EXECUTIVE SUMMARY

Using a homegrown seven-day case management program, a Florida hospice gives case managers more time to work with patients, improving quality and efficiency of care.

• The program provides consistency by having two case managers work collaboratively to follow the patient seven days a week.

• After-hours calls declined significantly once the program was initiated.

• The hospice found that it was easy to find volunteers for the weekend shift because some case managers liked having weekdays free to attend advanced degree college programs or to spend time with their children.


An Orlando, FL, hospice organization restructured care management to give patients and staff more meaningful and effective encounters. Called the seven-day case management revolution, their homegrown program gives case managers more time to get to know their patients.

The idea was initiated at a senior leadership meeting, says Violet Argo, RN, BSN, CHPN, executive director of Cornerstone Hospice and Palliative Care.

Hospice case managers are registered nurses who lead the care of patients in an interdisciplinary team that also includes a chaplain, home health worker, registered nurse, and physician.

Traditionally, hospice case managers worked eight-hour days, Monday through Friday. For evenings and weekends, there is an after-hours on-call service.

“Only 14% of the workforce work after hours,” Argo says.

These evening and weekend shifts might include two shifts, such as a 4 p.m. to midnight and a midnight to 8 a.m. shift. “Some organizations will offer to pay nurses more to cover a 16-hour shift,” she says.

The problem with the traditional workflow was that patients need a lot of help, and they might not feel comfortable with someone they will meet only if there’s an emergency. There would be 60-70 calls and visits after hours and on weekends each month. Since making the change, the after-hours calls dropped to between 10 and 15 calls per month, Argo says.

Hospice leadership began to see this as a less efficient way to handle patient care during off hours.

“We started thinking about offering our patients longer hours, case management hours, rather than hours by nurses who really didn’t know them,” Argo says.

Shifts change Mondays through Thursdays from the original 8 a.m. to 4:30 p.m. to a shift that began at 8 a.m. and lasted until 6 p.m.

“Each patient has two case managers, one for Monday through Thursday, and one for Friday through Sunday,” Argo says. “They’re responsible for knowing everything about their patients, including which symptoms are controlled and when they can start new medication.”

This change facilitates a continuum of care and improved quality of care, Argo says.

For example, if a patient needs an IV antibiotic started after hours, the weekend case manager can make that visit, she explains.

“Our census grew as a result of this model,” Argo says. “Nursing homes and assisted living facilities love our model because they know their patients are being seen routinely over the weekend, and they know the case managers’ names.”

As a result, the hospice’s quality care scores about whether someone would recommend the hospice to other people rose to above the national average, and the after-hours calls plummeted, she says.

“We’re not getting the after-hours calls we did, and that means the two dedicated case managers are doing such a good job with patients that their need to call after hours is minimal,” she says.

“At first, when we made the change there was hesitation and people thinking patients don’t want to be seen on the weekend,” Argo adds. “That concern was dispelled very quickly.”

Patients quickly bonded with their weekend case managers, even calling and asking for them, she says.

For the best results, the program needed flawless communication between the weekday and weekend case managers, Argo says.

“We did not dictate how the handoff should be done, letting the pairs make those decisions,” she explains. “We are careful when we pair up people that we find people who will get along.”

Any problems with workflow are quickly discovered.

“If you and I are partners and you’re not doing what you should be doing, I will know and will not be happy,” Argo says.

When problems occur, Argo expects the case manager pairs to speak with each other first.

“If that doesn’t work, then go sit with the manager to figure out what the problem is,” Argo says. “This change improved staff productivity and quality scores. We also noticed that our after-hours calls to the center dropped dramatically.”

Case managers can handle communication in ways that work best for them. Some pairs choose to meet for breakfast on Friday mornings for a verbal report and handoff, Argo says.

“Breakfasts work for them,” she adds. “I have pairs that communicate by phone, and others strictly do emails of all the things they’ve done for patients.”

Although case managers often don’t work on weekends, the hospice has not experienced difficulty finding volunteers for the weekend shift. “We had zero problems recruiting for those positions,” Argo says.

“On our team, we have a few people who are working on their nurse practitioner degrees, and they’re able to go to school during the week and then work on the weekend,” Argo adds. “We also have mothers who want to be home with their children during the week, and one nurse just likes to work on the weekend.”

The weekend shift is 36 hours and is paid the same as a 40-hour week, plus there is bonus pay. The model has worked so well that other hospices have expressed interest in learning more about how it works, Argo says.

“There was a hospice that came and spent two days with us and then implemented the model,” she says. “A couple dozen hospices have asked about it.”