Have an 8 hour day with no overtime??

hoolahan, ASN, RN · Mar 10, 2002

Dear Wendy,

Welcome to home health. First let me tell you about my caseload. I have somewhere between 30-35 cases currently, we are only supposed to have 25. I am not sure b/c I had so many come and go this week, the count would be final today, but carpets are being cleaned so i can't get in to office to check my list and we are not computerized. I do 7 "credits" a day, one new = 2 credits, and 4 or 5 revisits (I credit each), usually 5, so I can keep pulling up from next day if a visit doesn't work out. I usually open a new q day, and on my saturday, I do 3 news usually, once and awhile they even make me take a revisit on top of that.

I do NOT believe in working for free. If I work 10 hours to get it all done, I put in for ten hours. So far, I talked w several other nurses on my team, and they do the same. None of us has been given any reprimand b/c our paperwork is done properly. Our supervisor knows we take good care of our pt's and we are doing the best we possibly can w so many pt's each.

As far as your paperwork for news. There is a problem. The other agency I worked for had way more paperwork, all b/c their process was different for sending oasis info to hcfa or wherever it goes. PT referrals were done to outside consultant, and my present agency they are in house. Makes things easier.

You do know, that on the OASIS, the only questions you MUST answer are the MO### questions, right?? The other assessments questions, we do not repeat, but write, see notes, see database, etc... I do not even ask about GYN history of elderly folks unless they had a GYN issue. Who the hell cares when their LMP was when they are 80?? Or the age they went thru menopause, it is long gone. I certainly do not carry around a snellen eye chart to test vision, another ridiculous question. If you are not shouting, their hearing is good, don't ask. Have them walk. You need to scrutinize the oasis. Take one home, cut the batches of questions up, and reorder them so they make sense in your sequence of asking them. ex, our oasis divides neuro and M/Skel about 5 pages apart, but I assess those together. Then after you have figured out your "head to toe" assessment, or whatever works good for you, then come up with one or two open ended questions that would elicit a respoonse for all or several questions at once. Eg, Tell me how you manage getting washed, dressed, and fed each day. Who helps you with your laundry, shopping, and getting around to doctor's office? Some questions you will have to ask more detail, like the can they use the phone one, esp if some degree of demential or forgetfulness, or disablity exists. Resp questions, observe the client. If they came 20 ft across the room to answer the door, and are winded when they sit down, does that resolve in 5 - 10 min? If so, I would say dyspneic w walking 20 ft, if not, I ask if they are sob while dressing, at rest, when does it occur, etc. I saw one woman the other day, she remained dyspneic at rest to me, but she did not feel dyspneic or would not have described herself as sob at all. Instead of do you get SOB? Yes. When? etc... ask, tell me about your breathing. You will get faster at the oasis. For recerts, I ONLY ask the MO questions, since in my agency we have to write a nurses note with that. One sup got on my case b/c I didnt write VS. I informed her it was in my notes, and it was NOT a manadatory question and I would not duplicate my documentation. She backed off. Can u check your voicde mail from home before you leave the house? Makes things go a tiny bit faster before I get into office. I know who I need to see right away, so they wont decide to find me just as I am about to get to 1st appt Try to do paperwork at home if you are near, or in a nice quiet library instead of the office. The chit chat, and I am very susceptible to it, is VERY distracting for me. If you need to get out of the office, and people stop you, kindly say I need to leave to see my first pt while the HHA is there or I cant get into the house, please leave me a voice mail and I will get bback to you asap. Give them your VM ext, smile, and leave!

Seeing a few pt's on your way in always helps. Take home your fasting lab pt's charts and early HHA sup visits, and see them on your way in, be sure to let your sup know the day before, so they wont give you the new diabetic who is waiting for you to teach insulin inject. Then, when you get to office, others have left already, there is less hub bub and interuptions. Take lunch after 1:30, and while you eat, call docs offices for routine stuff that doesn't have to be done in the home, don't bother calling them between 12 and 1:30, they put the service on the lines, and its a waste of time. Call all docs before 2:30 on fridays, many close early on friday.

Finally, get a little spiral pad. On the inside flap, write all super important numbers, companies fax, local DME's, pharmacies, community agencies transpo services, home visit podiatrist, HHA scheduler number, etc. Everyday, write down your voice mails, and things you need to remember to do next time u are in the office, as you get them done cross them off. This covers your but when u are trying to remember 25 things at once, when someone say, did you ever reach so and so, I look in the book, and say blah blah blah. Of course I write it in the charts too, but those little things the sup tells u to do, stuff like that, I have a quick ref.

That's just how I do it. MY patients get good care, I admit I have missed an occasional HHA sup, but only to triage to someone who needed me more urgently, and only if there were no other nurses who could see the pt. Nobody is perfect. You have to be as organized as you can possibly be to get through the day. I often work 10 hour days, and as long as they give me this much work, and there are so many demands for the paperwork to be just so, I will continue to put in for that time. We have 2 teams of nurses who are afraid to put in for OT. They make the rest of us look bad, but they are donating their time to the people who will not really appreciate it. as long as they keep doing it for free, we will never have reasonable case loads b/c everyone will think this job can be done in 8 hours, and it aint happening. Its not you its medicare and managed care that is killing the agencies and us.

Just keep doing the best you can. Make suggestions for improving the process. But, don't work for free, PLEASE!!

Excuse all typos, too tired to fix.

live4today, RN · Mar 10, 2002

Hi Wendy and Hoolahan! :)

During the days when I use to work Home Health, I was already working for a couple nursing agencies doing "inpatient care". On occasion, this one Home Health Agency would contact one of the agencies I worked for and ask if they could borrow some of their nurses to help out since they did not have enough nurses to do all the work they had to get done. Not one nurse with my agency wanted to work for what they called the "cheapo agency", so my agency called me up, asked me if I would help them out, and after taking care of "all the particulars... ", I agreed to help them out. The pay was "cheap" as the other nurses said, but I enjoyed Home Health, so I accepted one dollar more per hour than they originally offered.

They called me over and over again to work for them, and even tried to entice me to come work "for" them so they wouldn't have to pay me "hourly" for my services. Ha! Do they think my momma raised a fool or what? :rolleyes: Anyway, I said, No thanks, that I was happy working where I was -- although I didn't mind helping them out on occasion.

No matter how many home health cases I was given for that day, the agency had to pay me $22.00 per hour. Now, if one patient took me two hours to complete, then that's just the way it was. If they hired me for the day, and only used me for four of those eight hours, then they had to pay me for eight hours. Now, granted this was in Southern California back in 1997. Not only did they have to pay me by the hour -- regardless of my patient load or how long it took me to complete -- they also had to pay mileage reimbursement. Needless to say, I was taking them to the bank more than they wanted me to, so they were steady trying to get me to come work for them. No, no. Working for them meant being paid "per case" which was only about $38.00, and they expected that case to be completed in record time so I could squeeze in many more. With the hourly pay, I didn't need to rush, but take what time I needed to do a proper assessment and patient teaching on each assigned case.

They also expected me to wear this pager that drove me nuts, so I turned it off a lot. especially during my lunch hour...yes, lunch hour! I loved doing home health care because I could give each client the time they NEEDED, and none of that time was ever abused by me, either. I dealt with human beings, not cases. Therefore, if I needed to spend more time with one client than the other, it was up to my discretion to do so. I never worked more than eight hours in this respect, unlike that agencies own nurses who were so burnt out trying to do "X" number of cases in a six or eight hour day. I believe in working smart, not hard!

wenron · Mar 11, 2002

Wow Hoolahan, thank you so much for your insight. Your organization is awesome!!! I will try the things you suggest. I think you're right... I should see a few pt's before I even come in. But what I found was that I'd have to stop by the office in the evening and I was again waisting more time because everyone wants to talk to me about pt's. I started going straight home after last pt seen (unless chart needed to be turned in) and it saved me at least an hour. I will also try to make calls at those times. Everything you said made sense. Thank you.

Oh, even you get 10 OT at times? See, I think agencies are losing more money with overtime than they would hiring another nurse and cutting down on pt's. Is this true or am I not getting something?

Wendy

hoolahan, ASN, RN · Mar 11, 2002

Wendy, they are advertising, having open houses, etc, but no one is coming. They are all making a killing working for agencies as staff in hospitals. There is no motivation to have so much paperwork, for such low money, relatively speaking.

Yes, I know exactly what you mean by getting snagged by people in the office, and yes of course I care about my pt's, but I also need to get work done. I forgot to mention, I also have a stash of all the important forms I need at home, which I am sure you already have.

I just bought a date bok that is the size of a credit card. I wrote all my important numbers on the covers, and there is enough room to write in things like a pt telling me they have a doc appt, or come after 2 pm, etc in it. I am hoping that will help me to do my scheduling each week. I still also worry I will miss someone on the schedule.

Renee, lucky you. I think if they start taking agency nurses to help us, they would lose all regular staff to the agency. We have never used agency yet, and I doubt we will in the future. You are lucky, since you didn't have to case manage I assume, during that time. I worked per diem for my agency on and off and it is so much simpler than case managing. I had 10 pt's on my schedule for today. I will probably have to open a new, so that means 5 of the pt's will be given away, so if any f/u is needed I will need to do it for my own visits, plus for the other 5, so essentialy I have 11 pt's of my concern today. That is why I don't get done in 8 hours. I sure wish we could have your help, though Renee!

PS did my final count (went in yesterday to drop off charts) and I have 27 pt's, I guess it just seems like 45!! I discharged 5, also seemed more like 8!

live4today, RN · Mar 12, 2002

All I had to do was discharge a few, admit a few...and those are the ones who took me two to three hours to complete, do wound care and dressing changes, check diabetic clients...monitoring their insulin, calling the doctor when needed, educating clients and family members on what they could do to help with their loved ones care, assessing cardiac and respiratory patients, etc. I did head to toe assessments on those patients that had a lot going on with them, and vital signs on clients with each visit. It was amazing how the vital signs varied from one home health provider to another. :eek: The client load I did take on kept me very busy indeed, but I loved every minute of it! I only had one client die on me while I was assessing her. I was suspicious of her hubby overdosing her, too, but couldn't be proved. I would love to do home health care again. Case management would not be something I could handle, I don't think, but then I've never tried it, so I can't really say if I would enjoy doing that or not.