Looking for a hospice caseload acuity tool

curiousauntie · Nov 13, 2010

Wow. I wish my company would think like that. One of our nurses has most of her patients in 2 different nursing/assisted living facilities, 5 miles apart. We have the same number of patients, all of mine are at home, and I drive at least 75 to 100 miles a day. I get questioned on why I routinely do 1 visit a week for most of my patients while that nurse does 2 or 3. The driving time is rarely taken into account. When I mention it, I get asked if I need help with time management. My patients that need more frequent visits get them, but it also means overtime at times. So, I get frustrated and right now am actively looking for another job.

IMHO, look at how many visits are needed per patient. If patient A needs 1/week, but patient B needs 4 or 5/week, due to wounds, IVs or the like, that patient should count as at least 3 or 4 one time a week patients...other than that, I don't really have any ideas, but really wanted comment on how more companies should be doing just what yours is doing. It would help prevent some of the burnout that happens with us.

caliotter3 · Nov 13, 2010

At least your company is addressing this. That puts them so far above the rest of the bunch.

tewdles, RN · Nov 17, 2010

We don't use an acuity tool for the field. We use the recommended ratios of 1.0 FTE CM/12-15 pt and it is up to the clinical management team to fine tune case loads to accommodate acuity and distance. The case nurses have frequent conversations with the manager(s) about the challenges and anticipated issues with their patients. It is the clinical manager's job to help those things get done that the case nurse cannot do...same with the MSWs and chaplains and the managers.

I think tools are fine...to a point. Beyond that point there must be a hospice professional making informed decisions about delivery of care.

sherpa · Mar 24, 2011

Hi,

I don't know about a specific acuity tool, however I can describe my day and why I am working at least 50-60 hours every week?

First, I love my hospice job, I am an rn case manager, in a growing office. We have had difficulty finding and keeping dedicated people, because, well, it's hospice and a very stressful job. It's not for everyone. My immediate boss is the rock we all stand on. She is so stressed, as she is trying to make sure our people all get taken care of, and take care of a growing staff, which currently is short by a 1/2 dozen people. Not easy.

That being said, my caseload varies between 16-20 people, plus recerts (I may see other case managers patients to do recertification visits, we split those evenly.) Our standard is to see everyone twice a week, and we do our own admissions, although we have a part time "admission nurse" but she is rarely available to us-and the families need us when they need us...sometimes our patients come in at night, sometimes they come on in the middle of the day and it's not scheduled.

I have been seeing 8 patients a day, plus meetings, family calls, and idt, admits, and recerts. This is not manageable. I say this because we have computers, we are supposed to document at bedside with, and there is about 8-10 forms for each patient plus a narrative note to be filled in on the computer for every patient, and it takes upwards of 10-40 minutes just to do that and put your md orders into computer, medication reconciliation, etc.

Also, when there is a patient doing poorly, well scratch everything I just said, and I am with the patient and family and md all day, coordinating social worker, chaplain, volunteer, and hospice aid support around me. I am not a one man team, and our team works awesome together.

So, I have patients in three locations, about 31 miles and 6 miles from each other. So let's do the math. I spend an hour plus on the road, so that knocks my "working" time to 7 hours. Then I spend at least another hour on the phone ordering equipment, giving/getting report, and organizing myself for the day. 6 hours. Spend another 1/2 to an hour on the phone with family members who need updates, and you are at 5 hours. Now I have a facility meeting today, which can run another 1.5 hours. I'm left with 3.5 hours. Now, providing I don't have a very sick patient, (which with 18+ patients is very unusual), and I don't get an admission, and the facility nurses don't collaborate with me, and I don't have last weeks or yesturday's work to catch up on, I go see my patients. The vital signs, reading the chart, and documenting takes up the better part of 45 minutes. That leaves 2.75 hours for 7 more patients.

Maybe I can see four more, then I am in overtime. And half of them by that time will have family visiting them, which means I'll be hugging family and talking to them about their nana's illness, which means maybe I'll see two.

So I am ending my day, leaving two or more patients unseen, and it's 7 pm. Now I have to go and print all my documentation and fill the charts, and make sure my care plans are up to date based on the collaboration with staff, mds, and families and patients that went on during the day. These people are sick, their acuity and their needs change in the blink of an eye.

So most of the nurses in my office, they use their "day off" to do their work, if you scheduled some kind of family function or had your kids basketball game, well, 7 out of 10 times you are not going to be there. Sometimes, my boss will call me at 3 pm, and tell me there's an admission at 4, or possibly later. An admission takes 5 to 8 hours to complete.

I love Hospice, but it is truly a broken system. The point of hospice was to be able to have the time to spend with patients and families, to be able to provide comfort care, and to be an extra hand to the nurses caring for these patients. Now we have become a medical model, governed by the same medicare/medicaid laws that have regular nursing overworked and frazzled. It doesn't work. I would like to see whoever makes the budgeting decisions for medicare or for the staffing of the hospice agency try to do any person's job in my office for a week.

Oh, and btw, you get weekends off, unless you decide to take on-call. But people still call you all weekend, your hospice aids who might be on for the weekend, mds, families, and on-call nurses who aren't familiar with your patients. Oh, and btw also, I am a 40 hour salaried nurse. I have never worked just "40" hours since I started. It cannot be done. It cannot be done in 50, sometimes 60. I carry work over from the week before, nearly every week. This week, I have lost four patients. I am still working on last Tuesday's work. Sometimes, it feels you will never catch up.

All the while, I get emails all day long from our auditors telling me I haven't put this one's orders in, or I need to redo this or that, as documentation has to be absolutely perfect or medicare will not pay the bill.

It's a hard, hard job. But when I get to spend the time holding a patient's hand. Hugging and supporting the wife who is falling to pieces losing her husband, and knowing that you did everything you could to make that person's passing a beautiful, peaceful experience surrounded by love, then none of the other stuff matters. I only wish, I could be home when I'm home, and spend more time with my family, as my family life has suffered dramatically, so I cannot see myself in this position for a long time. My office seems to have a major turnover, nobody stays for long term, we only have one nurse who has been there for a long time, out of 7.

Hospice needs to be looked at, it is only getting worse, the level of work vs the ability to do it, it is humanly impossible, even on my best week. Good luck to all who get into this business, and I hope the wind is always at your back, and your caseload never exceeds 12. :cool:

curiousauntie · Mar 27, 2011

Sherpa,

No wonder your office has major turnover! I worked like that for about 2 years, and the past 4 months it has gotten dramatically better. How? My 2 bosses were fired and we got a fantastic "temp" boss, then the permanent boss started, and between the 2 of them they fought to get more staff, better staffing ratios, better aides and better education for all the staff. I have always loved hospice, but often hated my job. At least I am an hourly employee. I did get overtime. I would NEVER work in that kind of environment for salary. You cannot effectively monitor patients and give the families the emotional support they need and deserve and be able to justify the loss of YOUR family time and emotional health. 2 years ago we were supposed to keep a case load of 15, and last year it increased to 18-20, and during that time I usually had 20 plus. I was working 50-60 hours a week and was so on the edge of burn out I was ready to quit, had resumes out and had interviewed for a new job when the higher ups finally saw that the bosses were completely ineffective.

Our new boss believes that you should never work more than 40 hours...she won't and would never expect us to. She cut our case loads to 14 and as she feels you must hire staff to grow the census (not grow the census then look for staff) with the new hires I now have 11.

My family suffered during the past 2 years due to my not being there and my exhaustion when I was. Do yourself and your family a favor...find a job with a boss that appreciates you and knows that working you to death is not a way to treat good employees!

AtlantaRN, RN · Mar 27, 2011

we have some families that will just want a nursing visit every 2 weeks, and others that don't need it=but will insist a patient have an aide 5x/week in the morning, and a nurse 5x/week in the afternoon (that isn't declining)....

i like the idea of an acuity tool....our place just counts the number of patients and doesn't look at acuity.... although sometimes the patients are great, but the families are a challenge.

tewdles, RN · Mar 31, 2011

When families are requesting unreasonable nursing visits because they are not able to complete the daily and ongoing care we are VERY direct about the need for either other in-home caregivers or placement in a facility. We will arrange an urgent respite, if necessary, to give them a few days to make appropriate arrangements. Most hospices CANNOT afford to set dangerous precedents of daily nursing visits simply to reassure the family...there are other, less expensive, and possibly more effective ways to provide that support. I certainly am aware that we have the occasional VIP patient for whom the agency execs may want that sort of attention. However, those are the very people who can generally afford addtional supportive care and we do not hesitate to be very clear about our role and availability.

I don't intend to sound "hard nosed" but if you allow a few demanding people to misuse the professional staff in terms of frequency of visits it has the potential to create dangerous staffing patterns for the other patients on service...and THAT is not acceptable.

nursetammyp · Aug 9, 2011

I just joined this group but I have been charged with working on an acuity tool/scale for our hospice case managers, just like you described that you were looking for. Have you developed a tool. Would you be willing to share it or share resources that you used?

I am the staff development/PI coordinator for a moderate size hospice.

thanks

jschut, BSN, RN · Aug 10, 2011

Hi,
I don't know about a specific acuity tool, however I can describe my day and why I am working at least 50-60 hours every week?
First, I love my hospice job, I am an rn case manager, in a growing office. We have had difficulty finding and keeping dedicated people, because, well, it's hospice and a very stressful job. It's not for everyone. My immediate boss is the rock we all stand on. She is so stressed, as she is trying to make sure our people all get taken care of, and take care of a growing staff, which currently is short by a 1/2 dozen people. Not easy.
That being said, my caseload varies between 16-20 people, plus recerts (I may see other case managers patients to do recertification visits, we split those evenly.) Our standard is to see everyone twice a week, and we do our own admissions, although we have a part time "admission nurse" but she is rarely available to us-and the families need us when they need us...sometimes our patients come in at night, sometimes they come on in the middle of the day and it's not scheduled.
I have been seeing 8 patients a day, plus meetings, family calls, and idt, admits, and recerts. This is not manageable. I say this because we have computers, we are supposed to document at bedside with, and there is about 8-10 forms for each patient plus a narrative note to be filled in on the computer for every patient, and it takes upwards of 10-40 minutes just to do that and put your md orders into computer, medication reconciliation, etc.
Also, when there is a patient doing poorly, well scratch everything I just said, and I am with the patient and family and md all day, coordinating social worker, chaplain, volunteer, and hospice aid support around me. I am not a one man team, and our team works awesome together.
So, I have patients in three locations, about 31 miles and 6 miles from each other. So let's do the math. I spend an hour plus on the road, so that knocks my "working" time to 7 hours. Then I spend at least another hour on the phone ordering equipment, giving/getting report, and organizing myself for the day. 6 hours. Spend another 1/2 to an hour on the phone with family members who need updates, and you are at 5 hours. Now I have a facility meeting today, which can run another 1.5 hours. I'm left with 3.5 hours. Now, providing I don't have a very sick patient, (which with 18+ patients is very unusual), and I don't get an admission, and the facility nurses don't collaborate with me, and I don't have last weeks or yesturday's work to catch up on, I go see my patients. The vital signs, reading the chart, and documenting takes up the better part of 45 minutes. That leaves 2.75 hours for 7 more patients.
Maybe I can see four more, then I am in overtime. And half of them by that time will have family visiting them, which means I'll be hugging family and talking to them about their nana's illness, which means maybe I'll see two.
So I am ending my day, leaving two or more patients unseen, and it's 7 pm. Now I have to go and print all my documentation and fill the charts, and make sure my care plans are up to date based on the collaboration with staff, mds, and families and patients that went on during the day. These people are sick, their acuity and their needs change in the blink of an eye.
So most of the nurses in my office, they use their "day off" to do their work, if you scheduled some kind of family function or had your kids basketball game, well, 7 out of 10 times you are not going to be there. Sometimes, my boss will call me at 3 pm, and tell me there's an admission at 4, or possibly later. An admission takes 5 to 8 hours to complete.
I love Hospice, but it is truly a broken system. The point of hospice was to be able to have the time to spend with patients and families, to be able to provide comfort care, and to be an extra hand to the nurses caring for these patients. Now we have become a medical model, governed by the same medicare/medicaid laws that have regular nursing overworked and frazzled. It doesn't work. I would like to see whoever makes the budgeting decisions for medicare or for the staffing of the hospice agency try to do any person's job in my office for a week.
Oh, and btw, you get weekends off, unless you decide to take on-call. But people still call you all weekend, your hospice aids who might be on for the weekend, mds, families, and on-call nurses who aren't familiar with your patients. Oh, and btw also, I am a 40 hour salaried nurse. I have never worked just "40" hours since I started. It cannot be done. It cannot be done in 50, sometimes 60. I carry work over from the week before, nearly every week. This week, I have lost four patients. I am still working on last Tuesday's work. Sometimes, it feels you will never catch up.
All the while, I get emails all day long from our auditors telling me I haven't put this one's orders in, or I need to redo this or that, as documentation has to be absolutely perfect or medicare will not pay the bill.
It's a hard, hard job. But when I get to spend the time holding a patient's hand. Hugging and supporting the wife who is falling to pieces losing her husband, and knowing that you did everything you could to make that person's passing a beautiful, peaceful experience surrounded by love, then none of the other stuff matters. I only wish, I could be home when I'm home, and spend more time with my family, as my family life has suffered dramatically, so I cannot see myself in this position for a long time. My office seems to have a major turnover, nobody stays for long term, we only have one nurse who has been there for a long time, out of 7.
Hospice needs to be looked at, it is only getting worse, the level of work vs the ability to do it, it is humanly impossible, even on my best week. Good luck to all who get into this business, and I hope the wind is always at your back, and your caseload never exceeds 12.

Wow... do you work in Indiana by chance? You just described me! :)

comfortcare · Dec 10, 2011

I work for a hospice agency in Maryland. During a recent meeting reviewing employee satisfaction results, we brought up the various issues identified so nicely in Sherpa's note. Obviously, this is a nationwide (international??) issue in hospice homecare. Of course, our director of patient care charged us with finding the solutions and tools. I would very much like to find an acuity tool we could use to document all the time we spend over and above the 40 hours for which we are paid--no overtime just salaried.