses are not suppose to be scheduled more than 6 productivity points per day. A start is 3 points, a recert is 3 points, sup is 1 point, and discharge is 1 point. Our nurses have spaced out their sup visits so they never have more than a couple a day. So they have 6 productivity points for 4 days per week with one office day where they don't see any patients.
I really appreciate the feedback about the discharges. I think I might have offended a couple of nurses by asking questions or by conducting reviews. That was not my intention at all. Whereas I can see how they might feel their judgment was being questions; I'm very careful how I word that conversation because I know how I would feel. I really do view the process as havng another set of eyes looking for something I could have missed. When I was a case manager and I was struggling for a reason to recert, I had no qualms about asking someone to take a look to see if they could find something i'd overlooked. I suppose I assume others are that open. I also realize how all case managers (including me) are prone to manage their own case load when they are understaffed and overwhelmed. I've done it. I've been there so I definitiely understand. My stance has been to really work to be in a proactive staffing position so the RNs don't feel the need to self manage their case load. I've not always gotten approval from my exec admin team. But I've been able to mostly keep the patient load around 30-35. We have a couple of RNs who have occasionally crept up to 40. I try to get a few of their patients reassigned as soon as possible. Ironically, those RNs are still with us.
Another point of dissastifaction is that RNs who resigned really did not like to make visits for other nurses. We really try to make sure this doesn't happen. However, there will always be times when it's unavoidable. They mostly see their own patients though. Vacations, call ins..or even those days when it'sa Friday and the RN has 4 or 5 recerts to be done may result in another RN making some of her visits. It's not optimal...it does interfere with continuity of care but it can not be helped. The built in office day may also cause an RN to have to see someone else's patient so an RN can have that office day. Bottom line is that the office days are dispersed evenly so they all get one...they all take vacations.. and we're all on the same team. We do not employ part time RN case managers at this time. We're not opposed to it. It's sometimes difficult to find that seasoned RN who only wants to do part time and it's really difficult to train a part time nurse to do home health. Thanks again everyone for the feedback. Keep 'em coming. Everyone's comments really force me to think about things from others viewpoint and is very helpful.
i would have to say that any visit that includes oasis questions should get more points than a regular visit. the oasis questions take time and thought to answer. also, in the past i've had problems with being assigned a new patient when the discharge of my other patients had not been completed. in essence, you are carrying a heavier load then you're getting credit for. i've been handed a new patient while being told " you're going to be discharging so and so this week". unfortunately, sometimes the patient you thought you were going to discharge has a problem which makes you keep him on service.
personally, i don't think part time nurses should be case managers. i do think that they should co-manage a certain amount of patients to lighten the burden of the case manager. i think 30 - 35 patients to case manage is alot.
I, too, think your agency sounds great. But I don't think you will get a good idea of what is creating your increased turnover rate from this type of feedback.
Have you been doing exit interviews?
If you are the direct supervisor for the staff that is leaving do you have your H.R. person or someone else do these interviews?
I think its easier to tell someone other than your direct boss what problems you had with the agency.
How about talking with the staff that isn't leaving about what they are hearing or seeing?
Could it be the level of experience in the new staff that you are now hiring?
I noticed that you questioned whether or not the casemanagement piece was causing a problem. I can't be sure from one little sentence, but do you see yourself micromanaging your staff? Are you maybe being a little too attentive and not allowing your professional RN's to make decisions regarding patient care? Just a thought, been there and learned the hard way that this is not appreciated in a manager! Good Luck.
Specializes in HH, ER, Primary Care, QI, Risk Mgmt,.
DKS3132: A neutral party from our HR department conducts the exit interview. HR gives me the feedback. I try to make improvements based on that feedback.
The subject of micromanaging is a valid one and something that I'm doing some soul searching on as well. I don't like to think of myself as being a micro manager so I work at that one. It's a difficult balance because the issues that my own job performance is evalated on is often directly linked to that of my staff. So~ I try to offer feedback in a coaching style so we can all reach our goals. Honestly, I'm not perfect in that micromanagement issue. Gosh~ I do try though because I completely hate being micromanaged. I am probably more guilty of micromanaging issues when they arise. I have lots of projects and other tasks that I'm accountable for so I really do have a whole lot of time to micromanage anything. Especially now that we're short staffed. Your point is well taken though! Thank you.
My primary reason to be on this site was to investigate if our caseload/ visits per day is too high and if our internal processes were not supportive enough for our RNs.
Someone had commented on a start of care being more time consuming than a recert. They take about 3 hrs to do We realize this and give it 3 points. I can do a recert in about 2 hrs. But we go ahead allow 3 points for a recert too so the RN will have plenty of time for proper coordination of care, chart reviews, etc.
I've actually been able to gleen several outsider perspectives and a few good ideas from this website and I'm very appreciative.
Thank you for the feedback. I'm really proud to work for an agency that is committed to working with our RNs to find that happy balance. We realize that in today's market, RNs have options. We are a for-profit agency but we're not only focused on the profit margin. However, with the changes in Medicare, we've had to put on our thinking caps and really learned to be smarter with the reimbursement that we receive. We have all sorts of tools for our nurses and the orificenal is getting larger. We have telehealth devices, clinical pathways, wound care algorithms. I've been in another agency where I took care of patients armed with a bag full of basic supplies, equipment, and an ink pen. Anything beyond that came out of my own pocket. It's exciting to know the agency I'm affiliated with is so much more than that. We are committing to improving patient outcomes and their quality of life.
productivity ..... A word that I hear all too often I work for hh agency in williamsburg va and the productivty expectation is completely unreasonable 1 or 2 admission 6 visits and drive 125-150 miles a day 20+ phone calls a day from the office and every staff member inviloved on a case calls to my home after hours when im not on call and 2-3 hours of paperwork a day. I have been doing this for four years and As the nurse in home care everything falls in your plate and i am really tired of it thinking about quitting nursing all together. If more nurse managers actually cared about the staff and the reality of being the field nurse would a wonderful world it be.
Specializes in HH, ER, Primary Care, QI, Risk Mgmt,.
UPDATE: I have hired 4 new RNs so I'm only one RN down at this point. They are in training. I have hired a mixture of RNs- a couple with previous home health experience and a couple without. So far, everything is working out well. They are eager to learn and excited about a new career path. The clinical supervisor and I work with the scheduler to ensure that the visit load isn't overwhelming. She and I are both case managing about 70 pts each to keep other nurses from getting overloaded as we train the new ones. We've both been on call for over a month now. However, there is light at the end of the tunnel and I'm confident it's not a train. :-) I think the existing staff can see that we do genuinely care and want to help them maintain that happy life-work balance. I have to say that I've gleaned a lot of insightful information from this site...from how I might be perceived to ideas on how to develop a more cohesive team. I'm always open to idea, suggestions, etc. So thanks to everyone who has commented.
KateRN1
1,191 Posts
In all honesty, if you come across to your nurses as you do to me here, then I don't think that the problem is you. I see that you are definitely interested in making the situation better and wanting to stop the high turnover rate. Perhaps the nurses weren't cut out for home health?
The more I read, the more I think that I would love to work for such as place, but you never know until you're in it. I love my job, but I don't have a tenth of the perks that your nurses do. I wouldn't know what to do with mileage, a company car, no fight for supplies, computerized charting, and the chance to have my charts reviewed. We have absolutely no QI/QA process at my agency.
In any case, best of luck to you. And many thanks for describing all the things that I know to look for in my next job. :)