how to choose hospice why staffing

Tuesday, March 15, 2005

How to choose a hospice: Why staffing matters

(This is part seven of a series on how to choose a hospice. To start from the beginning go here.)

In part 5, I talked about how many patients each nurse has. This time I want to talk about how much attention you should expect and who you should expect to get it from.

First, frequency of visits. Your nurse should visit at least twice a week. Any nurse that thinks they can keep up on a hospice patient’s condition by visiting once a week is delusional. Find a hospice that promises two nursing visits a week. It shouldn’t be too hard.

Second, find out who makes the visits. The question you should ask is if the same nurse will visit every time. There are two different theories on how to use nurses. As with everything in hospice one is best for the patient and one is best for the pocketbook.

The theory you want your hospice to have is the theory that believes that having the same nurse seeing you every time generates better care. There are things that only an RN is allowed to do, and most of those things are only done once every two weeks. A good hospice has the RN make every nursing visit. That keeps them as up to date as possible. A bad hospice has the RN make one visit a week and an LPN make the other. While this is better than those that offer only one visit a week, it is still not good enough. The biggest thing a nurse needs to know about a patient is what is normal. Some have high blood pressure, some low, some are 98.6 temp every day, some are a little lower, some are short of breath at all time, some are not. For a nurse to know when something is wrong, they have to know what it looks like when it is right. The only way to find that out is for the same nurse to see the patient every time. Now, a RN make about $5 an hour more than a LPN so there is great pressure from the bean counters (especially in large corporate hospices) to use LPNs as much as possible. In those situations Case Managers may take care of 20-30 patients instead of the 12-15 I suggested earlier. I have nothing at all against LPNs, but for the sake of consistency, you should choose a hospice that doesn’t use many LPNs. You want the same nurse to come every time. The only way that will happen is if RNs make all the visits. The routine use of LPNs is an indication that the hospice is taking care of the bottom line at the expense of the patient.

There are two more parts to this series. Next, find out why staff recomendations matter.

10
comments:


Anonymous
said…

I very much resent your opinions that consistent nursing visits should be made by RN’s. I am an LPN and very very good at what I do. I can guarantee you that my patients get just as good of care from me, if not better, than they do from the RN’s.


Anonymous
said…

The point is not that LPN’s are not as good as RN’s. The point is that continuity of care is difficult to preserve when more than one person is routinely visiting. Even with top notch communication skills, there will be things that are missed because what is so small a change as to be un-noteworthy at one visit, may become the harbinger of disaster at the next.

smiller0063
said…

I do agree that it is very important for a regular nurse to visit each week. I think that when there are two different nurses visiting there are two bonds developed with both the patient and family. Each nurse will see something a bit differently and when the nurses collaborate about the patient they are both able to bring more information to light than just one will. Also when conferring with the rest of the team especially during rounds with the hospice MD two nurses are able to bring different thoughts and ideas to the discussion. I have found that patients will tell one hospice nurse some information and will tell the other hospice nurse other information. Much of what is shared comes from the relationship they have with their hospice nurses.

Please explain your position where you say, “You want the same nurse to come every time. The only way that will happen is if RN’s make all the visits.” …..If the same LPN comes once a week for 20 consecutive weeks would you not have the same nurse coming every time?? Would that LPN not be aware of what is normal for their patient i.e.… (Vital signs, resp status, pain level, ADL functional status, comfort level, mental status/LOC ect.)


Anonymous
said…

tunnel vision is a terrible thing/ that combined with stereotyping can create a person living in their own narrow world…


Anonymous
said…

Our hospice uses both LPN’s and RN’s. Visits are rotated between the RN and LPN. An LPN can provide just as good of care as an RN. We have a VERY high turnover for RN’s (usually last 6 to 10 months). LPN’s, however, seem to not mind the long hours. I’ve been in the field for almost 6 years as an LPN. I KNOW I provide quality, loving care for each of my patients.

hospice4life
said…

I have to agree with HospiceGuy on this one…when you see a physician, do you appreciate seeing one in a group that rotates the doc you see? Probably not, I know I wouldn’t…I want the doc to KNOW and remember me…so that her/his focus can be on comparison and changes, instead of just getting to know me or “refreshing” his/her memory. Using the same nurse all the time gives patients confidence and is the best choice for excellence in care. And, true, there are some tasks, such as recerts and updates to the POC that should always be done by an R.N., so the RN should be the patient’s nurse, period.

exflygrl
said…

I had the unfortunate experience of having Vitas Hospice of Fort Lauderdale provide care for my elderly parent. The indifference shown by most of the the LPN’s and CNA’s was appalling. The Vitas doctor personally saw his patient only once in ten months, and was kept up to date by phone.

One hand didn’t seem to know what the other hand was doing. Most of the time the staff did paperwork and ignored the patient. The paperwork was then copied by the next care giver without checking its accuracy.
Several times I found the night shift LPN’s fast asleep and oblivious to any medical problems. I reported several incidents, however the level of care never improved.

Instead of grief counseling, I think Vitas should offer anger management classes. With a few exceptions, their staff (including the RN’s who come by for their weekly ‘stop and chat’ have no concern for the comfort and well being of their patient. It is a sad commentary, considering they are well compensated through Medicare.


Anonymous
said…

exflygrl, sorry for your loss, could you not fire Vitas and receive another hospice instead?

Sara RN
said…

I am a hospice RN, have been for 5 years. I disagree that only one nurse should see each patient. First, it is better for the patient and the team to have more than one nurse’s input. Secondly, if one nurse goes on vacation or leaves the agency, there is a continuity of care with the other nurse already knowing the patient and family. Families get extremely attached to their nurse(s), and I have seen the pain that they experience in “losing” their nurse, coming in as the new nurse. The LVN’s that I have worked with are wonderful. Also the idea that every patient must have at least 2 visits a week is not good criteria for choosing a hospice. I have had patients that barely need one a week. Medicare does not want us to use “cookie cutters. The best care comes from caring nurses who look at each patient and family as unique, and work with their team to meet their needs


Anonymous
said…

This is a response, not only to “staffing matters,” but also to “size matters.” The two are related. My father is enrolled in a large, community-based, nonprofit hospice (current patient census is around 450). Because the hospice is large, they can afford a complete hospice team that makes visits on a regular basis. The RN visits once or twice a week, depending on my father’s needs. She usually comes with the social worker, who has developed a tight relationship with my mom. The CNA comes once a week. In fact, it was the CNA who noticed a droop in my father’s face that turned out to be a slight stroke. She called the RN, who came with the social worker to admit my dad to the hospice inpatient unit (another benefit of a larger hospice) for observation. The chaplain, also a frequent visitor to my folk’s house, sat with my dad at the inpatient unit until we could get there. The music therapist (do smaller hospices have music therapists?), who followed my dad at home, had a feeling that he’d be very anxious on the inpatient unit, so she arranged her schedule to visit him there, knowing her music would calm him. All of these people made a positive difference in our family’s experience of a scary incident. Rather than harping on “RN and only RN,” I’m surprised the Hospice Guy didn’t say more about the team philosophy of hospice as an important staffing issue. Of course you want consistency, but consistency from the whole team. No one team member is more important than another. They all contribute to patient care in their own ways.