Redeemer Health

Sarah DiPadova

The hospice field is becoming increasingly 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 for patients and their families while supporting employees' worklife balance. Hospice service differs from home care service in several ways, but most notable is that the visits can be longer, more frequent, and more emotional, and while the focus is still on the patient, the whole family is included in care. Additionally, home care is paid per visit, but hospice is paid at a daily rate (with the exception of 24-hour continuous care).

The philosophy of hospice is that it focuses on providing palliative care to patients with life-limiting illnesses. It focuses on relieving patients’ pain and other symptoms while tending to family & loved one’s emotional and spiritual needs. Along with this, hospice provides the needed support for the caregivers both before and after the death of a patient. In hospice, a time limit cannot be placed on the nursing visits. 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, medications and staff overtime. Any one of these could make or break a company’s budget.

With this question in mind, let us take a look at two leading models of care available in the home care and 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 to 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 they are 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 25 quick visits, the hospice company is still reimbursed for the pre-set per-day rate. In fact, offering hospice nurses a “bonus” for surpassing productivity only costs the company money. While the company is paying out additional “bonus” money, the hospice is getting the same reimbursement. So, is this really the best approach for a hospice program?

"The philosophy of hospice is that it focuses on providing palliative care to patients with life-limiting illnesses. It focuses on relieving patients’ pain and other symptoms while tending to family & loved one’s emotional and spiritual needs"

Let us look at hospice visits and what they entail. From a nursing standpoint, hospice patients have longer visits than home care, and there is no way to pre-determine how much emotional support a patient and their family may need. Remember that the staff is 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 or admission is more important to the agency. 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. If there is an issue with getting pain or other symptoms under control, the nurse could spend several hours at 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 a hospice? It is much like forcing a square peg into a round hole; it is frustrating & counterproductive for all involved, and it does not support the nurses spending quality time with patients and their families. The same people who respond to the hospice quality survey.

It is 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 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 surveys and responses possible. One negative review can have an enormous impact on a company’s ability to obtain new referrals. Quality measures are reviewed and rated, as well as the number of visits made within the last 3 days of life. This information is available to the public when shopping for a hospice company.

 So, in the hospice realm, where companies are rated based on quality of care (as perceived by families after death) and time spent with patients and their families, maybe a case management model is a better fit than a productivity model. 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 and medications, and visits with other disciplines and volunteers. This would build a trusting rapport with the patient and their family.

Productivity could still be measured on the back end to ensure compliance with agency expectations of work hours, but it would not be the driving force of employee work expectations. This would support the idea of quality individualized care, building a trusting relationship, and supplying families 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 of incoming referrals.