2 job offers - 1 HH other Home Hospice

[Jarrn]

Hi Everyone,

This is my first post, I have been following the forum for about 5 years and have found it very valuable! Thank you all.

I am an RN with 2 years experience in ER and Infusion nursing. I have relocated to Southern California and have two offers on the table that I need to respond to Monday. I was hoping you may be able to give me some feedback.

The first is home hospice as an RN Case Manager. It is full-time at $42/hr with benefits (crappy benefits, but benefits) and mileage. I have a genuine interest in hospice nursing as I have had 3 family members in hospice the past few years and the nurses were nothing short of extraordinary. I often connect very well with my patients and their family members and feel I can relate to their difficult situations.

My reservation about this position is that I have no real understanding of what the case management aspect is, and the manager did disclose that they are very short staffed and are making a lot of changes within the agency. I see potential to dumped on big time. I also have a feeling that although they claim the orientation is sufficient and they will not cut me loose until I am ready, I suspect I will get tossed to the wolves.

Now, the HH position is part of a hospital system. There is a lot of infusion which I am familiar with and have a child who gets home infusion -- so this is especially dear to me. However it is PPV and I have never worked this way before. There is also the Oasis charting that I keep reading about. The SOC rate is $98 and revisits are $55. Mileage is paid and they pay for travel time but practically at minimum wage -- which seems odd to me. Benefits are better. We are required to maintain at least 25 units per week. On call is two evenings a month and 2 weekend shifts per month are required. There is a beeper pay but she said she did not remember what it is, so I suspect it sucks. She also mentioned something about getting paid $10 to drop off labs.

I am concerned about making a decent wage this way, does the PPV really wind up being worth it after all the time spent charting? I can always pick up an extra patient per day, the manager assures me there is no worry about low census, but the hospice job is hourly and a sure thing as far as income and it is hard not to take that for the peace of mind.

I feel more inclined to go with the home health position as I think my experience is more suitable and maybe save hospice for down the line -- but the PPV has me pretty nervous. Are there more questions I should be asking them? Do those rates sound decent for Southern CA? Also, is the charting significantly different (time-wise) between home health and hospice?

Thanks in advance.

[Jarrn]

I forgot to add that one uses Allscripts and the other McKesson. Not sure if the charting is typically more brutal for one over the other?

[Libby1987]

Northern California rates are higher all around so your starting PPV may be comparable. I wouldn't work for anything other than PPV. It gave me an opportunity to make more money and I wasn't micromanaged for productivity. I made about 12K more than my hourly would have paid as I became more efficient and savvy.

At the 25 unit/week expectation, you're going to make min $1,375/week plus an additional $55 for any extra routine visits you pick up. You'd make $300 more/ week with the hospice gig but trust me, it will come with a lot of after hours out in the field, versus on your couch as you learn to slog through the HH paperwork. Those small struggling companies will likely run the wheels off of you. And when you get a 4pm hospice admission, you can't just hit the essentials, go home and follow up the next day. A knee replacement or CHF discharge is entirely different than the first hospice visit as you can imagine.

The first year in home health is HARD! In every aspect. But it is a marketable skill set that improves with time. You can somewhat easily transfer to hospice but not the other way around. The knowledge base needed for HH is very broad and the expectations of disease mgmt are high. Hospice is a niche where your HH experience will be relevant while you need to learn palliative care and their reimbursement system, as well as you will use many of your HH skills.

The HH job should pay you hourly during orientation, which should be 1 month minimum. The PPV structure will incentivize you to become efficient and effective, which in the end will give you more job satisfaction. You can always find an hourly agency down the road where you can work with less frustration. And/or you can find an agency that allows you a flex schedule and that's where HH becomes what you make it. There is a phenomenon that exists between hourly and PPV staff, those that have never worked PPV often lack what the PPV staff had to learn. It's a hard thing to explain convincingly but 20 years in HH has shown me this to be true.

Also, for a long career in either, make it a goal to find an employer that works hard to maintain territories, and then live in it if you can, that makes a huge difference in job satisfaction.

[Jarrn]

Thank you so very much for the detailed reply.

You basically articulated exactly what my hesitation was with the hospice position, and helped me understand and value the PPV structure a bit more.

At this point in my life I greatly value the flexibility to go home and work on paperwork, or work later and pick up an extra patient IF I want to that day. We moved all the way here from the east coast and I have a pool and beautiful mountain view and it certainly would not be the worst thing on earth to side outside and learn some of this paperwork/OASIS beast.

The clinical supervisor and nurse manager emphasized to me that they group staff into territories and actually gave me two zip codes I would be working in. They did mention thar occasionally I could be asked to pick up a patient outside of my area but that they would make sure it was in the bordering area. The area I would be working in is about 14 miles from my home and NOT in the area of the brutal traffic I have already encountered. The hospice position would be about 20 miles away and I would cover an area that was prob 20-35 miles from home. Considering mileage to the first patient is not covered in either case, this seems like another plus towards the HH position.

They did say the orientation for HH was a month, but it seemed like a lot of it was classroom orientation and only 2 weeks in the field which does not seem like much.

[Libby1987]

That's a short orientation but with your previous experience you should be able to pick up the clincal aspect fairly easily.

Some areas to refresh/learn:

Acute on chronic disease mgmt in the out patient setting i.e. CHF, COPD, DM 2, venous insuffiency..

Current wound mgmt: some basic include protect the peri wound, keep wound base mucous membrane-like moist, debridement treatments, tx and prevention of anti microbial growth,msupportive care.

OASIS assessment: don't fight it. At start of care you are going on a problem finding mission and determining level of assist needed to be safe as well as lowest functionality. If you try to look at the patient from an optimistic standpoint, you won't be justifying the need for amount of care actually needed nor will your agency be properly reimbursed. It's a very big deal and you are partly responsible for determining reimbursement. Also connect the dots, if your patient is a fall risk, they're not going to be independent in anything. That for some reason is a very hard concept for every RN I've worked with. They tend to hate OASIS because not only lengthy (though memorizable) but they keep getting corrections for stating that a patient who is a fall risk can say safely prepare a basic meal... Wrong, they are not independent if they are a fall risk. Always try to think about a loved grandparent, would you tell them the day they're home from the hospital that you'll be back after they bathe, dress and cook for themselves? Why not? That's what the OASIS is asking, it is not askimg what they pull off out of necessity or determination/stubbornness. That is the hardest concept for nurses, avoid that pitfall of a mindset.

[Jarrn]

I felt it was a little short, too. Should I ask for more time before I accept the offer? What is more typical.

Thank you for the info to refresh on, and for the OASIS explanation. That is really helpful. Actually encountered the same with my grandfather and trying to qualify him, so that was a great example that I am familiar with.

[Libby1987]

A month is what we used to provide and then transitioned into working independently. This meant a few weeks of a light load, a full day for the first start of care. Then a start of care and one routine visit..

Now it takes a minimum of 4 mos which means shadow for a month then transition but we aren't getting nurses with recent acute care experience.

What I would ask is if there's a transition period, how long that lasts and what is their timeframe before full productivity.

Regardless of the answers, prepare for boot camp, there is a ton of very broad non intuitive things to learn and you will be slow at first. Documentation, reimbursement. regulations, lingo, focus of care, working with your team, resources, scheduling, time mgmt, coordinating, skills, supply ordering, ancillary contacts, making changes on the fly without getting rattled..

I've loved it but it takes a while to become comfortable and efficient.

[mb55]

Hey!

Which did you end up going with? HH or Hospice?

I'm in the same exact position right now and don't know which one to choose 🙁