Sometimes working overtime is the only way to get the job done on time
A fair schedule? It’s neither easy nor impossible
Working overtime is not the sole property of health care professionals or new hires eagerly climbing the corporate ladder. There is an understandable — and somewhat undesirable — aspect to putting in more than the 50 or 60 hours many home health professionals put in, especially when that extra time cuts into family time. For home health care agencies venturing into the world of overtime, the problem is how to distribute the on-call hours evenly and how to fairly compensate employees.
Coming up with a win-win solution is not always as easy as breaking down the hours into even amounts. "It took a long time to work out a call plan that seemed fair. Although home care is a very different animal, our nurses needed to know that they were receiving the same treatment when on call as [someone working in] the lab or radiology," says Teresa Craft, RN, director/home care for Covington County Hospital in Collins, MS.
Lisa Sprinkel, director of Carilion Home Care Services in Roanoke, VA, knows firsthand how difficult establishing a good working system can be and what happens if you fail. "Our hospital-based agency was experiencing a considerable amount of turnover, which those leaving us attributed to the on-call experience. . . . We average about 3,000 admissions per year and are committed to expedient service, so we frequently have admissions that must be done in the evening. Occasionally, we’ll have several visits that must be done at 8 p.m. for medication administration, etc."
Hiring for on-call duties exclusively
To make the on-call experience more palatable for all involved, she says, Carilion devised a novel approach and advertised for and hired two on-call positions. "One on-call nurse works Monday through Thursday from 2 p.m. until 8 a.m. She is paid a salary and is expected to see scheduled p.m. visits as well as any PRNs [as needed cases] that are called in. Our weekend on-call nurse works from 2 p.m. on Friday until 8 a.m. on Monday and sees scheduled patients, manages the beeper, and sees or assigns PRN calls to her backup nurses.
"We routinely staff at least four, sometimes five, nurses every weekend. In addition to our weekend on-call [nurse], we have one other full-time weekend RN and one full-time weekend LPN [licensed practical nurse]. Then our nursing staff rotate weekends, about one per month," she says.
Sprinkel says this new routine has "been a tremendous staff satisfier and has resulted in a decreased turnover rate. When it comes down to it, it’s not really the work that’s associated with on-call [duty] here. It’s the perception of being chained to the beeper that’s overwhelming."
Assigning weekend-only on-call duty
Carilion Home Care Services is not the only agency to assign nurses to weekend-only duty. Olympic Medical Home Health in Port Angeles, WA, also has a weekend nurse who takes calls from Friday evening to Monday morning, explains Alberta Stamp, RN, nursing supervisor. That nurse is paid for an eight-hour day both Saturday and Sunday, she says, plus a flat rate of $30 a night for the evening shift.
Other nurses share the rest of the call and are paid $30 a night and then hourly if they are called out, she explains, adding that it "amounts to one to two days a month of [working] on call."
Kathy Kieke, RN, MSN, care center director for St. Cloud (MN) Hospital Home Care and Hospice, says her agency has "a team of on-call nurses, five in all, who share the weekday and weekend on-call [duty]. We also have a nurse who works 1 p.m. to 9 p.m. Monday through Friday who takes the scheduled late-in-the-day visits and admits."
On-call nurses receive $4.85 an hour when they’re just carrying the beeper, and [they receive] their regular wage, plus $1 an hour additional pay, when they are working. None of these staff are scheduled to work holidays, she says.
One former home care agency administrator says her agency had full-time, triage registered nurses on staff who took the calls from home on phone lines paid for by the agency. These nurses, she explains, worked from 5 p.m. to 8 a.m. and covered all programs from home care to private duty and hospice to DME/IV (durable medical equipment). These nurses did not make visits, she says, but program staff worked rotating shifts to cover those visits and were paid time and a half from the time they left home until the time they returned.
When full-time goes on call
Not every agency can afford or wants to hire nurses solely to cover the on-call hours. In these cases, as all too many home care professionals know, it is left to the full-time staff to take over. Having a plan that is the same for everyone across the board has "made it much easier to establish a workable call-back plan." Craft says.
At Covington County Home Care, she says, "nurses rotate call, which starts Monday at 8 a.m. and runs for seven days. When a LPN is on call, there is a RN assigned to backup call. The call schedules are posted three months at a time, so everyone can plan accordingly, and weeks can be swapped between staff, if needed. This has been our policy for several years and works well."
Covington call staffers are paid "$10 a shift for all shifts that do not fall into the regularly scheduled working hours of 8 a.m. to 4 p.m. which is $160 a week. We get time and a half for everything over 40 hours, which is basically what the hospital does."
Helen Eriksen, PPS nurse auditor at Abington Memorial Hospital Home Care in Willow Grove, PA, explains that all her agency’s full-time nurses take call duty, which usually adds up to about two to three weeks out of the year. For their extra work, they are paid $2.50 an hour, plus the hourly rate if any visits are made. Specialty teams, Eriksen points out, handle their own call hours separate from the general home care patients.
Another supervisor, whose agency has a similar program, says her agency’s nurses, if they are called out, are paid an hourly rate for a minimum of two hours in addition to the $2.50 an hour they are already earning on call. Another supervisor explains that her regular nurses are on call and rotate through the cycle about once every three months for primary call and again for secondary call duty. Visits, she says, are paid on a per-visit basis in addition to what nurses are earning as a base call rate.
Peggy Ford, performance improvement coordinator at Via Christi Home Health in Wichita, KS, explains that her agency, after analyzing several options, recently went to a case manager model whereby the agency’s "field staff are divided into disease management teams. Each team has a salaried case manager who coordinates the clinical and financial aspects of care. Then there are between two and four visiting staff assigned to each case manager to do the routine visits. The case managers do not take call."
Using appropriate staff for routine needs
As for evening and weekend call duty, Via Christi has continued to use a noncase manager system. Under this program, she says "the noncase manager staff obtain the open paperwork, review the patient’s rights with them, etc., but the case manager completes the initial assessment within 48 hours and completes the OASIS [outcome and assessment information set] and 485 paperwork.
"The full-time visiting RNs rotate call one week at a time and receive $2 an hour in addition to receiving their per-visit pay for time worked while on call. We also track phone time by hours and minutes and convert it to per-visit pay," Ford continues. "Opens that must be done on the weekend are handled by the visiting staff on call, and then the case manager on Monday completes 485 and OASIS. We also have RNs assigned to work weekends," she explains. "Each RN will work every fifth weekend to handle scheduled weekend visits for which they are paid per visit and entitled to take a day off during the week."
The maternal/child team, Ford adds, are paid on the same scale as the general RNs, but as there are fewer of them to share the responsibility, they are on call more often.
No rest for the weary
While full-time nurses and LPNs earn overtime pay for their call duty, rarely is this the case for administrative call. Only one home care manager said that she was paid for her call duty (about one night every three weeks) for which she received a flat fee per night. Kieke and others say that being on administrative call is part of their job description, and hence they don’t see any additions to their paychecks. Kieke says she is fortunate in that she shares her duty with that of the hospital staff and so it comes up only quarterly.
One home care supervisor says not only is she on call 24/7 for her agency but she is on administrative call for her agency’s hospital roughly every six weeks. "Administrative call for me rotates each week," says Ford. "Intake has [people] on call to handle referrals that come from the hospitals on the weekends. They work eight hours on Saturday, then receive the on-call rate for Sunday for the eight-hour shift."
At Olympic Home Health, explains Stamp, "We have four management levels that share on a two-week rotating basis. We are on for administrative backup, i.e., if the answering service cannot reach the nurse or there is an administrative problem. There’s no pay involved, it is just a part of our duties."
No matter what system is used, it may feel to many home care professionals whether they are in the field or in the agency office, that they are always, in some sense, on call. Becky Massey, director of home health services for Thomas Memorial Hospital in South Charleston, WV, sums it up like this: "I am on call 24/7 except when I’m out of town."
[For more information, contact:
• Teresa Craft, RN, Director/Home Care, Covington County Hospital, Sixth and Holly, P.O. Box 1149, Collins, MS 39428. Telephone: (601) 765-6052.
• Helen Eriksen, PPS Nurse Auditor, Abington Memorial Hospital Home Care, 2510 Maryland Road, Willow Grove, PA 19090. Telephone: (215) 481-5800.
• Peggy Ford, Performance Improvement Coordinator, Via Christi Home Health, 727 N. Waco St., Wichita, KS 67203-3951. Telephone: (316) 269-1711.
• Kathy Kieke, RN, MSN, Care Center Director, St. Cloud Hospital Home Care and Hospice, 48 29th Ave. N., Suite 15, St. Cloud, MN 56303. Telephone: (320) 240-3265.
• Becky Massey, Director, Home Health Services, Thomas Memorial Hospital, 4605 MacCorkle Ave. S.W., South Charleston, WV 25309-1398. Telephone: (304) 766-3447.
• Lisa Sprinkel, Director, Carilion Home Care Services, 1917 Franklin Road S.W., Suite A, Roanoke, VA 24014-1103. Telephone: (540) 224-4800.
• Alberta Stamp, RN, Nursing Supervisor, Olympic Medical Home Health, Olympic Medical Center, 939 Caroline St., Port Angeles, WA 98362. Telephone: (360) 452-6211.]
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