What is the ideal caseload?

doodlemom · Jun 17, 2006

I think 10-12 is ideal. I've never had an LVN to work with, but I would imagine 18-20. Since the LVN cannot do the weekly assessments, don't you have to do all of the weekly assessments yourself?

req_read · Jun 18, 2006

I agree with doodlemom… 10-12 is ideal… assuming your agency is interested in providing good care.

Because I sell books to hospices I sometimes hear some whining about how our “poor little hospice” is strapped for cash. However, I used to run one myself so am not so easily fooled.

It is not terribly complicated to figure out… hospice is reimbursed on a per diem basis. There are four different categories, but the overwhelming majority of income is for routine daily care. If you know your average daily census you can compute your agency’s approximate monthly income in seconds.

The average routine daily per diem rate is right around $120… give or take depending on your location. The figures hosice4me cited were 15 pts per RN and 25 patients per RN with an LPN.

15 pts generate $54,000 income per month.

25 pts generate $90,000 income per month.

Using doodlemom’s figures (10-12 pts per RN or 18-20 pts per RN with an LPM) we get…

$36,000 to $43,200 generated by 1 RN and

$64,800 to $72,000 generated per RN/LPN team.

Now think about your caseloads… how many of those patients are requiring expensive treatments or meds? Counter-balance that with the money being raised by donations and your volunteers. See what I mean? If you want to make money don’t work for a hospice, own one.

But my main point is this… 10-12 pts per RN to provide good care… more than that to make good money.

Hospice4me · Jun 18, 2006

I am glad to hear that I am not the only one that thinks 10-12 is the ideal caseload.

I posted the question to get some confirmation that our caseloads are too high. I have had as many as 23 patients by myself! As far as the question of weekly assessments, our state regs say that a LPN cannot make assessments, only gather information and report to the RN; therefore, the LPN may only make a visit every other week. The RN must make a full assessment everyother week and is responsible for assessments on any pt with an acute change. What that means is, generally, the RN visits half the caseload one week and half the caseload the next. She is responsible for all recerts, careplanning, etc. So, if she has a 24 caseload, she will be responsible for 12 assessments (plus any additional acute change visits,deaths etc) but be responsible for 24 patient's charts. Personally, I would rather have 23 patients myself. Not that I have any problem with LPNs, I just feel that I don't know all that is going on with my patients and it is easy miss important careplan changes if you do not have an LPN that communicates well with you.

aimeee, BSN, RN · Jun 19, 2006

In our hospice we figure each patient will routinely be visited twice a week and more if needed to manage their symptoms. 5-6 visits per day is what is reasonable when you spend enough time with the patients to do your job well and add in prep time, windshield time, charting time, collaboration with other team members and physicians, etc. Half a day is spent in IDT and there is often another meeting for inservice or something during the week. Therefore 12 is the maximum caseload you can carry of a good mix and not cut corners or go into overtime.

We tried using LPN's a few years ago to share the caseloads with the RN's and found it compromised continuity too much. Even if they communicate very well, there is just no substitute for seeing the patient/family yourself to pick up on those subtle changes. It also interferes with the process of building a relationship with the patient/family when their length of stay is only days to weeks.

req_read · Jun 19, 2006

Reading these posts is disturbing. Hospice has always been subject to abuse by virtue of the way it is set up. Much of how well it works depends on the integrity of the agency.

Yes… there are minimum requirements. Then again, most patients & families need more than minimum requirements. When caseloads are so heavy that the RN can do little more than make an absolute minimum of visits, what kind of service is that? I mean, if you see each patient once every other week, how much time is spent with that patient/family… talking, listening, being with, supporting, teaching? Does anyone do that any more? Or do agencies just not give nurses time?

I observed something of this rush to “productivity” after I quit hospice and got a private duty job. The wife was dying of brain mets and the husband had Alzheimer’s. Nothing was in place at first, but I got hospice in and was surprised to see how it was handled. A nurse whizzed through once a week in the proverbial cloud of dust. “How’s it going… here’s some chux & wipes… see ya next week.” Zoom… off she went… hot on the trail to make another “assessment.” By the time the old gal died we had enough extra chux & wipes to hold a garage sale.

From reading these posts I get the impression that is pretty much what hospice is becoming. Which makes it all the more important for the patient/family to have access to a book on dying process. Then the RN can get in the requisite number of visits and not have to slow down.

req_read · Jun 19, 2006

aimeee,

That is very encouraging.

Justhere, BSN, RN · Jun 19, 2006

Ideal case load would be being able to see all your patients and give them the care they deserve.

My father-in-law was in hospice 3 years ago. We got great care until the week he died. The first visit the nurses made he requested that when he died that the hospice nurse be there to pronounce his death because he didn't like the coroner in the small town where he lived and was gonna go to the funeral home in the neighboring town because the coroner also ran the funeral home. They promised that that would not be a problem at all, that when the time came they would be there. He had an aid that came out at night to stay with him from 11 to 7, she was wonderful. But the night he passed, we called the nurse to tell her we thought he was going because he was chain stoke breathing. They said they would stop by and check on him because another nurse (not his nurse) was in another town close checking on another patient. At 1030 I unofficially pronounced my father-in-laws death, I saw him take a haphazzard breath and I got my stethoscope heard a couple of beats of his heart then it was silence. We called the nurse, who told us she would not be coming to pronounce him because the other patient was dying and the coroner would have to come pronounce him. Then she called the aid and told her not to come because he had died (we found this out when the aid came to his funeral). My mother-in-law and I cleaned him up and then called the coroner, which broke her heart because she had promised him that she would not let that man touch him.

At the end when we need the hospice nurse the most she was not there.

Hospice4me · Jun 19, 2006

Unfortunately, at a caseload of 15 or more it is all the RN can do the make the minimum visits. Heaven forbid someone is not doing well and needs extra attention. I feel like the all need extra attention!! Req Read you are right that it seems like they come through in a cloud of dust.......run in, run out. Even our most caring nurses given minimal attention to the "stable" patients and have to prioritize just to meet basic needs. I am trying to make it clear to our company that patient care suffers. We have grown not by advertising but by word or mouth because of good care; however, now I am afraid that "word of mouth" will be negative instead of positive. When you have these caseloads, even the best nurse can't hide the fact that she is pressed to go onto the next visit. I had a patient say "I liked it better when you could spend more time with me" I was heart broken!!! Now I am on the warpath so to speak and will not sit back and let this continue without a fight. Anyone who has any opinions on staffing and caseloads please post for me. I will be taking quotes from them and putting them together with comments from our nurses to forward to our home office. Thanks everyone!

Hospice4me · Jun 19, 2006

Penny4URthoughts......Fortunately, we do not have that problem. Our policy is that EVERY death or impending death requires the presence of the RN/RN on-call. We also provide 200-400 hours of continuous time care per month for dying patients. I am thankful that the care of our dying patients is truly a priority. Unfortunately, because the nurses are so overwhelmed, the "stable" patients do not get the time they deserve. Anyway, I am truly sorry that you had such an awful experience. Thankfully, this is not the norm for us.

doodlemom · Jun 19, 2006

Ideal case load would be being able to see all your patients and give them the care they deserve.
My father-in-law was in hospice 3 years ago. We got great care until the week he died. The first visit the nurses made he requested that when he died that the hospice nurse be there to pronounce his death because he didn't like the coroner in the small town where he lived and was gonna go to the funeral home in the neighboring town because the coroner also ran the funeral home. They promised that that would not be a problem at all, that when the time came they would be there. He had an aid that came out at night to stay with him from 11 to 7, she was wonderful. But the night he passed, we called the nurse to tell her we thought he was going because he was chain stoke breathing. They said they would stop by and check on him because another nurse (not his nurse) was in another town close checking on another patient. At 1030 I unofficially pronounced my father-in-laws death, I saw him take a haphazzard breath and I got my stethoscope heard a couple of beats of his heart then it was silence. We called the nurse, who told us she would not be coming to pronounce him because the other patient was dying and the coroner would have to come pronounce him. Then she called the aid and told her not to come because he had died (we found this out when the aid came to his funeral). My mother-in-law and I cleaned him up and then called the coroner, which broke her heart because she had promised him that she would not let that man touch him.
At the end when we need the hospice nurse the most she was not there.

Wow! This is horrible! We are required to attend all of our deaths (and this is how it should be.) If we have 2 at one time then we send another nurse out. This is unacceptable and I have never heard of an agency operating in this way. I am so sorry that your family had to go through with this. I would definitely file a complaint.

req_read · Jun 20, 2006

I actually put more emphasis on teaching than trying to actually be there (at the time of death.) My hospice was in a very rural area… and when I say “rural” I mean I sometimes drove over 100 miles one way. People who reside that far out tend to be self-reliant… especially when they get good teaching & support. What I considered my greatest achievements were to get the family to the point where they might not call me at all until after the death… then call and say, “We are fine. Everything went fine. Everyone is here and we are having sort of a ceremony. Take your time.”

But getting to that point takes time and teaching beforehand. With some of the caseloads y’all are talking about you could provide little if any preparation, teaching, building of trust… the things it takes to get your families comfortable. The best you could hope for is just putting out fires… if you even have time to do that.

I think it is wonderful for hospice nurses to compare notes, stick together… and stand up to greedy administrators!