The Monthly Publication of the National Hospice and Palliative Care Organization

The Monthly Publication of the National Hospice and Palliative Care Organization Print-friendly PDF From June 2013 Issue Determining Caseloads Gilchrist Hospice Care on Its Process By Regina Shannon Bodnar, RN, MS, MSN, CHPCA Staffing! Having the right people in the correct numbers is an essential foundation of a qualitydriven hospice organization. But a hospice is not a hospice is not a hospice. In the same way that you individualize patient care, the art of knowing your ideal caseload numbers for clinical staff as well as administrative support must be based on an insightful understanding of both your business model and your community. Fortunately, NHPCO s Staffing Guidelines for Hospice Home Care Teams, which was released in March of 2011, walks you through an analysis process to help you determine what your caseloads should be, based on these factors and others. At Gilchrist Hospice Care (GHC), where I serve as the director of clinical services, utilizing this analysis process has helped me delineate differing needs by service line and, in some cases, also by team. And in this article, I show you precisely how. But first, some background. The Analysis Process The Staffing Guidelines is a well-organized 36-page document that utilizes a multi-step systematic assessment process to estimate optimal staffing levels for hospice programs, with the process broken out into digestible sections. While an introduction with an overview is included in the document, let me briefly review the process for the purpose of this discussion: Want More Background Section I covers the prep work you should perform first. This About the Guidelines Development? includes: o o A review of pertinent statistics from NHPCO s National Summary of Hospice Care to give you an understanding of what hospices, nationwide, are currently doing; and A review of those factors that will influence your final caseload determinations, such as length of service, staffing models (e.g., Admissions Model; Bereavement Model); and organizational characteristics. Section II covers the actual staffing analysis process, which calls for the completion of two one-page worksheets. This involves assembling your hospice data; comparing your current staffing caseloads to the national caseload statistics from the National Summary; and estimating your own staffing caseloads accordingly. See the introductory article in the March 2011 issue of NewsLine, which includes details about the rationale for establishing the analysis process. 1

Section III covers the evaluation process, and is followed by sections which provide completed worksheets for three hospice programs to serve as examples, a convenient glossary of terms, and the pertinent tables from the National Summary. As you can see, implementing the guidelines does require an investment of time, but based on my experience, it is time well spent. GHC s Analysis by Service Line Gilchrist Hospice Care (GHC), which serves patients in the jurisdictions of Central Maryland, has an average daily census of approximately 600 patients. Our organization is arranged around three clinical service lines: 1. Inpatient Care (44 beds across two facilities) 2. Facility Based Care (three home hospice teams caring for patients in skilled nursing facilities and assisted living communities) 3. Home Hospice Care (six home hospice teams caring for patients in private residences, with one designated exclusively for pediatric patients). Since it was first released, we have used the guidelines to analyze our needs and appropriately budget resource dollars for each of these three service lines.(gilchrist Kids is excluded from this discussion since it is staffed differently, based on the experience of pediatric-care colleagues around the country.) Some Influencing Factors As part of the prep work that should precede the analysis, we considered factors unique to our organization that will impact staff caseloads. For example, across our organization, there are four particular features of our programmatic design that heavily impact staffing: We have a NEWS Crew that covers nights, evenings and weekends, and is staffed with RNs, LPNs and, to a lesser degree, supportive services. This Crew is responsible for responding to the pre-scheduled and on-call needs of our patients and families after business hours and on weekends. We also employ a designated admissions team and Hospital Liaison Crew seven days per week to conduct introductory visits and enroll eligible patients on service. Our bereavement services are provided by a designated team of professionals separate from the interdisciplinary care team. And in late 2011, we established a daytime triage team to handle clinical calls during business hours to help reduce the number of interruptions on field staff. Given this programmatic design, our primary care teams do not provide bereavement services, our clinical teams do not handle admissions or provide 24/7 coverage (except on six holidays per year), and our supportive services staff has infrequent after-hours responsibilities. That said, additional discernment by each of our service lines is required which I review next. The Guidelines in Practice Staffing for Facility Based Care Our Facility Based Care (FBC) is composed of three teams: FBC-East, FBC-Central and FBC- West. 2

We have long accepted that the care provided by these teams requires enhanced communication skills (since staff is working with family, facility staff and physicians); flexibility in work hours to ensure around-the-clock attention; and a true commitment to building and maintaining a respectful partnership in the care of the patients. Shown below is the completed copy of Worksheet 1 for this particular service line (this Worksheet appears on page 17 of the guidelines). As you see, we entered our data on Length of Service and Routine Level of Care, and then assigned a directional indicator (+/-/=) to represent higher, lower or equal caseloads for the categories under the Staffing and Organizational Models. Factors Associated With Care Model FBC East FBC Central FBC West Length of Service 101 108 121 Staffing Model Admission Model +/- + + On Call Model + + + RN/LPN Model + = - Shared Team Model = = = Bereavement Model + + + Staff Turnover Rate + + + Organizational Model Percent of Routine Level of Care 99 99 99 Access = = = Aide/Homemaker Delivery Model + + + Use of Ancillary Therapy (e.g. PT/OT; art, music) + + + On completion of the Worksheet, we discovered that much was the same across our three teams. We also found that the average Length of Service (LOS) for patients served by these teams (i.e., 101; 108 and 121) was significantly higher than the national average of 69.1 days as reported in the FY2011 National Summary (Table 7), as was the Median LOS of 19.1 days. In addition, our staff turnover rate of 10.3 percent (and 12.3 percent for nursing) was significantly below the national agency mean of 23.6 percent, as reported in the FY2011 National Summary (Table 11). But a bit of variation bubbled up as well. An LPN floater has been successfully integrated into the FBC-East team, and covers cases when an RN team member is off. This averts the need for the other RN case managers to assume coverage responsibilities when a nursing colleague is using benefit time. Theoretically, the RNs on this team should be able to carry a slightly larger caseload of patients because they no longer have coverage responsibilities (or the fluctuation in the patient care responsibilities that coverage brings with it). 3

These FBC teams have also expressed an interest in conducting a pilot to admit their own patients and not use the services of the admissions department. They are hopeful that this will increase the likelihood of team members connecting earlier with family members, which is a frequent challenge for patients residing in facilities. Because of greater flexibility in scheduling, they also hope it will decrease the time between referral and admission. This pilot, which is clearly poised for success, would dictate the need for smaller RN caseloads. It is also worth noting that the FBC-Central team has a well-established RN/LPN partnership that provides care across settings for residents of a large continuing care retirement community. Their caseload is nearly double that of an RN working independently and the arrangement has resulted in many positives, such as continuity of care, increased responsiveness to emergent needs, and a collegial camaraderie envied by many. It does not, however, impact the caseload size of other team members. Let s now turn to the portion of Worksheet 1 concerning the Organizational Model: Organizational Model FBC East FBC Central FBC West Percent of Routine Level of Care 99 99 99 Access = = = Aide/Homemaker Delivery Model + + + Use of Ancillary Therapy (e.g. PT/OT; art, music) + + + The percentage of routine patients served by our FBC staff is nearly 2 percentage points higher than the national average as reported in the FY2011 National Summary (99 percent versus 97.1 percent). We also fully utilize hospice aides, routinely use physical therapy to promote patient safety, and have thriving volunteer and music therapy programs (which are reflected by the directional indicators (+/=) we assigned to these categories). Also, the GHC Expanded Care Program of concurrent care is well established, but not frequently tapped by FBC patients because of their diagnostic mix and other factors. Thus, together, these findings suggest that GHC disciplines assigned to facility based care teams could carry caseloads that are larger than those reported in the FY2011 National Summary. Other Factors Impacting Caseloads Worksheet 2 of the Staffing Guidelines (page 19 of the document) lists 13 other factors to consider when determining staffing caseloads. Our completed worksheet for the FBC service line is shown below. Other Factors to Consider for Staffing Caseloads FBC East FBC Central FBC West GIP and Continuous Care Variables = = = Multiple Non-core Roles for IDT - - - Facility-based Variables (routine home care) Primary Care Team Models + + + Provision of Community Services + + + 4

Psychosocial Issues: High Social Complexity = = = Rate of Growth = = = Specialty Programs + + + Spiritual Care Support Model +/- +/- +/- Staff Safety: Require Multiple Staff or Escorts/visits + + + Travel time: Increased = = - Volunteer Utilization + + + Other We found that, even though we have two stellar inpatient facilities, the use of our inpatient settings for FBC patients is infrequent. Continuous care is available and is often the first choice for symptomatic patients, based on the belief that moving an FBC patient from a familiar setting (and the faces they recognize) is frequently not the right thing to do. We also appreciate that our FBC team members are moving in the direction of embracing their responsibility as the end-oflife care experts for the facilities in which they work. This will bring enhanced responsibilities for FBC team members to conduct resident, family and professional education programs that are presently performed by other employees of the organization. One true outlier in our analysis of Other Factors to Consider was travel time for the FBC-West team. This team has a significant cluster of patients who are located more than 30 miles from the team office. It was determined that this finding should not affect the caseloads of all team members, but could most easily be addressed by introducing an RN/LPN partnership to this portion of the service area. Like all partnerships, the relationship is key to a successful RN/LPN pairing. We are presently in search of an LPN to complement the talents of the RN in this area. Until a partnership is launched, however, navigating the geography to best meet patient needs will be accomplished through well-considered scheduling and continued judicious use of per diem staff. Another point to note is in regard to our spiritual care support. In addition to their work with patients and families, our chaplains offer support to facility residents and staff members. In conjunction with our bereavement department, the chaplains conduct memorial services in many facilities on a quarterly basis. This is balanced by GHC s commitment to honor patient and family relationships established with community clergy. Putting It All Together When considering all the factors collectively, it was determined that our RNs could and should carry caseloads in slight excess of the national average of 11 patients, as reported in the FY2011 National Summary. This decision is driven mostly by GHC s organizational commitment to our NEWS Crew, admissions team, and bereavement department, as well as our vigorous volunteer program and the acknowledgment that travel for most team members is reduced in time and distance due to the clustering of patients in partner facilities. I do anticipate a modification to staffing numbers for our FBC-East team once it is positioned to assume responsibility for conducting its own admissions. Staffing for Home Hospice Care Shown below is Worksheet 1 for our Home Hospice Care (HHC) service line. There are five teams in this service line that care for patients and their families in private 5

residences. However, they also receive support from a NEWS Crew, admissions team, hospital liaisons, triage team, and bereavement department. These teams are just beginning to migrate toward an RN/LPN model of care, with some adapting earlier than others. These teams are also moving towards a modified Shared Team Model that translates into all members of the team assuming broader responsibilities. Factors Associated With Care Model Central East West Howard Harford Length of Service 68 99 59 97 84 Staffing Model Admission Model + + + + + On Call Model + + + + + RN/LPN Model = = = + + Shared Team Model = = = = = Bereavement Model + + + + + Staff turnover rate + + + + + Organizational Model Percent of Routine Level of Care Access - - - - - Aide/Homemaker Delivery Model + + + + + Use of Ancillary Therapy (e.g. PT/OT, art) = = = = = In looking at the Routine Level of Care for these home hospice teams, note that we have deliberately left that row blank. This is due to an earlier organizational decision to change team assignments for a patient when the patient transfers from a home care team to an inpatient hospice setting. This results in no home hospice team having a patient at the general inpatient level of care. Like our FBC teams, our HHC teams recognize the important role that hospice aides play as care providers and team members. We staff these positions assertively, recognizing that if our aides are to truly meet the basic needs of patients and families, they need to visit them more frequently than any other member of the team. We are also assertive in incorporating physical therapists (PT) into all plans of care, acknowledging that those patients who are ambulatory and using assistive devices potentially benefit most from the skilled assessment and coaching that PT brings to the plan of care. Each of these findings suggests that the care teams could carry larger caseloads than those reported in the National Summary. As I noted earlier, GHC also has two stellar inpatient facilities. These facilities are frequently used by our HHC teams for patients who require complex symptom management. To facilitate seamless transitions in care, a bed is reserved at all times for use by home hospice patients. In cases of an anticipated weather emergency, the number of beds allocated for use by home hospice patients is increased. Given this practice, the coordination and handoff of patients is predictably less complex. So, even though transfers into the inpatient setting happen with regularity, this design supports the home hospice RN case manager in carrying a larger caseload. 6

Other Factors Impacting Caseloads When assessing other factors that may impact staffing caseloads for the HHC teams, one team, in particular, stands out as different from the others. The Central team cares for patients in Baltimore City and the edges of the surrounding counties and, as shown in Worksheet 2 below, the complexity of psychosocial issues encountered by this team (as reflected by the directional indicator) suggests that social workers should carry smaller caseloads. The issue of staff safety is also more commonplace for this team (also reflected by the directional indicator). Given that more time is required for the coordination of joint visits and/or the utilization of escort services, it was determined that all clinical disciplines on the Baltimore Central team should carry slightly smaller case loads. Other Factors to Consider for Staffing Central East West Howard Harford Caseloads GIP and Continuous Care Variables + + + + + Multiple Non-core Roles for IDT + + + + + Facility-based Variables (routine home care) n/a n/a n/a n/a n/a Primary Care Team Models + + + + + Provision of Community Services + + + + + Psychosocial Issues: High Social Complexity - + + + + Rate of Growth = = = = = Specialty Programs + + + + + Spiritual Care Support Model +/- +/- +/- +/- +/- Staff Safety: Require Multiple Staff or - = = = = Escorts/Visits Travel time: Increased = = = - - Volunteer Utilization + + + + + Other Putting It All Together In addition to the factors already noted, our triage department manages the majority of weekday calls from patients cared for by our HHC teams. This supported our determination that these teams could carry larger caseloads than the agency means by discipline, as reported in the FY2011 National Summary (Table 14). And this is by design. Our goal is to limit the asks for work outside of direct patient care, so these teams can focus almost exclusively on providing interdisciplinary care that is true to the core principles of hospice. The one exception is our Central team. The multitude of complex psychosocial issues and very real safety concerns associated with the patients they serve suggests smaller caseloads are necessary in order to deliver quality care and a positive patient and family experience. Travel time for both our Harford and Howard County teams is also acknowledged as a potential issue since each covers a broad geography. The distribution of patients is occasionally problematic and must be conscientiously assessed. In Closing The key to staffing success is the commitment to thoroughly understanding all of the factors which impact the day-to-day operations of the clinical program and a commitment to re-assess those factors regularly. As I hope this article illustrates, NHPCO s Staffing Guidelines can help 7

you get there. Regina Shannon Bodnar is a registered nurse with more than 35 years of clinical and leadership experience. She currently serves as the director of clinical services for Gilchrist Hospice Care in Hunt Valley, MD, a position she has held since 1993. She is also an active member of NHPCO, including service as both a member of the Quality and Standards Committee and the Task Force charged with development of the NHPCO Staffing Guidelines. Staffing Guidelines: Available in PDF and Print NHPCO s Staffing Guidelines for Hospice Home Care Teams can be downloaded by members, free of charge, from the NHPCO website. Printed copies ($14.99 for members) are also available for purchase from the NHPCO Marketplace and can be ordered online or by calling the NHPCO Solutions Center at 800-646- 6460 (M-F, 8:30 a.m. to 5:30 p.m., ET/EDT). 8