Unreasonable expectations/bandaid care

chloesmom · Aug 18, 2005

I am an RN with 5 plus years of hospice nursing. I work for a non-profit hospice which has been in business over 20 years. For the past three years we have been in competition with a for-profit hospice. We have three teams, one being a NH team. Recently we have been told that in order to be productive we will be carrying a case load of 13-15 patient with possibly more in the future. We are now expected to cover our own patient's and any other nurse's on our team who is on vacation or out sick. We do have the help of an part-time LPN. We take on-call one day a week, have a week-end on call nurse and are told we cannot have overtime (even if on-call--have to divvy out patients to prevent overtime). Our work hours are 8am to 5pm--usually never get a lunch-have to answer to pager until 5pm and only get paid if get paged and need to call in or call about patient concerns.We have been told to do ur charting while in the home making visits (computerized) and to make our visits shorter. Recently told we have to keep pager on 24 HOURS A DAY because we might miss a voice mail (pagers keep voice mails regardless of whether on or off) and do not get paid for this. Our hospice use to be considered the best in the area, but due to the constraints and patient load, many of us are getting burned out and patient care is being compromised. Any suggestions or comments. Our supervisor does not take suggestions and the director just gives lip service.

I know what you are talking about.I work for a for profit agency and am ready to quit. Hospice is not what it used to be. In the past, at my old agency in a large city we had a caseload of 10 to 11. I did no more than 4 or five visits a day.I had a small area and drove 50 miles or less a day. We were on call one weekend in a six week period.

At my current agency I do call once or twice a month on the weekends plus once a week. I currently have 16 patients and yesterday I drove 200 miles, 5 visits plus IDT meeting. So far this week I have done 19 visits and have two more days left in which to work. I live in a rural area and left my house a 5:30 am and got home a 7:00 pm. They make no allowances if you have a huge territory. They wont reduce your caseload one bit if you have a large area to cover. Yesterday between two patients it was 77 miles, sometimes its between two patients 100 miles or more.

My manager early on tried having me keep my pager on on my days off and even when I was sick. I told her no. Whats the point of having a day off if you still have to answer patients calls? The turnover is horrible in this agency. I feel like I am just doing home health but my patients all are terminal.

It's just a horrible money game now with hospice. I wish I could give you some advise here other than quitting, but I am so tired now that I can't think straight!

Katillac, RN · Aug 18, 2005

I am an RN with 5 plus years of hospice nursing. I work for a non-profit hospice which has been in business over 20 years. For the past three years we have been in competition with a for-profit hospice. We have three teams, one being a NH team. Recently we have been told that in order to be productive we will be carrying a case load of 13-15 patient with possibly more in the future. We are now expected to cover our own patient's and any other nurse's on our team who is on vacation or out sick. We do have the help of an part-time LPN. We take on-call one day a week, have a week-end on call nurse and are told we cannot have overtime (even if on-call--have to divvy out patients to prevent overtime). Our work hours are 8am to 5pm--usually never get a lunch-have to answer to pager until 5pm and only get paid if get paged and need to call in or call about patient concerns.We have been told to do ur charting while in the home making visits (computerized) and to make our visits shorter. Recently told we have to keep pager on 24 HOURS A DAY because we might miss a voice mail (pagers keep voice mails regardless of whether on or off) and do not get paid for this. Our hospice use to be considered the best in the area, but due to the constraints and patient load, many of us are getting burned out and patient care is being compromised. Any suggestions or comments. Our supervisor does not take suggestions and the director just gives lip service.

Of course it's unreasonable. It's also illegal. Unless you are salaried, you must be paid for the hours you work. You must be paid for all time during which you perform an activity that benefits or could be expected to benefit your employer. That means carrying the pager, including if you do it during lunch or when you are "off duty". Your employer can propose a microscopic rate for being on call or carrying the pager, BUT those hours must be counted at a rate of 1:4 towards overtime, so if you are carrying the pager overnight you accrue an additional four hours a night towards overtime. Additionally, you must have 24 hours off during a seven day period during which you have no work responsibilities, including on call or carrying a pager. It's labor law.

Nurses, both hospice and acute home health care, often post about all the time they spend at their kitchen tables doing documentation. An employer allowing employees to perform work without pay EVEN IF THEY VOLUNTEER is in violation of the law. Many nurses tolerate it, but it sounds as if your hospice is deteriorating quickly. If all of the nurses signed a letter to the administration saying that they knew their employer wanted to comply with labor law and bringing to their attention that the new policy did not comply, would they fire you all? Probably not. . . but on the other hand I've heard of some cutthroat places that would do it. However, when the Labor Department gets wind of it they will owe you all a bunch of back overtime pay, and even more if the Labor Department concludes you were fired for whistle blowing.

You might want to bring to your IDG the "problem" of not having enough time to meet your patients needs in the time that you are given. As the RN case manager in your cases YOU get to decide how much time your patients need. Believe me, Medicare won't want to hear, "I would have liked to have addressed the pain he was having, but I had three more calls to make." Your letter to your administrator could also say, "We are afraid that under the caseloads and time constraints now placed on us we will be in violation of the standards of care that Medicare obliges us to maintain."

Good luck with this. What they are doing makes a mockery of the hospice concept. At the rate they are driving you you are at huge risk for burnout. The caseloads you are describing aren't illegal, but I believe that they are not sustainable long term nor will you be able to deliver appropriate patient care. Once you no longer work for them, I'd call the state, the Labor Department, Medicare, Medicaid, the newspapers and anyone else you can think of. Copy your nurses letter to all of them. Driving staff like this results in huge turnover and massive deficiencies. If they get audited and get "condition level" violations against them it will cost them tens of thousands of dollars. Perhaps then the director will listen. Or perhaps not; the sad thing is that some of these large organizations will just fire a "nonproductive" director and spin the revolving door again.

For the record, my hospice is a not-for-profit. Our target FT caseload is ten, we seldom drive more than 100 miles per day, our On Call reimbursement is generous as are our benefits and we have mostly nurses that have been here for years. My point is that you can have a hospice that treats its patients and staff well and not go broke. The greed that your hospice's corporate management displays is appalling.

fab4fan · Aug 20, 2005

A caseload of 13-15 patients sounds like a dream, to me. I have 22 at the moment.

Katillac, RN · Aug 20, 2005

A caseload of 13-15 patients sounds like a dream, to me. I have 22 at the moment.

Oh, my word! How ever do you do it? Between initial assessment, weekly wound, pain, and follow up assessments, HHA care plans, nursing care plans and their updates, HHA supervisions and recertification documentation and IDG and travel time, not to mention all of the phone calls, how do you even have time to lay your eyes on 22 patients a week? I'm exhausted just thinking about the pace you must have to keep up!

Holy cow, my hat's off to you!

fab4fan · Aug 21, 2005

It's not going particularly well, that's for sure.

Katillac, RN · Aug 22, 2005

It's not going particularly well, that's for sure.

Sounds like you are feeling a little overwhelmed. I wish things were going better for you. My mailbox door is open if you want to PM.

Kat

req_read · Aug 28, 2005

Katillac's response was excellent... darned good advice.

I started & ran a small, hospital-based hospice in a rural community before retiring. I drove some unbelievable distances but my average daily census was never high. I was lucky. I ran it how I wanted, which was to provide the best care possible, create good PR for the hospital and break even financially. I do not know how things have changed in the last 8 years, but if reimbursement is anything like it was back then, I do not see how anyone could get rich running a hospice without cutting every corne, abusing the staff and basically, screwing the public. Yet, from what I read and hear, that seems to be the trend.

Unfortunately, some nurses add to the problem by buying into their administrator's crap. How many times have I heard nurses boast about how many patients they manage and see. It's sort of sad really... bragging about how much abuse one can absorb.

All of nursing seems to be moving in that direction. A lot of us older nurses, who have seen the changes over the years, are terribly saddened by it all. Older nurses with years of invaluable experience get shoved out and burned out. Nurses are considered by administrators to be a perishible commodity... they hire young nurses, burn them up, throw them away and go get new ones. Hospice was one of the last bastions of sanity in that regard. Staff tended to be idealistic and uncommonly devoted to their work and patients. It was also one of the last places where nurses could actually practice nursing. But that all seems to be changing as the money mongers gradually increase their strangle-hold on the business.

Nurses can make a difference though. Tippi, I strongly encourage you to take Katillac's excellent advice. Take some names and kick some butt! If nurses won't stick up for themselves, no one else will.