Home hospice CM questions

dosamigos76, RN · Aug 16, 2022

Ask about on call and admissions nurse?

CrochetNurse154 · Aug 17, 2022

Congrats on landing a second interview! I found hospice to be an extremely rewarding specialty. So, onward to the questions:

1) Yes, this is completely reasonable. IMO, home hospice should be no more than 15 patients per nurse. I will say, this also depends on territory. Since you're field-based, the time you travel in between patients can make or break your day. Ask about how large an area you're expected to cover. I've worked at several agencies, and the larger the agency, typically the smaller the area you have to cover. At one agency, I only covered one county in my state, but that drive from one side of the county to the other took about an hour one way. Thankfully there were 3 of us that covered that county, and we basically made 3 territories in the county for us to each cover. Another agency had me covering patients in 6 counties (this was about 25 patients using RN/LPN teams), and to go from one patient to another could take 90 mins or more.

2) To give you an idea of your workday, I would say at least 75% of your day as a hospice CM is spent doing patient care. As the case manager, your job is to visit those patients weekly or as required- some patients may need 2-3x weekly visits, or even daily if they're actively dying. For a caseload of 12-15, that usually ends up being around 20-25 visits a week, sometimes less. Those visits consist of nursing assessment and vitals, interventions for any issues and education to the family regarding what is happening to their loved one. You'll also be doing things like post mortem care during death visits. I’ve also managed NG tubes, PEG tubes, PCA pumps, Pleurex drains and an array of other lines and tubes. The other 25% of your day is spent coordinating care. This could be returning calls from other patients/families for care questions, following up on new orders needed, talking to your interdisciplinary team, etc. Challenges were dealing with things like road construction, bad weather/roads, etc. but also included the same types of things as you see in the inpt setting: needy families, those that exaggerate or downplay their symptoms, high acuity vs stable Mabels.

3) Lesson 1- do NOT get in the habit of taking charting home! Don't even think about it! I promise it's an awful cycle to get stuck in and it leads to burnout, so avoid it at all costs. It always sounds nice to just take it home and sit on your couch in your jammies finishing things up, but when you get in the cycle, it's near impossible to break.

Prepare and pre plan as much as able. This means grouping patients together that are in the same areas on the same day. If you’re going into a SNF and have 2 or 3 residents to see, see them all at the same time. Don’t backtrack if you can help it, because drive time eats away at your day. Carry a trunk bin of supplies you may need on the fly when out on the road, because you don’t just have a supply room down the hallway ? . If you’re an hour away from the office and don’t have what you need… it’s a pain LOL. I always carried basic wound care supplies, incontinence supplies and barrier cream, Foley kits, irrigation supplies, and any supplies that my specific patients needed. So if they had a pleurex drain for example, I’d keep a spare container in my car just in case. PCA? I kept extra tegaderm, central line dressing supplies etc.

Also be ready to be flexible. You don’t “clock in” and “clock out” in the same sense of how you would at a facility. Some days I might not see my first patient until 10am, other times I was seeing my first one at 7:30am. Same thing with ending your day. You might see 6 of those stable Mabels at 1 SNF, and be done in < 6hr, other days you might see 4 patients and each visit might last 2 hrs apiece. Finally, give yourself some grace to learn what hospice is all about. You easily need to give yourself a year to really understand what you’re doing and the why and how behind it.

4) A few questions I would ask: are you picking up on call at all or is there a dedicated on call team to cover after hours? Is there an admissions nurse or are you doing your own admissions? If you have to do an admit, who covers your visits for the day (another RN, an LPN, are they just getting rescheduled to a different day?) Is this salaried or hourly? Both have their pros and cons.

I hope my novel was helpful! Again, congrats and hopefully welcome to the hospice club! Let me know if you have more questions or need clarification on anything ?

NightNerd, MSN, RN · Aug 17, 2022

@dosamigos76 thanks, I didn't think about admissions at first, I'm sure that can be time consuming!

@CrochetNurse154 thank you for all of the great details! That is a lot of good stuff to know and consider and will definitely be in mind for the second interview. I have enjoyed working inpatient hospice in the past and am interested to see what this new endeavor could bring.

vampiregirl, BSN, RN · Sep 5, 2022

Home hospice nursing is a really rewarding area of nursing. Finding a good agency makes a world of difference!

CrochetNurse154 gave you fantastic recommendations. My day is typically similar to hers. If I have charting or phone calls to complete at home, I have a designated "work" area to complete these tasks. Avoiding the creep of charting taking over the evening is essential to mental health.

I transitioned from home hospice into inpatient back into home hospice. The work flow may be a little different but I think my inpatient experience was invaluable because I'm used to having to manage severe symptoms when they occur. I'm comfortable asking for the appropriate orders.

Some of the differences in home hospice is the types of education we provide. Instead of implementing interventions, we need to be able to effectively teach caregivers how to identify non-verbal signs of discomfort and how to implement interventions (medication and non-pharmacological interventions). Some caregivers will not know how to provide bed bound care or assist patients with ADLS. I did education regarding caregiver/ family self-care in inpatient but this education is more extensive in the home setting. Figuring out how each caregiver learns best and how to best help them remember things is important - some caregivers prefer to write out things themselves to help them remember, other caregivers appreciate when I write out things for them and review it with them.

Best of luck to you!