Redeemer Health

Sarah DiPadova

Sarah DiPadova, Director of Clinical Operations at Redeemer Health, holds a MSN in Nursing Education. She is a certified hospice palliative care RN who obtained her certification as director of clinical operations in hospice through CHAP.

DiPadova holds a forensic license as well and work independently as a SANE (Sexual Assault Nurse Examiner). She has a strong background in public/community health specializing in Heart Failure and Diabetes management. She is passionate about the benefits of hospice and palliative care and that they are not utilized as early or as often as they should be.

Throughout her career she has worked in the operating room, emergency room and in cardiac care.

Why Quality Care Matters in Hospice Services

The world of healthcare has become increasingly difficult to maneuver through not to mention highly competitive. It can be grueling to gain ground that has been lost due to short staffing or incomplete referrals. Hospice companies especially, are finding it challenging to balance a profit margin with maintaining quality care of patients and their families while supporting employees work life balance. Hospice service is different than home care service in several ways but most notable is that the visits can be longer, more frequent, more emotional and while the focus is still on the patient the whole family is included in care. Additionally, while home care is paid per visit hospice service is paid at a daily rate (with the exception of 24hr continuous care).

 When you look at it, the philosophy of hospice care is that it focuses on providing palliative care to patients with life-limiting illness. It focuses on relieving patients’ pain and other symptoms while attending to their families’ emotional and spiritual needs. Along with this they provide the needed support for the caregivers both before and after the death of a patient. In hospice a time-limit cannot be placed on a nursing visit. So what models are available to utilize in order to ensure that nurses are productive and patients are well cared for? How can it be measured? In hospice, because it is paid out per day close attention needs to be paid to cost containment such as soft supplies, DME and medications. Any one of these could make or break a company’s budget.

“Hospice care focuses on providing palliative care to patients with life-limiting illnesses, addressing their physical pain, emotional and spiritual needs of their families, which is crucial in ensuring quality care and support during the most challenging times."

With this question in mind let’s take a look at two leading models of care available in the home care/hospice fields and what they mean for patients and the nursing staff. The first model is the Productivity Model. The goal of the productivity model is to maintain a measurable number of visits for each nurse. Home care receives payment based on each approved visit so this is a logical choice.  Having a productivity requirement is not only a guide on what is expected of the nursing staff but also a way to determine anticipated revenue. Of course travel time and distance need to be taken into consideration when determining productivity expectations. However, when considering hospice services, we see that it is paid at a daily rate not per visit (with the exception of continuous care). So whether the nurses make 18 quality visits a week or 30 quick visits, the hospice company is still reimbursed the pre-set per day rate. So is this really the best approach for a hospice program.

Let’s look at hospice visits and what they entail. From a nursing stand point hospice patients usually have longer visits then home care and there is no way to pre-determine how much emotional support a patient and their family may need. Visits by spiritual counselors, home health aides and social workers are also part of the service.  Remember that the staff are encountering patients and families at the absolute worst time of their lives therefore they cannot be made to feel that they are being rushed, that their time is being cut short or that another patient is more important. There is a great deal of education and end of life planning to be addressed that cannot be given a scheduled amount of time to complete. Sometimes if there is an issue getting pain or other symptoms under control the nurse could spend several hours at the home adjusting medications, waiting for a reaction and educating the patient and caregiver. So, what is it like trying to fit a productivity model into hospice? It is much like forcing a square peg into a round hole, it is frustrating and counterproductive for all involved.

It is important and understood that employers need to ensure that their employees are doing their jobs in a timely manner and remain productive. It is also important to note that quality care is the driving force behind referrals and remaining a productive business. Now, families have the ability to easily access provider surveys and compare multiple providers at one time.  Therefore, it is more important than ever that quality care is given to ensure the most positive of surveys and responses as possible. One negative review can have a huge impact on a company’s ability to obtain new referrals. Quality measures are reviewed and rated on the site. This information is available for anyone to look up.

So in the hospice realm where companies are rated based on quality of care and the time spent with patients and their families (as perceived by families after death) maybe a case management model is a better fit. Each nurse can be assigned a specific range of patients to case manage based on acuity and area traveled. They would be responsible for case managing all of their needs such as end of life education, ordering supplies, medications and visits with other disciplines. Not to mention building a trusting rapport with the patient and their family.  

Productivity can still be measured on the back end to ensure compliance with agency expectation of work hours but it would not be the driving force of employee work expectation. This would not only remove the stress and frustration put on the nurses to “hurry up” and get to the next visit but would support the idea of quality individualized care. It allows the time needed to build a trusting relationship with their patient and their family by supplying them with much needed support and education. This would go far in meeting the hospice quality standards set forth by CMS and improving patient/family satisfaction surveys. All of which are key to obtaining a continuous flow if incoming referrals.