Triage system juggles after-hours responsibilities
Triage system juggles after-hours responsibilities
No single answer for on-call challenge
To manage and prioritize after-hours calls from patients and the public, Hospice of Northern Virginia (HNV) established a telephone triage system. Although this sophisticated system is probably beyond the means of most small to medium-sized hospices, it illustrates the range of creative solutions that have been developed to address the perennial challenge of on-call coverage for the needs of hospice patients after the office is closed.
"The point I try to get across is that 76% of the patient's day is covered by an after-hours system," when weekends are factored in, says Denise Skinner, RN, BSN, CRNH, HNV's triage manager. "The reality is that if there's a problem in the home, it has the greatest statistical chance of happening after hours."
The triage department employs registered nurses to field all calls to the agency after 5 p.m. and on weekends. With a current caseload of 350 to 400 patients, HNV employs seven triage nurses working a patchwork schedule of overlapping after-hours shifts. The hospice also provides similar triage services for Hospice Care of the District of Columbia, which has a census of 40 to 60 patients. Triage staff are stationed at HNV's inpatient facility, with access to its back-up resources and information. The triage office also has information such as a medication list for each hospice patient, computer access, multiple telephone lines, and ergonomically correct equipment.
Actual visits to patients' homes, when warranted, are performed by separate staff for each of HNV's four regional teams, but the triage system ensures that emergency calls from patients and families go straight to a qualified nurse, not an answering service or a voice mail system. This approach also ensures that the on-call nurse making an after-hours visit to a patient's home is not interrupted with routine questions such as equipment needs, Skinner says.
The hospice receives about 1,000 after-hours calls a week. In February, 2,809 of these calls were directly related to hospice patients, and 360 visits were made in response to patients' homes. Other calls include general requests for information, after-hours referrals of new patients, questions from attending physicians, family members who find it hard to call from work, or out-of-state relatives wanting more information about hospice care or their loved ones' prognosis. "You'd be surprised at the weird things we hear," Skinner says, adding that the triage system also serves the larger community's end-of-life needs and presents a professional image of the hospice to any after-hours callers.
The triage nurse asks specific questions to assess the nature of patient-related inquiries. The questions of worried family caregivers often can be easily answered on the phone. "Our patients are well-prepared and often already have the proper medication or equipment in the home. But what they need is someone to re-instruct them," she says. They may feel free to say things to an anonymous triage nurse that they would never say to their case manager.
The triage nurse also offers team problem-solving, consultation, and emotional support to the on-call nurse in the field, as well as keeping track of where the nurse is - an important safety consideration. (See Hospice Management Advisor, March 1998, pp. 29-33.) "The scope of services we can provide is greater than a nurse and answering service system. We can also arrange for direct after-hours admits to the inpatient unit," Skinner says.
A drain on morale, and on the pocketbookOn-call coverage - and how to pay for it - is one of the favorite topics of hospice shop talk. Particularly for smaller hospices, the caseload may not support employing dedicated on-call staff, yet having to carry a pager at night is one of the biggest complaints of daytime nurses. An ineffective system can be a drain on staff morale, as well as a threat to the quality of nurses' judgment and patient satisfaction with hospice. Actual demand for on-call services can be extremely unpredictable.
How to pay on-call staff for their time is another difficult question. Options include salaries, an hourly rate for all the time carrying a pager, hourly or episodic rates only while making actual visits, or some combination. A common approach is to pay $1 to $2 for every hour the person is available on-call, plus a standard professional hourly rate for time spent on the road, in the home, on the phone, or charting.
Peter Moberg-Sarver, president and CEO of Hospice of Central New York, Syracuse, expresses the dilemmas of managing on-call coverage. "Either you pay through the nose to maintain a system separate from the regular staff, or you stress the hell out of your regular staff. And we have found that a hybrid system doesn't work all that well either. We promised our day staff that they wouldn't need to do on-call, but if one or two on-call staff leave, you can't replace them overnight."
"On-call is the perennial hospice question, and I don't think there is a good answer," observes Bernice Wilson, RN, MS, executive director of the Ohio Hospice Organization. "The Medicare benefit requires hospices to provide 24-hour care, and hospices keep trying to figure out a better way to do it. But there is no one magic solution. You've got to make it fit your organization. Finding the approach that works for you takes trial and error - and then things change in the organization and it doesn't work anymore," Wilson observes.
"We've gone through several permutations of on-call over the past seven years," Skinner confirms. "We changed to the triage nurse system in part because of the cost. The triage approach came in cheaper" than what the hospice was doing before, she explains. "It's not inexpensive to offer a comprehensive triage program, but you need to look at the wear and tear on your staff, and the psychological costs for nurses who work all day and go out at night," or the need to cover scheduled visits for a nurse who was up most of the night before with patients.
Sarah Gorodezky, MA, director of Hospice of Napa, CA, relates that she surveyed other hospices about on-call approaches while she was director of Alive Hospice in Nashville, TN. Based on that survey, the Nashville hospice hired an on-call supervisor who could screen after-hours calls, make supervisory visits to the home, track trends in on-call visits, and provide more continuity to daytime staff. "We came to the realization that this was 16 hours of the day and our highest-risk time. These are very sick people, and crises happen more often at night," she explains. Plus it seemed that most of the complaints the hospice received were for incidents that occurred after hours.
"It wasn't cheap, but it really made us feel more secure that when visits were made they were really justified," Gorodezky says, adding that this issue can go either way - either too many visits that are not needed, or not visiting when one is called for. It was also determined that a visit should be made to the home if the family called more than two times in an evening, regardless of the presenting concern, because that suggested something else might be going on.
Although smaller hospices may have a harder time balancing these various concerns, Wilson suggests that it might be possible for two or more adjacent hospices to share on-call systems and staff. The professional and managerial staff hired to run those agencies may also need to wear more than one professional hat - for example, an administrator who is a nurse and can fill in with visits, or a social worker who is also licensed as a registered nurse.
"Our nurses are hired with the understanding that they would have to do call, but that I'd try to find a nurse who'd take call," reports Ruth Lindsay, RN, executive director of Hospice of North Central Ohio in Ashland. The hospice recently hired a nurse to a part-time salaried position, taking four nights a week and every other weekend. "I tried to make the position budget-neutral" by giving this nurse the equivalent of a set number of hours per shift, plus time for paperwork and scheduled phone calls to patients on the weekend, Lindsay says. "The woman who took the job is happy with the salary, and the other nurses are ecstatic," she adds. "Sometimes you're lucky to find someone who is suited to that job."
"It's a different kind of hospice work," Skinner says about triage nursing. In addition to the flexibility and highly honed nursing skills required of all on-call nurses, the triage nurse "has to be able to think without seeing. It requires rapid decision-making based on clinical expertise, and the ability to form a connection with someone under stress."
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