What is the ideal caseload?

aimeee, BSN, RN · Jun 20, 2006

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.

I agree. We would never even THINK of telling someone we were not coming and to call the coroner. We would find a way to get SOMEBODY there.

I do want to say though that there are other reasons besides greed to have high caseloads. Sometimes a combination of census growth and staff attrition can result in understaffing. Recruiting new nurses and training them properly takes time so there may be periods when staffing levels are not ideal. However, there should be evidence that the hospice IS taking action to maintain caseloads at a manageable level and if your caseload is high nobody should be chastising you for having overtime.

Hospice4me · Jun 20, 2006

We are on salary, so we do not get overtime. Of course, that means that all of the nurses are working over 40 for no additional money. However, because we are salaried, it allows us to be very flexible with our time (when our caseloads are at the right level). Part of our problem is growth and we have had some nurses go to home health/other hospices in management positions or QI/QA positions that paid considerably more money. Like you said it takes time to recruit, hire, and train. The bad thing is, we have been in this cycle for 2 years. When we finally see light at the end of the tunnel, someone resigns! Very frustrating for us left to take on extra patients!

req_read · Jun 20, 2006

Yes, not all administrators are greedy. Some are simply inept.

One of the difficulties inherent to these threads & posts is we get a very vague picture of what is going on when someone asks a question, and so responses must necessarily be general in scope.

For example: If caseloads are becoming unmanageable secondary to growth, what is driving that growth? Was growth sought or did it just sort of happen out of the blue? Is someone recruiting physicians to refer to that agency? If so, are those recruitment efforts scaled down when there is not sufficient staff? Or does recruitment forge ahead despite knowing staff is insufficient? Are there other hospices in town? Or is this the only one. If there are other hospices, are you referring clients to them when you are swamped or keeping them all… knowing you cannot provide good care? Details such as these are seldom given.

In a hospice the nurses (plus aides, SW etc.) take care of the patients. They tend, by nature and training, to be fairly good at what they do. It is the administration’s job to provide the infrastructure that makes it possible for the nurses (et al) to do their jobs. When breakdowns occur in this arrangement it is most often the fault of administration. In other words, there are more good nurses than there are good administrators.

I once said to an assistant administrator, “You know, they say that good help is hard to find… and that is true… good help is hard to fine. But I’ll tell you what, finding good managers is darn near impossible.” He did not respond.

Now, you can argue that is due to greed, or to lack of foresight, or lack of a willingness to take risks or just plain old ineptitude. But if your hospice is growing (and everyone knows it) it is the administration’s responsibility to be aware of that, to chart the rate of growth, to anticipate, plan for and put solutions in place BEFORE you are no longer capable of providing good care.

The salary idea could... potentially... be one innovative solution. But only if administration is willing to keep paying those salaries when census is low. In this situation it sounds like things always just seem to work out so that census is never low, nurses never get a breather... and oh yes, by the way, income is maximised. And isn't it funny that this "cycle" is now two years old with no end in sight.

Sometimes you have to stop examining every tree, stand back and look at the whole forest.

Hospice4me · Jun 21, 2006

Much of what you say is true. We do continue to take on additional patients without considering the staffing. We have asked many times at what point they would stop admitting. Unfortunately, the way we are set up, the department admitting is separate from the side taking care of the patients. The admission side has the attitude that it is our problem not theirs to make sure we are staffed. Fortunately, we are finally getting the chance to voice our opinions. Finally, they are realizing that RETENTION is horrible here and there must be a reason AND something must be done NOW! Yes, the salaries will continue once we are staffed. We have placed comment cards out for everyone so that they can give thier comments or concerns and we are forwarding them to our CEO. Unfortunately for our Administrator, the tools needed to hire and keep nurses have not been given up until now. Our Administrator, however, is not the sit back and take it kind of person. She has said enough is enough. She is tired of carrying caseloads in addition to her duties, she is tired of hiring and training good nurse only to lose them to other agencies who offer better pay, caseloads, benefits etc. We have at least 10 other Hospices in the area, so YES competition is very stiff for any experienced hospice nurse. Also, the administrator was given permission to hire MORE nurses than we need because of projected growth, but the competion is so great that we have been unable to hire enough nurses. That is why they are increasing our pay above the average to help recruit. Anyway, with some luck we will be staffed soon. Decreasing our standard caseload from 15 to 12 is our next project!! Thanks for all your comments.

req_read · Jun 21, 2006

Hospice4me,

It sounds like you may be making some real progress… let’s hope so anyway.

FYI: The NHPCO website (in the What’s New section) has a link to a MedPac report on Medicare’s Hospice Benefit. With all you are dealing with already I would not be surprised if you have little interest in digging through reports. The report is similar to the GAO report of 2004 and really adds little to that from what I can see. However, interesting bits of information include data showing marked increases in the numbers of free-standing and for-profit hospices. Suffice to say, business people seldom venture into areas where they do not expect to make money.

Secondly, one study shows that for-profit hospices show profit margins of 18% while not-for-profit hospices show profit margins of 2%. The NHPCO adds a caveat however; i.e. that this data included fund-raising activities. On the other hand, the Rand report added a caveat of their own; i.e. that the NHPCO’s data was collected on a strictly voluntary basis from a limited number of hospices.

Bottom line is… hospice is being scrutinized and recommendations for much more detailed examination in the future are being made. For you that boils down to more paperwork.

More disturbing however is that the NHPCO seems at least (if not more) interested in defending large, for-profit hospices than in setting standards for nurse’s caseloads… which of course translates into quality of patient care.

Link to NHPCO’s report is

http://www.nhpco.org/i4a/pages/Index.cfm?pageID=4904

Link to the full report is near the bottom of that page.

I realize nurse’s tend to be caregivers more than politicians, but putting pressure on agencies and the NHPCO would, I think, be a good thing. Current trends are for large, for-profit hospices to provide minimal care and make as much money as possible while the NHPCO makes excuses for their conduct… and patients & nurses are left dangling.

Justhere, BSN, RN · Jun 25, 2006

Thanks everyone for there comments, my father-in-law passed 3 years ago, since then that hospice has gone out of business, due to their practice, we were not the only ones we heard of them doing that to. Keep up the good work like it seems like you are doing. Hopefully they will get the kinks worked out soon.

jharper · Jun 25, 2006

Our Hospice tries to target 9 patients per equivilant full time RN and does not use LPNs for continuity reasons. But the math is a bit different.

Some RNs want to work a few hours extra on Weekends to make 20 hours pay a week extra for on call, though management won't let an RN work two weekends in a row because they are afraid of burnout without time off.

So if you have 2 RNs, each working a regular week (which is salaried) and trade off every other weekend on call, that is 3 equivilent RNs so there is a load of 27 between the 2 RNs, but we get some extra pay if we want it. The hospice does not REQUIRE any on call for its staff.

We think this is pretty fair for everybody. The hospice is "for profit"

What do you all think?

doodlemom · Jun 25, 2006

Our Hospice tries to target 9 patients per equivilant full time RN and does not use LPNs for continuity reasons. But the math is a bit different.
Some RNs want to work a few hours extra on Weekends to make 20 hours pay a week extra for on call, though management won't let an RN work two weekends in a row because they are afraid of burnout without time off.
So if you have 2 RNs, each working a regular week (which is salaried) and trade off every other weekend on call, that is 3 equivilent RNs so there is a load of 27 between the 2 RNs, but we get some extra pay if we want it. The hospice does not REQUIRE any on call for its staff.
We think this is pretty fair for everybody. The hospice is "for profit"
What do you all think?

I don't really understand how this works. So if you decide that you don't want to be on call, who would see the extra 9 patients during the weekend? And who would see them during the week when they need prn visits?

jharper · Jun 26, 2006

I don't really understand how this works. So if you decide that you don't want to be on call, who would see the extra 9 patients during the weekend? And who would see them during the week when they need prn visits?

I'm sorry I wasn't clear. If you have chosen not to participate in the weekend work for whatever reason, the on-call or PRN nurse takes the call. There are nightime nurses assigned, though sometimes, depending on the patient, I want to be called so I have the choice to go out.

Of course some days I work more than 8 hours, some days less. It all works out.

If I have to go out and I think it is outside of my "normal" duties, I get paid for a PRN visit. We get paid a flat fee for a PRN routine Visit (about 2-2.5 pay) and a more if it is an Admit (3 hours). The nurses here all agree that this is an "honor system" and nobody has ever not been paid for a PRN.

doodlemom · Jun 26, 2006

So basically you have 13 or 14 patients to case manage - is that right?

jharper · Jun 30, 2006

So basically you have 13 or 14 patients to case manage - is that right?

No -- I have 8 right now (everyone has about 7-10) I think. If I work a weekend, I am covering another Case manager's patients if the call in. So, yeah, I could talk to a lot mote than just mine but I don't manage those cases.

anotherkindredspirit · Jul 1, 2006

Hi, all. I am new to your forums...and am enjoying reading your posts. What brought me here tonight is an interest in the the caseload question! Our clinical manager used to quote the "national average" is 8-10 patients, I think. Maybe it was 10-12. Anyway, we recently have been told we may be expected to carry a census of 15. We are a small not-for-profit. We do our own admissions and take on-call 5 nights in a six week schedule, one of which must be a sat. or sun. As of today I have 6 patients in an ECF and 3 in the home. With the current plan, I will be accepting 5 more patients next week. Does anyone know where I can access this "national average" we have been told about??? I've worked 9 hours overtime in the past 3 days and after 6 years have finally hit the wall both physically and emotionally. Supposedly we won't compromise patient care...but I agree with a previous poster in that my patients are more than a little bit aware that my visits aren't as long. The "good" ones that normally would have received 2 visits/week from me are now receiving only 1. I don't feel bad about the feelings I have on behalf of my patients, but I am ashamed at myself for being on the pity pot which, I admit, I am.