Major differences in hospice RN Casemanager and Admissions RN

tewdles, RN · Oct 22, 2009

Hi I am looking for some information regarding the major differences between the admissions nurse and RN casemanager in hospice care. I am looking for job duties, expectations of on call hours and duties and pay scale differences. Also any feedback on why you prefer one over the other one would be great...thanks for your help!!

First off, not all hospices have "admission nurses". Some hospices use the case managers for all care; admissions, case management, triage, on call visits, everything.

Typically, in the USA, hospice admission nurses complete admission visits as their primary role. They may occasionally be asked to cover a routine or prn visit, but that would only occur if their admission burden was low. The admission process in this scenario is focused on an immediate plan of care for urgent and immediate needs of the patient and family. That admission may take anywhere from 1-3 hours to complete (including the paperwork) dependent upon the complexity of the care and the symptom status of the patient. Admission nurses generally work hours between 8 am and 8 pm. Admission nurses may or may not participate in the oncall rotation of the hospice. There is a pay differential between case nurses and admission nurses for some hospices but not for all. My experience is that if there is a difference, the case nurses make more money in hospice and just the opposite in home care. Admission nurses do not have ongoing relationships with patients or families. The duties of the admission nurse include obtaining the basic information for delivery of care...DNR status, religious preference, identification of who will survive this patient for bereavement purposes, what if any arrangements have been made for funerals, verification of terminal diagnosis and any co-morbidities, current medication list (EVERYTHING the patient takes right down to multivitamis and herbal remedies), current functional status of pt, etc. From this info, plus the physical and environmental assessments the admission nurse recommends an initial plan of care to the managing physician and to the patient. In this type of practice the RN case nurse should visit within 48 hours to establish a more comprehensive, long term plan of care.

The case nurse is responsible for the daily care of the patient. That does not mean that he/she does all the visits. Rather, it means that all MD orders, all identified needs, all POC changes, ANYTHING that is changing for the patient is carried out, accomplished, or initiated in an extremely timely fashion. So...if the patient needs the MSW to write a letter for the spouse's employer, it is the responsibility of the case nurse to insure that the exact need is communicated to the MSW in a timely fashion AND to insure that the task is completed in a timely manner. The case nurse is the patient advocate within the hospice system. The case nurse insures that the patient and the patient family have a loud and proud voice in the team process. Case nurses make sure that if the patient has a preference about some aspect of hospice care, that their preference is honored in the plan of care. The case nurses are often the discipline who has the greatest contact with the patient outside of the HHAs. The ability to develop trusting relationships with patients, their families, facility staff, and referring physicians is an important skill for case nurses. Case nurses are the glue that holds the individual POCs together both for the team and for the patients and families.

I personally prefer to case manage. That is because I enjoy the development of the interpersonal relationship that is so crucial to hospice care delivery. As an admission nurse I simply saw the vast majority of the people one time, just to get them started. That was not as fulfilling for me. As a case nurse I have worked for organizations that utilize admission nurses and those that do not. I really don't mind completing admissions for persons that will be on my case load...it is nice to begin building that relationship right from the start. It is, however, easier to maintain a sane schedule when not performing admissions (IMO).

How a hospice agency approaches after hours and weekend oncall is a really big deal for case nurses. I have worked for an agency which required up to 150 hours per month of oncall per case nurse. That worked out to 10, 15 hour shifts per month. That expectation is exhausting for the full time case nurse. Unlike home care, hospice patients commonly require nursing intervention after hours. Hospice patients are not referred to urgent care or ERs except in rare circumstances. We are their care resource for pretty much anything and everything. Additionally, we report to the bedside if the patient dies, unless they are in a medical setting that can pronounce the death and the family declines our presence. So if you are oncall for a busy hospice you will very likely not be in bed sleeping most of those night shifts.

Good luck.

thoughton · Oct 23, 2009

Thanks for taking the time to answer me, this was very helpful in understanding the specific roles and on call worked. I will have to take all of this into consideration.

brettara · Nov 21, 2010

Applying for An RN Hospice Admission position in massachusetts ? can anyone tell me what the hourly rate is going now a days. I have been a nurse for 12 years and have an interview tomorrow. Please someone reply :nurse: