The NHPCO’s Staffing Guidelines’ worksheet uses a 10-12 patient caseload as the baseline for increasing or decreasing caseload based on 11 indicators such as acuity, Average Length of Stay (ALOS), average drive time, etc. Of particular importance in this process is adherence to the NHPCO advice that primary consideration that should be used by a hospice to determine optimal staffing caseloads is the hospice’s ability to meet the needs of patients and families through appropriate use of resources and achieving the quality goals set by the hospice program.

 

Using the NHPCO Staffing Guidelines worksheet, a comprehensive analysis of Hospice X was conducted, considering the following indicators:

• Average Length of Service > 7 days

• Uses admission specialist(s)

• Uses dedicated on-call staff

• Uses RN/LPN Model

• Uses Shared Team Model

• Uses Bereavement Team Model

• Staff Turnover Rate < 24%

• Routine Level of Care < 97% of Patient Days

• Disease-modifying therapy included as covered service in hospice POC

• CNA % of FTE <19%

• Use of ancillary therapy (art, music, massage, PT/OT, etc.) emphasized

• Uses Continuous Care Model

• Contract beds available for General In-Patient (GIP)

• IDT has multiple non-core roles

• Has facility-based patients

• Patient calls handled by primary RN during business hours

• IDT staff routinely provide community services such as crisis outreach and bereavement services to non-hospice individuals.

• High proportion of patients/families with complex psychological issues

• Hospice is currently experiencing growth

• Utilizes disease, condition, or treatment specific programs

• Spiritual Care Model utilizes dedicated chaplain(s)

• Hospice services are performed in high crime/ risk areas

• >50% of patients are rural

• Volunteers are trained and utilized to provide non-clinical in-home services

 

Responses to the above indicators were analyzed and compared to the NDS data published by the NHPCO. Based on the analysis, a recommended RN caseload for Hospice X was established.

 

Based on the results of this analysis, the evidence weighed in favor of supporting a caseload of at least 12 patients per RN case manager.

 

The 12 (+) patients should be visited at a minimum once, documentation completed, and additional care modalities coordinated by the RN within a 40- hour workweek. Additional duties such as phone calls, emergency visits, staff training, etc. should also be completed within the established workweek.

 

This exhaustive analysis of Hospice’s financial statements and staffing patterns revealed that the Registered Nurse (RN) case managers were not performing to capacity, and were, in fact, claiming from 30-50% overtime each pay period. In keeping with Hospice’s history of “whatever it takes” to ensure patients and their families were appropriately comforted, RNs typically allowed as many as two to three hours per patient home visit, seeing each patient at least twice each week.

 

Based on my recommendations, Hospice administration decided to introduce a new staffing model, eliminating one RN full-time equivalent (FTE) position, and disallowing regular overtime without prior approval. The proposed changes would require RNs to complete their home visits within an average of 60 minutes, increase their patient caseload from 5 patients to 12, better coordinate other patient services, such as social and pastoral care, and complete their work within the allotted 40-hour workweek. To best introduce these changes to the organization, Administration agreed that I would facilitate a series of meeting with the staff to explain the changes, the reasons behind them, and to engage staff in developing a plan to implement the changes.