Careful management of hospice care manager workloads correlates with longer lengths of stay and improved margins.
Length of stay is an important metric from both a clinical and business standpoint. For many patients length of stay is a week or less, which is too short for them to receive the full benefit of hospice care.
From a business perspective, patient populations who experienced longer lengths of stay boosted hospice margins by as much as 20% during 2016, according to a report from the Medicare Payment Advisory Commission (MedPAC).
Recent research from BerryDunn has found that limiting case manager workloads can positively impact length of stay.
“No matter what data point I looked at, I went back to that caseload and every single time if you got past 25, both your patient satisfaction and your quality outcomes are diminished,” Lindsey Doak, home health and hospice leader for BerryDunn, told Hospice News. “The smaller the caseload, the more you have control of your patients. But also, if you have a caseload of 25, you are able to see your patients at least once a week. Whereas once that increases, you can no longer maintain that. You’re sending out another clinician.”
Historically, caseloads for hospice nurse case managers have hovered around 10 to 12 patients, but these numbers have been trending upwards.
Among the hospices that BerryDunn surveyed, 88% of the best performers kept case managers’ workloads between 13 to 18.
BerryDunn polled more than 1,000 hospice and home health agencies in its National Healthcare at Home Best Practices and Future Insights Study. Of those, 249 were hospice agencies that ranked in the top 15% on Consumer Assessment of Healthcare Provers & Systems (CAHPS) scores. The survey questions focused on operational, clinical, and financial best practices.
The No. 1 complaint that families report on hospice CAHPS surveys is that they wish their loved one had entered hospice sooner, according to the U.S. Centers for Medicare & Medicaid Services (CMS).
Patient admission times and lengths of stay also have implications for hospices’ revenue streams. BerryDunn researchers found a direct correlation between length of stay and a hospice’s likelihood of profitability.
Among hospices with an average length of patient stay between 41 and 60 days, around 82% yielded higher daily revenue. Those whose average stay was 40 days or less achieved a 29% positive profit ratio, while those with 81 days or more had 0% or negative profit ratios, according to BerryDunn.
“If you look at the caseloads, organizations that have that 19 or less or 20 to 25 have increased profitability standards, with the key metric being five to five-and-a-half visits that they’re adding,” Doak said. “You have fewer patients, but now you’re better able to manage them, and then you’re able to increase your productivity because you have a caseload that’s more manageable. That is then having a relationship, because we know that productivity relates to your profit surplus margin.”
But reducing workloads can be a challenging proposition in an industry in which labor shortages are the biggest headwind. These staffing woes have long plagued the hospice industry, but have only worsened since COVID-19 hit the United States in 2020.
Roughly 18% of health care workers have left their jobs during the pandemic, while 31% have considered leaving the field altogether, according to a nationwide 2021 Morning Consult survey. Burnout, poor wages and the pandemic itself were leading reasons.
Despite rising demand for care, these pressures have caused a number of hospices in the United States to shut down, sell their businesses or downsize. The corresponding reductions in clinical capacity have also led to record numbers of declined hospice referrals.
One strategy that some hospices have adopted is to involve more social workers in case management while trying to stay in that 13-25 patient range.
“Most organizations would tell us that an increase in the utilization of social work, so incorporating social work into the patient’s care is increasing their the quality of their life at the end of life, and then also increasing their median length of stay,” Doak told Hospice News. “So we’re seeing them live longer, a matter of days, which in hospice is fairly significant.”
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